Ministry of Health Ghana

Transcription

1 Ministry of Health Ghana Holistic Assessment of the Health Sector Programme of Work 2012 Ghana Version 11 th June

2 Table of Contents List of abbreviations and acronyms... 3 Acknowledgements... 4 Executive summary... 5 Introduction Assessment of the Health Sector Performance in 2012 using the Holistic Assessment Tool Assessment of indicator trends Regions of excellence and regions requiring attention Implementation status of the POW Agencies assessments and performance contracts Follow-up on Aide Memoire recommendations Conclusion Annex 1: Sector Wide Indicators and Targets POW Annex 2: Sector wide indicator trends based on 3% proportion Annex 3: Holistic Assessment Tool and Analysis Annex 4: Indicator definitions and calculations Annex 5: Analysis framework for POW 2012 implementation Annex 6: Capital Investment Update POW Annex 7: Procurement plan

3 List of abbreviations and acronyms ART Antiretroviral Therapy CHAG Christian Health Association of Ghana CHPS Community Health Planning and Service CIP Capital Investment Plan DFID UK Department for International Development DHIMS District Health Information Management System DMHIS District Mutual Health Insurance Scheme EmOC Emergency Obstetric Care EmONC Emergency Obstetric and Neonatal Care EPI Expanded Programme on Immunisation FP Family Planning GHS Ghana Health Services GOG Government of Ghana HIRD High Impact Rapid Delivery HMIS Health Management Information System HR Human Resources HRD Human Resource Directorate IGF Internally Generated Funds IMR Infant Mortality Rate ITN Insecticide Treated Net KATH Komfo Anokye Teaching Hospital KBTH Korle-Bu Teaching Hospital MDG Millennium Development Goal M&E Monitoring and Evaluation MICS Multiple Indicator Cluster Survey MMR Maternal Mortality Ratio MoH Ministry of Health MTEF Medium Term Expenditure Framework NCD Non-Communicable Disease NDPC National Development Planning Commission NHIA National Health Insurance Authority NHIF National Health Insurance Fund NHIS National Health Insurance Scheme OPD Out-Patient Department POW Programme of Work PPME Policy, Planning, Monitoring and Evaluation SBS Sector Budget Support TBA Traditional Birth Attendant TH Teaching Hospital U5MR Under-Five Mortality Rate WHO World Health Organisation 3

4 Acknowledgements The holistic assessment of the health sector 2012 Programme of Work was done internally by the Ministry of Health. A team of five people from Ministry of Health and Ghana Health Service undertook the review and holistic assessment. The members of the team were Dr. Afisah Zakariah, Daniel Degbotse, Dan Osei, Dr. Anthony Ofosu and Dr. Andreas Bjerrum. The team would like to thank all individuals who contributed to this review and who kindly gave their time and support to the review process. 4

5 Executive summary The year 2012 represented the third year of the implementation of the current Health Sector Medium Term Development Plan ( ). The review has placed emphasis on the performance of the sector according to identified health objectives as outlined in the Four-Year Sector Medium Term Development Plan and the derived Annual Programme of Work for The review assessed the overall sector performance for the year 2012 using the agreed Holistic Assessment tool. The Holistic Assessment tool was adopted in 2008 and has been used to assess the sector performance since its inception. The report is organized into six chapters and a conclusion. 1. Assessment of the Health Sector using the Holistic Assessment Tool The purpose of the holistic assessment is to form a basis for a balanced discussion between the Ministry of Health, its agencies and development partners to reach a common conclusion of the sector s performance. The outcome of the assessment is that the health sector in 2012 was a positive sector score of +3, which is interpreted as a highly performing sector. 2. Assessment of indicator Trends Health Objective 1: Bridge equity gaps in health care and ensure sustainable financing arrangements that protect the poor The equity index for supervised deliveries by region improved and reached the target of 1.7 comparing the best to the worst performing region with regards to coverage. Performance improved among both the best and worst off regions. Almost all regions performance were above 50% except Volta Region at 46.5% and Northern Region at 49.9%. Coverage increased in all regions except for Ashanti Region, which experienced a drop of 2.1%. The poorest staffed region with regards to nurses is the Northern Region Volta and Upper West Regions stand out with critical reductions in midwife populations. The Doctor to population ratio did not change much and with 11 times less doctors per population in Upper West Region compared to Greater Accra Region equitable distribution of doctors remains a major challenge to the health sector with one nurse to 1,601 population compared to the national average of one nurse to 1,251 population. The National Health Insurance since its introduction has led to increase in utilization of OPD services across all the regions. Ashanti region like all the regions showed an increase in OPD attendance till 2012 when it experienced a drop in OPD per capita Health Objective 2: Strengthen governance and improve efficiency and effectiveness of the health system In 2012, the ministry introduced performance contracts with four agencies: the three Teaching hospitals and Ghana Health Service. Government of Ghana contribution increased by 126.9% from GH 771 million in 2011 to GH 1,750 million in Internally Generated Fund (IGF) increased by 8.9% from GH 392 million in 2011 to GH 427 million in Contribution from donors in 2012 was GH million whilst there was GH million contribution in the same period of the previous year, an increase of 12.2% over the same period of 2011.Total Gross Revenue, recorded by the Ministry was GH 2,489.8 million. The Ministry recorded a total expenditure of GH 2,613.4 million for the period under review Debtors have decreased from GH in December 2011 to GH 115.9m in December 2012, a decrease of 15.8%. 5

6 Health Objective 3: Improve access to quality maternal, neonatal, child and adolescent health and nutrition services The total fertility rate increased from 4.0 to 4.3. Meanwhile the contraceptive prevalence rate for the same period has improved significantly, increasing to 23.4% from 16.6% in The proportion of pregnant women attending four or more antenatal care visits increased slightly to 72.3%. For the 2011 MICS report, the corresponding figure was 86.6%. Over the past 3 years, supervised delivery coverage has increased by 28.2%, and over the past 5 years by 66.5%. Coverage of supervised deliveries in 2012 was 58.5%, based on the estimated expected delivery of 4% of the population and 77.9% based on 3% estimate The MICS gave the country a skilled attendant at delivery coverage of 68.4%. The proportion of children below the age of six months that are exclusively breastfed has significantly dropped since 2008, and the current performance at 45.7% is below 2003 levels and far below the target of 70%The national Infant Mortality Rate (IMR) increased by 6% over the DHS 2008 figure from 50 to 53. IMR is highest in Volta, Upper West, Northern and Brong-Ahafo Regions. Northern Region and Upper West Region have since 2003 had relatively high U5MR. Upper West Region has been able to bring down under-five mortality rate by 50%. Health Objective 4: Intensify prevention and control of communicable and non-communicable diseases and promote a healthy lifestyle According to the MICS 2011, use of ITNs has improved by almost 50% since 2008 and the proportion of children under five sleeping under ITN the previous night has also increased. The national prevalence of malaria parasitaemia in children aged 6-59 months based on microscopy was 27.5% with the highest prevalence in Upper West Region (51.2%) and Northern Region (48.3%). Lowest prevalence was recorded in Greater Accra Region (4.1%). While the national number of expected malaria cases among children has not dropped significantly, case-fatality of malaria for children under five years has improved, dropping from 1.2 in 2011 to 0.6 in 2012 deaths per 100 confirmed malaria cases. In 2012 coverage of Penta 3 was 87.8%. The MICS gave the corresponding survey based coverage of 92.1%.. The country continues to maintain surveillance for guinea worm. While the proportion of the population with access to improved sanitary facilities that are not shared increased, the access to all improved sanitary facilities, shared and not shared, reduced. TB treatment success went up to 86.2% but the target of 89% was not achieved. The adverse outcomes reduced from 16.7% to 13.8%. Health Objective 5: Strengthen institutional care including mental health service delivery The total number of mental health nurses in the three psychiatric institutions was 1,068. This comprises both community psychiatric nurses and registered mental nurses. Total number of patients seen during the year was 67,732. No formal training exists for training community psychiatric nurses. The current crop of community psychiatric nurses amount to 400 who are registered nurses converted to practice as community psychiatric nurses. Institutional infant and under five mortality rates improved significantly in 2012 with more than 50% reduction in both. Institutional Maternal Mortality (immr) dropped significantly from 211 maternal deaths per 100,000 live births in 2011 to 193 in While immr at Komfo-Anokye Teaching Hospital continued to be high with 1,252 deaths per 100,000 deliveries, Korle-Bu Teaching hospital reduced institutional maternal mortality ratio significantly from 1,133 in 2011 to 841 in The continuous high maternal mortality ratio at the teaching hospitals calls for stronger and more structured collaboration between the teaching hospitals and the referring hospitals and clinics at all levels. 6

7 3. Regions of excellence and regions requiring attention In the review of POW 2011, the review team introduced a simplified holistic assessment based on regional performance of selected indicators to identify the region of excellence and the region requiring attention. The scoring of each indicator follows the rules of the holistic assessment adapted to regional analysis. It is important to note that the regional performance assessment is only indicative since it is based on a limited number of service delivery indicators In the regional analysis of POW 2011, three regions came out with a score of zero or below. In the current review all regions have a positive score, which indicates a relative improvement over 2011 for these selected service delivery indicators. The two regions doing very well are Central and Upper East Region, those not doing so well are the three Regions Volta, Ashanti and Brong-Ahafo. 4. Implementation status of the POW 2012 In the Programme Work for the year 2012, some activities were planned to be implemented under the five strategic objectives. The extent to which these activities are carried out determines the performance of the health sector. Reasons for non-performance in some instances range from non-availability of funds to lack of a clear framework for implementing such planned activities. The objective of the Ministry of Health is to improve coverage of PHC services at sub-district level through strengthening community health systems. The Ministry planned to do this by expanding CHPS coverage to achieve 500 new functional zones during the year. Although the target was exceeded some challenges remain. The development of the health care financing strategy could not be carried out. The capitation pilot was undertaken in Ashanti Region. Though the leadership development programme training is progressing as planned, an assessment of the relevance of the programme in enhancing performance of district and subdistrict teams is necessary. Although a performance contract was signed with the Ghana Health Service and the three teaching hospitals, contract management in terms of supervision, reporting and evaluation was not adequate. A lot of health bills have been passed into law, efforts aimed at operationalising the law through legal instruments however needs to be facilitated. The Ministry of Health developed a private sector policy, however it was not printed or disseminated. This policy will provide for cross-sectoral activities in the mobilsation of resources for health and health care. The implementation of the MAF action plan has delayed. Indeed part of the MAF plan is being implemented at all levels. Although the community case management of malaria, diarrhoea and acute respiratory disease is being implemented in some districts as planned it is facing challenges. Community health workers face difficulties in recouping funds for the drugs they dispensed at the community level. I The adolescent health strategic plan and policy was disseminated to all stakeholders during the year. The emergency obstetric care equipment meant for the three remaining regions (Upper West, Greater Accra and Volta Regions) has not been delivered according information provided during the review. 7

8 The pneumococcal, meningococcal and rotavirus vaccines including second dose of measles vaccines were successfully introduced. It was planned to disseminate and implement the National Nutrition Policy. The draft of the policy has been developed and is being prepared for submission to cabinet. Nutrition, Malaria and Child Survival Program was implemented to improve the nutritional status of children using community based approaches in districts in Upper West, Upper East, Volta and Central Region. To reduce malaria case fatality for the vulnerable groups, ACTs for treatment were procured and distributed through the AMFm programme. LLINs Hang Up campaign was organized in all the regions. The plan for the year was to maintain the polio free status of the country and validate eradication of guinea worm and polio. To achieve this, surveillance activities including case searches were intensified. The plan for the year was to increased case detection for NTDs. To achieve this, the Ministry finalized the NTD Master Plan for Ghana for the period 2011 to 2015 in collaboration with WHO. The plan was shared with the relevant stakeholders. Mass drug administration was conducted for Onchocerciasis, schistosomiasis and Lymphatic Filariasis in communities and schools The scaling up of the detection and management of non-communicable diseases through the implementation of the national strategy for cancer control and expansion of screening program for hypertension, diabetes and sickle cell were also not done. Though the guidelines for the cancer programme have been developed they are yet to be printed. 5. Agency assessments Centre for scientific research into plant medicine The Centre for Scientific Research into plant medicine was set up to conduct and promote scientific research relating to the improvement of plant medicine. Total staff at post at the centre is 192. The centre screened and selected 4plants each for diabetes, hypertension and malaria respectively and 2 plants for prostate cancer. Preliminary analysis on 4 anti hypertensive plant extracts showed promise in decreasing blood pressure over a four week period in laboratory rats. Safety and efficacy evaluations of three out of four herbal products which not dose dependent showed considerable reduction in parasitemia. With regards to Dissemination of research findings (4 research papers and 6 technical reports) on quality, efficacy and safety of herbal medicines; Two (2) papers were published Allied health profession It also works with other relevant organizations to provide accreditation to qualified training institutions providing allied health programmes. It regulates practice standards of professionals. Planned activities include among others the development of guidelines for accrediting training institutions and programs in collaboration with the National Accreditation Board. A total of 34 applications were received from training institutions for accreditation. A workshop on curricula for allied health programs in the West African sub-region was held. The allied health professions Bill was passed by parliament and is awaiting presidential accent. 8

9 Food and Drugs Authority From the number of activities planned to be implemented for 2012, Food and Drugs Authority was belt to ; Train One hundred and ten (110) food manufacturing industries in Food Safety Management Systems. Train Street Food Vendors in 30 Food Service Establishments in Basic Food Safety and Hygiene practices. Three Hundred and Seventy samples of antimalarial preparations on the market were sampled and screened with Minilabs. The first round of Quality Surveillance of Uterotonic preparations namely Oxytocin Injections and Ergometrine Maleate Preparations (Injections and Tablets) was carried out 279 samples were analysed of which 178 (63.7%) failed. The Public Health Bill, 2012, (Act 851) (which includes the Tobacco Bill, FDA Bill and Clinical Trials) was passed into law. The challenges of the authority are Inadequate operational vehicles. Limited border post-activities. For the coming year post-market surveillance functions will be enhanced to rid the market of fake, substandard and unwholesome regulated products. Ghana College Of Physicians And Surgeons The Ghana College was established to promote specialist education in medicine, surgery and related disciplines. It also promotes continuous professional development in medicine, surgery and related disciplines including research. The college in 2012 planned to publish a journal and a newsletter and install ICT infrastructure to aid in the colleges training programme. The college has 24 faculties. Other key activities planned for the year include accreditation of training sites and medical knowledge fiesta. The college published one journal and 2 newsletters and organized 20 CPDs out of the expected 24. A knowledge fiesta was also organized for English speaking West Africa to exchange knowledge on current happenings in the medical field. An ICT infrastructure sponsored by MTN was installed and commissioned during the year. Some of the challenges of the college include Developing alternate funding arrangements for post graduate medical education, maintenance of College building and accreditation for training for decentralized sites. The College will continue with its core functions of producing specialists in medicine, surgery and related disciplines and develop options for funding post graduate specialist training The college will also support implementation of WAHO initiative towards harmonization of curricula and accreditation criteria with subregional Colleges. Ghana Health Service The Ghana Health Service identified 8 main priority areas for improvement in 2012 under the five strategic objectives The major priority activity under this objective one was the scaling up of the Community-based Health Planning and Services (CHPS) as a close-to client policy to increase access to basic health services. This achievement was made possible by simplifying the community health community training manual and trainer of training programmes for the regional teams. One of the major challenges of the Ghana Health Service is the availability, distribution and appropriate mix of relevant health staff at the health facilities. 9

10 The GHS introduced the leadership and management capacity development as a capacity building effort in the Central region in Since then 161 health personnel have been trained. The processes were started for the Implement the MAF country Action plan for improved maternal and neonatal care. Activities were initiated to develop and implement the National Nutrition Policy and strategy. All Districts (170) were also trained In Community Management Of Malaria (CMM) and and some districts commenced implementation of CMM. As part of effort to improve prevention and control of communicable diseases, the GHS planned to procure and distribute ICT equipment to support district level surveillance activities, which was done in three regions. The following guidelines, policies and strategies were developed or reviewed Laboratory accreditation guidelines for clinical labs in hospitals Laboratory Quality Control of Taylor & Taylor Analysers in selected Laboratories in Greater-Accra Region Antimicrobial policy for Ghana Community Mental Health Strategy The Ghana Health Service plans to re-prioritize the numerous activities in 2013, to ensure that the key ones are implemented. Komfo Anokye Teaching Hospital A patient satisfaction survey conducted during the year indicated that 62% of hospital clients were satisfied with the hospital s services. Customer Care Service Training was organised for staff during the period under review to improve services provided to clients. A Magnetic resonance Imaging (MRI) Centre was completed during the year and handed over to the hospital Services at the center commenced. Work on the uncompleted Maternity & Children s Block was reactivated whilst construction of Eye Centre is 95% complete OPD attendance and services provided at the hospital either declined or remained stagnant over the period. Sustain activities aimed at reducing mortality, (especially maternal mortality), and improving general care outcomes were undertaken. The maternal mortality however did not reduce. Daily clinical meetings and monthly maternal mortality meetings were held to audit all Maternal Deaths. Continue to support Doctors & Nurses to pursue training programme in Emergency Medicine 5 Doctors and 20 nurses qualified as Emergency Physician and emergency nurses respectively. The Hospital embarked on several outreach programmes in eye screening and surgeries, ENT, Cleft, Child Health and Infectious Diseases during the period under review. The Hospital visited One Teaching Hospital and Eight Districts. Twenty-five (25) research activities initiated by directorates during the period are on-going. Two (2) research reports were completed and disseminated:some of the challenges of the Hospital were,congestion, especially at maternal & children s wards, Delays in the payment of health insurance claims and unrealistic tariff,old & Non-functional Oxygen Plant and Rent Expenditure for House Officers & Residents 10

11 Korle-Bu Teaching Hospital The hospital has a total staff strength of 4419 with clinical staff constituting 72% (3,184) and Non clinical staff 28% (1,235). To improve maternal health outcomes and general clinical outcomes, a number of projects and programmes were initiated. A Blood bank established at the Maternity Block Laboratory and the renovation of the Maternity OPD, 4 th and 6 th Floors which was started at the beginning of the year are 80 to 90% complete. The hospital saw a reduction in maternal deaths. The emergency department is being refurbished to improve emergency medicine services. Capacity building in Client/Patient care aimed at addressing Staff attitudes was initiated. About 50% of staff have undergone the training. The challenges of facing the hospital are High cost of incentives to attract and retain critical staff. Tamale Teaching Hospital The objectives for the hospital in 2012 were among others to strengthen and improve governance and efficiency of the TTH s management systems, provide excellent quality Maternal and Child Health Service and attract and retain health staff. In an effort to improve general hospital management through informed decision-making, an ICT Firm was commissioned to develop a Health Management Information System. The hospital introduced measures aimed at improving maternal and neonatal outcomes. Radiology/Endoscopy/Urology services including new and improved imaging services have been introduced. National Ambulance Service The Service opened 97 new ambulance stations during the year bringing the total number of ambulance stations in the country to 121. Thirty-five emergency medical technician basic (EMTB) were upgraded to emergency medical technician advance (EMTA) during the year. Inadequate Budgetary Allocation and late release of funds hampered the programme and activities of the service. Lack of dedicated training facility leading to delays in training schedules National Health Insurance Scheme Some of the objectives of the scheme at the beginning of the year was to ; To increase efficiency in the financial operations of the scheme, to increase active membership to 45% of population by December 2012 and to provide support to increase access to quality basic health care services in all districts To strengthen premium collection scheme level, a consolidated premium account was established. The World Bank is supporting the Health Insurance Project (HIP) whiles DANIDA is supporting the authority with an M&E advisor. Until recently, returns from investment formed a substantial part of the total funds of the scheme. However due to recent financial difficulties, the authority had not been able to invest and have had to plough back its savings to keep the scheme afloat. To reverse this trend, the authority developed an investment policy and guidelines to provide guidance to the authority. The authority realised 6.5% real rate of returns on investment exceeding its target of 4%. The NHIA intensified clinical audit of the district schemes and providers. The authority also hoped to improve efficiency by diversifying provider payment mechanism. 11

12 Some of the challenges facing the scheme are Financial sustainability of the concerns,ict Challenges Claims Management, Renewal of membership by clients and Irrational Prescription of medicines by providers. 12

13 Introduction The year 2012 represented the third year of the implementation of the current Health Sector Medium Term Development Plan ( ). The review has placed emphasis on the performance of the sector according to identified health objectives as outlined in the Four-Year Sector Medium Term Development Plan and the derived Annual Programme of Work for The review assessed the overall sector performance for the year 2012 using the agreed Holistic Assessment tool. The Holistic Assessment tool was adopted in 2008 and has been used to assess the sector performance since its inception. For the second year running, the review was performed by an internal team drawn from the Ministry of Health and its agencies. For this year s review, a section on agencies performance was added. The new census data from 2010 was available for the year s review. From the census report, the proportion of children under one year as well as expected pregnancies was estimated to be 3% of the total population. When this proportion is applied to the data several indicators exceeds 100% coverage. Since most of the analysis in this report is based on trends over time, and the targets of the HSMTDP was based on 4% the review team finds it technically sound to continue basing the analysis on the 4% as in the previous reviews. However data based on the 3% is made available for comparison and official purposes. The report is organized into six chapters. The first chapter deals with the health sector performance using the holistic assessment tool. The second chapter discusses the trends of sector wide indicators. The third chapter provides an assessment of regions of excellence and regions requiring attention. The fourth chapter looks at the implementation status of the programme of work The fifth chapter is a brief report of the agencies performance. The sixth chapter follows up on the recommendation of previous Aidememoire. Annexes are provided with further details of the basis of the analysis. 1.0 Assessment of the Health Sector Performance in 2012 using the Holistic Assessment Tool 1.1 Sector score The purpose of the holistic assessment is to form a basis for a balanced discussion between the Ministry of Health, its agencies and development partners to reach a common conclusion of the sector s performance. The outcome of the initial assessment is that the health sector in 2012 was a positive sector score of +3, which is interpreted as a highly performing sector (For the detailed analysis of the indicators and the holistic assessment calculations, please refer to Annex 3: Holistic Assessment Tool and Analysis). Health Objective 1 0 Health Objective 2 0 Health Objective 3 +1 Health Objective 4 +1 Health Objective 5 +1 Sector score +3 13

14 Table 1: Sector Score 2012 Table 1 shows the overall scores for the five Health Objectives in the HSMTDP Table 2 provides a detailed overview of the indicators and trends from 2007 to Annex 2: Sector wide indicator trends based on 3% proportion provides a presentation of trends of sector wide indicators over time based on the latest projections from Ghana Statistical Services. 14

15 2012 POW Target Performance (4%) Performance (3%) Source Health Objective 1: Bridge equity gaps in health care and nutrition services and ensure sustainable financing arrangements that protect the poor 1 % children 0-6 months exclusive breastfed % % 45.7% 45.7% MICS 2 Equity: Poverty (U5MR) : MICS 3 Equity: Geography - Services (supervised deliveries) * 1.66* 1: GHS 4 Equity: Geography - Resources (nurse: population) * 1.73* 1: MOH 5 Equity: NHIS Gender MICS 6 Equity: NHIS Poverty (F) (F) 0.69 (F) MICS 7 Outpatients attendance per capita (OPD) * 1.04* GHS /TH 8 % population living within 8 km of health infrastructure N/A - 9 Doctor: population ratio 1:13,683 1:13,499 1:11,698 1:11,833* 1:10,217* 1:9,700 1:10,452 1:10,452 MOH 10 Nurse: population ratio 1:1,537 1:1,353 1:1,494* 1:1,516* 1:1,262* 1:900 1:1,251 1:1,251 MOH Health Objective 2: Strengthen governance and improve efficiency and effectiveness in the health system 1 % total MTEF allocation on health 14.6% 14.9% 14.6% 15.1% 15.8% 15.0% 15.4% 15.4% MOH 2 % non-wage GOG recurrent budget to district level and below 49.0% 49.0% 62.0% 46.8% 55.3% 50.0% 38.5% 38.5% MOH 3 Per capita expenditure on health MOH 4 Budget execution rate (Item 3 as proxy) 110.0% 115.0% 80.4% 94.0% 82.1% 95.0% 86.8% 86.8% MOH 5 % of annual budget allocations disbursed to BMC by end of year % 39.0% 31.0% 89.8% 50.0% % of population with valid NHIS membership card % 33.4% % 34.0% 34.0% NHIA 7 Proportion of claims settled within 12 weeks % % IGF from NHIS N/A 66.5% 83.5% 79.4% 85.0% 75.0% Health Objective 3: Improve access to quality maternal, neonatal, child and adolescent health services 1 Maternal Mortality Ratio (MMR) per 100,000 live births Total Fertility Rate MICS 3 Contraceptive Prevalence Rate 16.6% % 23.4% MICS 4 % of pregnant women attending at least 4 antenatal visits 62.8% 63.8% 81.6% 71.1% 71.3% 80.1% 72.3% 96.4% GHS 5 Infant Mortality Rate (IMR) per 1,000 live births < MICS 6 Under 5 Mortality Rate (U5MR) per 1,000 live births < MICS 7 % deliveries attended by a trained health worker 35.1% 42.2% 45.6% 48.2% 55.8% 60.0% 58.5% 77.9% GHS/TH 8 Under 5 prevalence of low weight for age % % 13.4% 13.4% MICS Health Objective 4: Intensify and control of communicable and non-communicable diseases and promote a healthy lifestyle 1 HIV prevalence among pregnant women years <1.7% - - GHS 2 % of U5s sleeping under ITN 55.3% 40.5% % 41.5% 41.5% MICS 3 % of children fully immunized by age one - Penta % 86.6% 89.3% 87.4% 88.1% 91.4% 87.8% 117.1% GHS 4 HIV+ clients ARV treatment 13,429 23,614 33,745 40,575 59,007 80, NACP 5 Incidence of Guinea Worm 3, < GHS 6 % households with improved sanitary facilities % % 15.0% 15.0% MICS 7 % households with access to improved source of drinking water % % 79.3% 79.3% MICS 8 Obesity in population (women aged years) - 9.3% TB treatment success rate 74.5% 84.6% 85.4% 87.0% 85.3% 89.0% 86.2% 86.2% NTP Health Objective 5: Strengthen institutional care, including health service delivery 1 Psychiatric patient treatment and rehabilitation rate % >bl. 84.8% 84.8% Chief Psy. 2 Equity index: Ratio of mental health nurses to patient population % >bl. 1:63 1:63 Chief Psy. 3 Number of community psychiatric nurses trained and deployed % >bl Chief Psy. 4 % tracer psychotropic drug availability in hospitals % 85.0% 85.0% Chief Ph. 5 Institutional infant mortality rate GHS 6 Basket equipment functioning in hospitals % % tracer drugs availability in hospitals % 90.0% 85.7% 85.7% Chief Ph. 8 % of hospitals assessed for quality assurance and control % Institutional under-five mortality rate GHS 10 Institutional MMR GHS /TH Table 2: Sector wide indicators , both 3% and 4% proportion of children under 1-year/expected pregnancies, greyed out indicators are not measured on annual basis. 15

16 2.0 Assessment of indicator trends 2.1 Health Objective 1: Bridge equity gaps in health care and ensure sustainable financing arrangements that protect the poor Equity: Under-five mortality With twice as many under-fives dying per 1,000 live births in the poorest wealth quintile compared to the richest, the under-five mortality inequality gap between richest and poorest children is widening. While children of the richest quintile seem to be on track to meet the MDG target, children from other quintiles and especially the poorest children are faring much worse. The same widening of inequity is observed for infant and neonatal mortality rates. Since 2003, according to the DHS and MICS there have been no observed reduction of infant mortality and only 5% reduction in neonatal mortality among the poorest children. There have been 35% and 43% reduction of infant and neonatal mortality among the richest quintile during the same period. Further analysis of these trends to isolate the determinants of high mortality among children, e.g. urban/rural dwelling, socio-economic status, education status of parents, child gender etc. is needed, in order to device strategies to ensure more equitable health development for children in Ghana. Wealth Quintile DHS 2003 MICS 2006 DHS 2008 MICS 2012 Poorest Second Middle Fourth Richest Equity Ratio Table 3: Under-five mortality rate , source DHS and MICS Equity supervised deliveries The equity index for supervised deliveries by region improved and reached the target of 1.7 comparing the best to the worst performing region with regards to coverage. Performance improved among both the best and worst off regions. Almost all regions performance was above 50% except Volta Region at 46.5% and Northern Region at 49.9%. Coverage increased in all regions except for Ashanti Region, which experienced a drop of 2.1%. Volta, Northern and Western Regions have worse midwife to WIFA (women in fertility age) ratio compared to the other regions. This could be the reason for the lower performance in these three regions. Upper East Region continues to improve its supervised delivery coverage over the years. It will be of beneficial to look to Upper East Region for best practices in supervised delivery coverage. Although Volta region is showing an improvement in supervised delivery, it has consistently been the lowest performer with regards to supervised delivery for the past three years. There may be various reasons for this performance which came up in the joint monitoring visit report to the Region in 2011, among the issues may be inadequate infrastructure, ageing and inadequate numbers of midwives and the fact that Volta Region is one of the regions with very few maternal and child health interventions outside the regular budget provided by the Ministry of Health. The region should over the coming years receive special attention and support to catch up with the other regions. 16

17 Figure 1: Supervised deliveries by region , source GHS Equity HRH distribution The indicator of nurse distribution did not improve over 2011 performance, but reached its target of being below 1:1.95. The poorest staffed region is Northern Region with one nurse to 1,601 population compared to the national average of one nurse to 1,251 population. Equity with regards to nurses has however improved significantly overall since The improvement over the years has been due to the establishment of new nursing training schools in all the regions. The recent stagnation is possibly due to the high failure rate among the nursing students over the past two years that has reduced the number of nurses who are passing out of the schools. The decision of Upper East Region to strictly implement the policy of retaining nurses that train in their region appears to be yielding good results. Other regions, especially Northern Region, should also adopt this approach. From 2011 to 2012, the numbers of midwives are reducing across all the regions with the exception of Ashanti Region, which showed a marginal increase. There appear to be a lag time between the increase in the intake of trainees to the midwifery training schools and the rate of retirement of midwives. There is the still the need to get more nurses into training; this can be accelerated if the community health nurses are given diplomas instead of certificates when they undertake the post-basic midwifery course. Most of them are reluctant to enrol in the post-basic midwifery course because they are awarded certificates. Figure 2 shows the percentage change in midwife population by region since Volta and Upper West Regions stand out with critical reductions in midwife populations. Despite these reductions, both regions have more 17

18 favourable midwife to WIFA ratios than the national average, and both managed to increase the number of women delivering in facilities by 18.1% and 53.7% respectively in the same period. Figure 2: Percentage change in midwife population by region , source Free Maternal Health Care Policy Review 2013 The doctor to population ratio did not change much and with 11 times less doctors per population in Upper West Region compared to Greater Accra Region equitable distribution of doctors remains a major challenge to the health sector. Greater Accra Region continues to be the region with the highest number of doctors per capita with one doctor per 3,540 inhabitants. Fifty percent of all Ghana s doctors are in Greater Accra Region and another twenty percent are in Ashanti Region. The number of doctors in training in Greater Accra and Ashanti Region might be accounting for these high numbers. The proportion of female doctors in Greater Accra is higher than for the other Regions, indicating that some of these doctors are in Greater Accra Region because of domestic reasons. Northern Region has consistently improved its doctor population ratio over the past three years, however this increase has only benefitted the Teaching Hospital. Twenty five government Hospitals in Ghana are without doctors. Eight of them are found in the Northern Region. There is the need for establishment of clear staffing norms for facilities and the Ministry of Health will need to address the inequitable distribution of doctors. 18

19 Figure 3: Doctor: population ratios (lower is better), , Source MOH Equity NHIS The gender ratio of NHIS cardholders remains stable with 23% (MICS 2011) more female cardholders (15-49 years) than male cardholders (15-49 years) compared with 27%(DHS 2008). Women aged years have higher need for health care services (including maternal care) than men of the same age group, and until NHIS reaches universal coverage the ministry both expects and desires relatively higher female enrolment. Inequity in terms of socioeconomic status of NHIS active members by DHS and MICS surveys has significantly worsened since The indicator is calculated as the ratio of valid cardholders among women years from the poorest quintile compared to women years in the general population. The MICS survey demonstrates a modest increase in cardholders among the poorest women, but this increase is largely overtaken by a relatively higher national increase in cardholders. Curiously, equity among men of the same age group is significantly improving over the same period. The observed trend indicates that there is a financial access barrier for women from the lowest wealth quintile to enrol onto NHIS and/or renew their membership card. Reports from the district hospitals suggest that the poorest citizens choose to register with NHIS only when they anticipate a need for health services and subsequently discontinue their membership. This can lead to adverse selection that potentially creates challenges for the financial sustainability of NHIS. The recent evaluation of the Free Maternal Health Care Policy concludes that NHIS membership provided to pregnant women under the policy favours the poor. The evaluation also reports an increase in equity in the utilisation of health facilities for delivery. Analysis of survey-based coverage of supervised delivery 19

20 confirms this finding. Between 2008 and 2011 the surveys demonstrate a relative increase of 60% supervised delivery coverage among women from the poorest quintile. Figure 4: Supervised deliveries by wealth quintile, , Source DHS and MICS Access to health services The National Health Insurance since its introduction has led to increase in utilization of OPD services across all the regions. The number of outpatients per capita continued previous years increase, and in 2012, the relative increase was 11%. OPD per capita reached 1.17, more than doubling 2006 figure. In regions like Upper East and Brong-Ahafo, which share borders with neighbouring countries, the high figure may be partly explained by patients coming from the neighbouring countries. Over 60% of those attending outpatient were females and overall women between the ages of years were seen more often at the OPD than any other age group for males or females (Figure 5). With the backdrop of doubling OPD per capita rate, 80% of total outpatients insured and 34% of the population being active NHIS members, important questions can be raised: 1. Could the high proportion of OPD services be a reflection of frivolous use of services by NHIS members (moral hazard)? 2. Could it be a reflection of high NHIS membership among those in need of services, i.e. persons only register when they fall sick and refrain from renewing membership the following year (adverse selection)? 3. Has the NHIS led to increased equity in utilization of health services, i.e. equal access for equal need? 4. Could it be due to data capture problems? While the third question is a goal of establishing NHIS, a positive answer to question 1 and 2 provide a financial risk to NHIS, and these issues should be further analysed and addressed. 20

21 Figure 5: OPD visits by gender and age-group 2012, source GHS Ashanti region like all the regions showed an increase in OPD attendance till 2012 when it experienced a drop in OPD per capita (Figure 6). It was the year that the capitation was piloted in the region. It is not clear whether this reduction in OPD was due to reduction in inappropriate utilization by insured clients or reduction in access on account of the capitation. Ashanti Region was also the only region where the proportion of OPD clients with insurance fell (from 82.6% to 76.9%). Figure 6: NHIS membership and OPD visits per capita in Ashanti Region, 2012, source GHS and NHIA 21

22 Northern Region s low OPD per capita rate might be a reflection of poor geographical access in the Region. Although financial access has been facilitated with the health insurance, their overall OPD per capita remained low compared to the other regions. With the increase in OPD visits across the regions, there has not been equally significant improvement in infrastructure of most of the facilities to accommodate these increases. It is now more important than ever to ensure good service and clinical quality. Strategies for quality assurance for clinical care services should be developed for inclusion in new HSMTDP. Figure 7: OPD per capita by region, , Source GHS The National Ambulance Service expanded significantly opening 97 new stations in Total number of stations is 121 covering 70% of the 172 districts that existed when the HSMTDP was developed and targets were set. 2.2 Health Objective 2: Strengthen governance and improve efficiency and effectiveness of the health system Improving efficiency and accountability In 2012, the ministry introduced performance contracts with four agencies; the three Teaching hospitals and Ghana Health Service. The ministry will sign performance contracts for 2013 with all its agencies Financing (based on MOH financial report 2012) In 2012, Government of Ghana contribution increased by 126.9% from GH 771 million in 2011 to GH 1,750 million in Internally Generated Fund (IGF) increased by 8.9% from GH 392 million in 2011 to GH 427 million in Contribution from donors in 2012 was GH million whilst there was GH million contribution in the same period of the previous year, an increase of 12.2% over the same period of In terms of percentage contributions by the various sources to the sector, GOG and IGF contributed 87.5% as compared with 78.6% in the same period of Donor contribution was 11.7% of Gross Revenue as against 17.5% of the previous year. 22

23 Total Gross Revenue, recorded by the Ministry was GH 2,489.8 million, the sources of which have been broken down in Table 4 and Figure 8. Source of Funds 2012 (as at December 2012) 2011 (December) Amount (GHC Mn) US Dollar (Mn) Percent Amount (GHC Mn) Percent GOG 1, % % IGF % % Program - Donor % % Budget Support % % NHIA % % F/Credits % % TOTAL 2, , % 1, % Table 4: Gross revenue distribution by source, source MOH Financial Report 2012 Figure 8: Percent gross revenue distribution by source, source MOH Financial Report 2012 The Ministry recorded a total expenditure of GH 2,613.4 million for the period under review (Table 5). Out of this amount, 63.4% was for Employee Compensation as against 53.9% for the same period of

24 Expenditure incurred on Goods and Services was 34.5% as compared to 38.0% in 2011 whilst that incurred on Assets was 2.2% compared to 8.1% in 2011 for the same period. For the Year Ended 31st December, 2012 (GH 'million) GOG IGF B/SPT MOH PROG NHIA F/CRED TOTAL Percent Employee Compensations 1, , % Goods and Services % Assets % TOTAL 1, , % Table 5: Expenditure distribution by item, source MOH Financial Report 2012 Figure 9 below shows comparative pattern of expenditure between 2011 and 2012 in absolute terms. Employee Compensation increased significantly from GH 754.7million in 2011 to GH 1,655.7millon as a result of the movement from the Health Sector Salary Scale (HSS) to the Single Spine Salary Pay Policy (SSSPP). Figure 9: Comparative Expenditure Distribution 2011 and 2012, source MOH Financial Report 2012 At the end of 31st December 2012, total cash balances were GH million as against GH at the end of 31st December These amounts represent balances standing in the books of the various health facilities nationwide and MOH/GHS Headquarters. Debtors have decreased from GH in December 2011 to GH 115.9m in December 2012, a decrease of 15.8%. A large proportion of the debts are IGF related, emanating from non-payment of service bills by the NHIA. Most of the debts are owed to the District Hospitals; institutions which are no more benefiting from GOG and Sector Budget Support/Health Fund but are now depending solely on IGF for the operation of the Goods and Services budgets. 24

25 2.2.3 National Health Insurance Active membership of the scheme stood at 34% short of the target of 45% (Figure 10). The indigent definition was revised and the common targeting developed. With these revisions, some categories of persons with disability and mental health patients were covered under the exemption policy. The Common targeting mechanism is being piloted in 90 districts. Fifty three thousand two hundred and seventeen out of 200,000 LEAP beneficiaries were covered. The National Health insurance authority accessed only 48% of all receivable funds during 2012 and this had implication for timely reimbursement to providers. An analysis by the NHIA showed that the scheme cannot be sustained at the current level of operation. A policy paper including sustainability analysis was submitted to the government for consideration. To strengthen premium collection scheme level, a consolidated premium account was established. About 46% of earmark funds for the ministry of health was released whiles 94% of expected funds was released to members of parliament. Until recently, returns from investment formed a substantial part of the total funds of the scheme. However due to recent financial difficulties, the authority had not been able to invest and have had to plough back its savings to keep the scheme afloat. To reverse this trend, the authority developed an investment policy and guidelines to provide guidance to the authority. The authority realised 6.5% real rate of returns on investment exceeding its target of 4%. Its investment income for the year was GHc27.67m as against a target of GHc18m. The NHIA intensified clinical audit of the district schemes and providers. During the year, 157 providers were audited and 128 schemes visited. An amount of GHc20.1 was recommended for recovery for the period with GHc7.5m recovered in A uniform prescription form was piloted in the Greater Accra Region and systems for linking treatment to diagnosis were developed. These were meant to increase technical efficiency. The authority also hoped to improve efficiency by diversifying provider payment mechanism. As a result Capitation was piloted in the Ashanti region for which a mid-term evaluation was conducted. 25

26 Figure 10: NHIS coverage (active members), , source NHIA 2.3 Health Objective 3: Improve access to quality maternal, neonatal, child and adolescent health and nutrition services Maternal health The total fertility rate has worsened from 4.0 to 4.3 since the previous survey compared to target of 3.8. Meanwhile the contraceptive prevalence rate for the same period has improved significantly, increasing to 23.4% from 16.6% in Unmet need for family planning reduced from 34.0% in 2003 to 26.4% in the 2011 MICS. These factors indicate that access to family planning is improving and raise concern that the increase in fertility may be a statistical variation that is not a true reflection of performance, and there might be the need to investigate this further. The consistently increased use of modern family planning methods and reduced unmet need for family planning presented in the surveys is consistent with routine figures from the public sector. While long-term CYP saw minimal increase from 2011 to 2012, short-term CYP increased markedly, and total CYP increased to 1,922,290 years in Analysis by GHS shows that an increasing proportion of family planning clients are accessing the services from the private sector including pharmacy shops, since this is more convenient for the clients. The non-collection of data from some private facilities, chemical sellers and pharmacy shops can lead to underestimation of routine Family Planning utilisation figures. Some of the long-term methods can only be administered by midwives and doctors. Since both midwives and doctors are likely to be occupied with other activities, these methods cannot be administered to meet the demand. The ministry is currently considering the possibility of shifting the task of administering these long-term family planning methods to other health personnel. Moreover, the calculation and understanding of CYP at the service delivery and data collection points also need to be investigated. 26

27 The proportion of pregnant women attending four or more antenatal care visits increased slightly to 72.3%. For the 2011 MICS report, the corresponding figure was 86.6%. The definition of this indicator presents challenges for some of the Regions with their figures being consistently above 100%. In the previous review the figures from Ashanti, Brong-Ahafo Volta and Greater Accra were omitted from the Analysis because of these errors. It is only in 2012 that all the regions have been able to get reasonable coverage for this indicator. This shows an improvement in the data quality. Figure 11: Antenatal care registrant and 4+ visits , source GHS Over the past 3 years, supervised delivery coverage has increased by 28.2%, and over the past 5 years by 66.5%. Coverage of supervised deliveries in 2012 was 58.5%, based on the estimated expected delivery of 4% of the population and 77.9% based on 3% estimate. The 58.5% represents a relative increase of 6.7% over The MICS gave the country a skilled attendant at delivery coverage of 68.4%. With improvement in the data collection on skilled attendant delivery, the routine data will be aligning reasonably well to the survey data from MICS and DHS. The good performance may be attributed to improved financial access from the free maternal health care policy, and improvement in the data collection Infant and Child Health The national Infant Mortality Rate (IMR) increased by 6% over the DHS 2008 figure from 50 to 53. This national average does show some large regional variations. IMR is highest in Volta, Upper West, Northern and Brong-Ahafo Regions. The reported trend in Volta and Brong-Ahafo Regions is worrying with significant worsening of IMR. Since 2003, Upper West Region has made an impressive effort to bring IMR down from 105 to 67. AR WR NR BAR CR VR UER UWR ER GAR Ghana DHS MICS DHS MICS Table 6: Infant mortality rate , source DHS (2003 and 2008) and MICS (2006 and 2012) The under-five mortality rate remained stagnant since Despite stagnation of national average of under-five mortality rate, significant regional variations occurred. Northern Region and Upper West Region 27

28 have since 2003 had relatively high U5MR. While Upper West Region was able to bring down under-five mortality rate by 50%, Northern Region achieved only limited improvement (Figure 12). Figure 12: Under 5 mortality by region , source DHS (2003 and 2008) and MICS (2006 and 2012) With the scale-up of CHPS, increased utilisation of ITNs, high EPI coverage and improving coverage of skilled deliveries since 2008, the ministry did expect to see an improvement of both IMR and U5MR. The ministry plans to analyse the underlying data thoroughly to identify reasons for the observed stagnation in child mortality indicators Nutrition The proportion of children below the age of six months that are exclusively breastfed has significantly dropped since 2008, and the current performance at 45.7% is below 2003 levels and far below the target of 70%. At district level, health activities to promote good nutrition, including exclusive breastfeeding, have received decreasing attention over the past years. Because of limited financial and human resources and since these activities are less integrated into the routine district level activities than for example EPI, the tendency has reportedly been to give preference to other activities. Moreover, the Ghana Health Service head quarter s monitoring and support to regions and districts in the area of nutrition has reduced. Factors external to the health sector are also likely to have influenced the trend, e.g. increased number of women engaged in the workforce and behavioural changes as a consequence of economic growth and attainment of middle-income country status. The under-five prevalence of low weight for age has reduced slightly to 13.4%. The slow reduction in the under-five prevalence of low weight for age is a reflection of the low performance of the sector in nutrition in general. The target of 8.0% is far from being achieved. The coverage of nutrition interventions in the country is not high. Most of the interventions like community management of acute malnutrition and community growth promotion cover only few districts and regions. The ministry is concerned about these trends and will work with its agencies to strengthen nutrition activities and promote exclusive 28

29 breastfeeding. There will be the need to fully integrate nutritional interventions into the activities of all the districts in Ghana. Health Objective 4: Intensify prevention and control of communicable and noncommunicable diseases and promote a health lifestyle Malaria and ITNs According to the MICS 2011, use of ITNs has improved by almost 50% since 2008 and the proportion of children under five sleeping under ITN the previous night reached 41.5%. Only Volta and Eastern Regions had completed their universal coverage campaigns prior to MICS 2011 data collection; seven other regions carried out campaigns during or after the data collection. With the completion of the hang-up campaigns for the whole country, 7,645,745 LLINs have been distributed and household ownership of ITNs stands at above 95%. The post hang-up campaign undertaken by the School of Public Health found that 69.2% individuals in the sampled households slept under ITN the previous night before the survey. The national prevalence of malaria parasitaemia in children aged 6-59 months based on microscopy was 27.5% with the highest prevalence in Upper West Region (51.2%) and Northern Region (48.3%). Lowest prevalence was recorded in Greater Accra Region (4.1%). Despite no clear evidence of causality, it is possible to attribute the high under-five mortality rate in Upper West Region and Northern Region to high prevalence of parasitaemia. There will be the need to intensify malaria control activities in these two regions to address their high under-five mortality rate. The MICS survey showed that only 15.9% of children under five with fever malaria test done to confirm diagnosis. Treatment for malaria is often based on clinical diagnosis. The Ministry is concerned about the access to and quality of diagnostic services related to malaria. While the national number of expected malaria cases among children has not dropped significantly, case-fatality of malaria for children under five years has improved, dropping from 1.2 in 2011 to 0.6 in 2012 deaths per 100 confirmed malaria cases Expanded Programme on Immunisation(EPI) Since 2007, EPI coverage has steadily been close to 90% with only slight variations. In 2012 coverage of Penta 3 was 87.8%. The MICS gave the corresponding survey based coverage of 92.1%. The high coverage is a demonstration of the strength of the EPI programme. The effect of low and erratic flow of funds to the district level appears not to have had much impact on delivering of immunization service. A lot more effort and input however will be needed to move the coverage the last few percentage point up and beyond 90%. Sustainability of the gains made in EPI and any improvement thereof will depend in improvement in CHPS implementation. The routine Penta 3 coverage in Upper West Region has been going down over the years but the MICS gave a coverage of 97.4%, so possibly the observed reduction might be due to data management challenges. The same situation pertains in Greater Accra Region with a low routine coverage for Penta 3 but relatively high MICS coverage. There is the need to improve data collection especially from the private facilities in the major metropolitan areas like Accra and Kumasi. 29

30 Figure 13: Penta 3 coverage by region , source GHS HIV/AIDS The number of HIV Clients receiving ARV therapy continues to increase. This increase is encouraging, however with the uncertainty surrounding the continuous supply of ARVs there are concerns about the interruption of treatment of clients. This development if not addressed promptly can result in development of resistance of the HIV virus to the drugs that are currently being used by the programme. There is an urgent need with the lost of the Global Fund funding to look at how the country is going to ensure continuous supply of ARVs for the increasing number of clients Water and sanitation Transmission of guinea worm has been interrupted and there has not been a single case in Ghana since May The country continues to maintain surveillance for guinea worm. 875 rumours of cases were investigated within 24 hours and Stop Guinea Worm Teams have been deployed in 16 previously endemic districts in Brong-Ahafo, Northern and Volta Regions. WHO has requested that the surveillance system be improved to ensure the country is certified as guinea worm free. Coverage of sanitary facilities that are not shared increased to 15% of the population but access to improved sources of drinking water worsened since 2008 and came slightly under the set target of 80%. While the proportion of the population with access to improved sanitary facilities that are not shared increased, the access to all improved sanitary facilities, shared and not shared, reduced. To improve upon these indicators, there is the need for inter-ministerial collaboration Tuberculosis TB treatment success rate continues to improve although at 86.2% the target of 89% was not achieved. The adverse outcomes reduced from 16.7% to 13.8%. The fieldwork to determine the national prevalence of tuberculosis was started. 30

31 2.5 Health Objective 5: Strengthen institutional care including mental health service delivery Mental health The total number of mental health nurses in the three psychiatric institutions was 1,068. This comprises both community psychiatric nurses and registered mental nurses. Total number of patients seen during the year was 67,732. The expected number of persons living with mental disorders is however expected to be significantly higher; international estimations indicate that 10% of the population lives with mental disorder, which amount to 2.59 million persons in Ghana. No formal training exists for training community psychiatric nurses. The current crop of community psychiatric nurses amount to 400 who are registered nurses converted to practice as community psychiatric nurses Institutional child and under-five mortality Institutional IMR improved significantly in 2012 with more than 50% reduction. There are, however, issues with the data quality and accuracy of this indicator, especially with regards to the capture of all deaths occurring in children under one year in the health facilities. The consistently high immunization rate and the drop in vaccine preventable diseases like measles may have contributed to the low Institutional infant mortality that was observed. The country has not recorded any deaths due to measles since Institutional under five mortality also improved significantly in 2012 with more than 50% reduction overall. All the districts experienced reduction with Upper West having a reduction of 91%. Despite concerns about data quality, the observed drop in the institutional under-five mortality rate might be a reflection of improvement in access to care. Health Insurance and community management of malaria, diarrhoea and acute respiratory infection are the main interventions that have improved access to care in the districts and communities. These interventions address the major causes of deaths in children under five years. The community interventions for these three diseases are being implemented nationwide, but in Upper West, Northern and Upper East Regions almost all the districts are now implementing the community based treatment programme. The improvement can also be attributed to an increase in the live births being seen in all the regions. 31

32 Figure 14: Under-five deaths by region Not adjusted for population sizes. Central and Northern Regions excluded because of unreliable data. Institutional maternal mortality Institutional Maternal Mortality (immr) dropped significantly from 211 maternal deaths per 100,000 live births in 2011 to 193 in While immr at Komfo-Anokye Teaching Hospital continued to be high with 1,252 deaths per 100,000 deliveries, Korle-Bu Teaching hospital reduced institutional maternal mortality ratio significantly from 1,133 in 2011 to 841 in During the year, Korle-Bu initiated and strengthened several interventions to improve maternal services, including education of hospital staff and general public on unsafe abortion, renovation of maternity OPD, addressing staff attitude, training in basic life support and establishment of blood bank at maternity lab. These initiatives appear to have had a positive impact on maternal mortality in the hospital. During 2012, Komfo-Anokye Teaching Hospital established a blood bank at the maternity area and all maternal deaths were audited. Despite these initiatives to improve maternal services, the hospital continued to have a high maternal mortality ratio and on average, every second day a pregnant woman died at KATH. The top-causes of maternal death at KATH were conditions related to high blood pressure, i.e. eclampsia and pre-eclampsia. Post partum haemorrhage was the second highest cause and abortion was third. The continuous high maternal mortality ratio at the teaching hospitals calls for stronger and more structured collaboration between the teaching hospitals and the referring hospitals and clinics at all levels. Recent investigations by Foods and Drugs Authority have revealed poor quality of the investigated medicines, which are potentially life saving in case of maternal emergencies. Almost 70% of all 279 samples of Oxytocin failed the quality test. Sub-standard medicines are likely to have a negative impact on maternal mortality ratio at all levels of the health care system. It is critical for the sector to analyse and address causes of sub-standard drugs in the health sector. 32

33 3.0 Regions of excellence and regions requiring attention In the review of POW 2011, the review team introduced a simplified holistic assessment based on regional performance of selected indicators to identify the region of excellence and the region requiring attention. The scoring of each indicator follows the rules of the holistic assessment adapted to regional analysis. It is important to note that the regional performance assessment is only indicative since it is based on a limited number of service delivery indicators, which may not reflect the true performance of the individual regions. Region Score Penta 3 ANC 4+ Skilled delivery FP acceptors OPD/capita immr TB treatment Central Upper East Eastern Western Greater Accra Upper West Volta Ahsanti Brong Ahafo Northern Table 7: Holistic assessment of regional performance in 2012 Table 7 shows the result of the regional assessment. In the regional analysis of POW 2011, three regions came out with a score of zero or below. In the current review all regions have a positive score, which indicates a relative improvement over 2011 for these selected service delivery indicators. The two regions doing very well, Central and Upper East Region, had access to extra budgetary funding, which they are obviously using very efficiently compared to Regions like Northern and Upper West Region who although benefiting from similar extra budgetary funding are not performing equally well. The three Regions Volta, Ashanti and Brong-Ahafo do not have any significant extra-budgetary support and depend only on the dwindling GOG funding possibly accounting for their lower than average performance on these specific indicators. From the analysis above it is clear that there exist factors associated with regional performance besides resource inputs. It will be of interest to the sector to examine how the two high performing regions manage to achieve the observed results. Despite the positive overall score of Northern Region, four of the seven indicators had a neutral or negative trend. Worryingly, the deteriorating trend of immr and FP acceptors is a continuation of the previous years trend, and stagnation of ANC 4+ in Northern Region also continued the trend from last year. This is despite considerable extra-budgetary support received by the Region. The analysis suggests that Northern Region may require special attention in 2013, and the review team recommends technical support to this region in order to identify the causes of the worsening performance. 33

34 4.0 Implementation status of the POW 2012 The HSMTDP ( ) has five objectives and under each objective key priorities and activities were outlined. The extent to which these activities are carried out determines the performance of the health sector. Clearly there were difficulties in implementing some of these activities. Reasons for nonperformance in some instances range from non-availability of funds to lack of a clear framework for implementing such planned activities. Some planned activities also depended on the extent to which external agents responded to requests for support on time. A robust system for sector wide planning and implementation of plans is critical for a coordinated response, good performance and impact on health outcomes. The review of POW 2012 raises concern about non-adherence by several agencies to the sector s annual programme of work. Moreover, the review suggests that the current capacity and framework within the sector to monitor and evaluate agencies performance is inadequate and must be strengthened. 4.1 Health Objective 1: Bridging Equity Gaps in Access to Health Care and Nutrition Services, and Ensure Sustainable Financing Arrangement that Protect the Poor Strengthen district health system with a particular emphasis on primary health care The objective of the Ministry of Health is to improve coverage of PHC services at sub-district level through strengthening community health systems. The Ministry planned to do this by expanding CHPS coverage to achieve 500 new functional zones during the year. Although the target was exceeded some challenges remain. Key among the challenges is the difficulty in deploying close to 9,000 CHOs into the zones or communities. Some CHOs are based in the hospitals and health centres and this defeats the objective of providing community based basic health services to deprived communities. The CHPS operational policy prescribes a package of equipment and logistics to aid the CHO in executing his/her mandate as required. Due to inadequate funding, districts are unable to provide the basic package to facilitate the deployment of the CHOs. This is one of the reasons why despite the increase availability of CHOs some have still not been deployed to CHPS zones. Weak consultative processes and poor supervision undertaken by the district and sub-district teams have also contributed to the poor performance of the CHPS programme. Weak consultative process results in poor community ownership and local government support for CHPS Develop sustainable financing strategies that protect the poor and vulnerable Under the Ministry s leadership and guidance, four main activities were to be undertaken. These include: Develop a comprehensive Health Care Financing Strategy Update National Health Accounts and initiate institutionalisation Pilot capitation payment in Ashanti Region Pilot project on identification of the poor using the common targeting instrument 34

35 The development of the health care financing strategy could not be carried out. This activity has not been carried out for the second year running and effort should be made to find out what the challenges are. This activity needs to be implemented to ensure the Ministry makes certain key decisions from an informed position. It is not clear what has been achieved under the plan to identify the poor using the common targeting instrument. This is a cross cutting assignment which involves several ministries including the Ministry of Health, which is being represented by the NHIA. There is the need to contact the repackaged Ministry of gender, women and social protection to reinvigorate the process. The NHIA however is piloting a common targeting mechanism in some 10 districts against the anticipated 30 districts. The capitation pilot was undertaken in Ashanti Region. It has been evaluated and disseminated. There is the need for more consensus building for decision to be made in scaling up Increase availability and efficiency of human resource Key activities under human resource have been running for the past four years without any clear and definite timelines for the process. The absence of staffing norms, deployment plans and a final HRH policy is affecting the management of human resource in the sector resulting in inequity in the distribution of critical staff in terms of numbers and mix. 4.2 Health objective 2: Improve governance of the health system Develop capacity to enhance the performance of the National Health system Though the leadership development programme training is progressing as planned, an assessment of the relevance of the programme in enhancing performance of district and sub-district teams is necessary. Currently there is no evidence to show any difference in performance with regards to core functions between the districts who have undergone the training and those who have not been trained. The technical assistance provided to support Monitoring and Evaluation and Budget has been beneficial. The M&E framework that was developed came late after the health sector medium term development plan was developed. It is recommended that it should further be adapted and aligned to the new HSMTDP under development. Although a performance contract was signed with the Ghana Health Service and the three teaching hospitals, contract management in terms of supervision, reporting and evaluation was not adequate. The agencies were expected to report regularly on progress but this was not done neither was there a proper appraisal of work done. The performance of the Ministry with regards to its obligations under the performance agreement was not monitored. To make this exercise meaningful, both the Ministry and its agencies should have their performance under the agreement assessed using mutually agreed indicators that can easily be objectively assessed. Under the agenda of enforcing adherence to sound PFM practices, all agencies of the ministry are to be made familiar with composite budgeting and programme based budgeting. The health directorates in most cases did not participate in the composite budget and planning that took place at the district, metropolitan 35

36 and municipal assembly levels because the health sector has still not been fully devolved. Secondly there were no clear guidelines on how the district health directorates were to participate in the development of the composite plans and budgets. In most districts they were not invited to participate in the exercise. With regards to implementation of programme budgeting, budgets have already been categorised based on programmes and there is the need to provide guidance to BMCs on how to access funds based on the programs Strengthen the regulatory framework Although a lot of bills have been passed into law, efforts aimed at operationalising the law through legal instruments seem slow. The Ministry of Health should lead the process of ensuring that the appropriate stakeholders are brought together to facilitate the development of the various legal instruments on time Strengthen inter-sectoral collaboration and public-private partnership A framework (cross-sectoral planning group on health) exists at the national level and is led by the National Development Planning Commission (NDPC). Similarly, structures exist at the regional and district levels for cross-sectoral activities. The challenge is that of participation. Most district directors of health services do not participate in District Assembly activities neither do the assemblies take responsibility nor initiate a process to get cross-sectoral activities on health going. The process of devolving the health sector to the district assemblies is gathering momentum. This will address some of these challenges. The private sector policy provides for cross-sectoral activities in the mobilsation of resources for health and health care. The delay in printing and disseminating the policy does not augur well for the development and promotion of private sector participation in health. There is an increased interest of the private sector to engage the public sector in improving access and quality of health care, lack of clear guidelines for these engagements is affecting progress in this area Strengthen systems for improving the evidence base for policy and operations research The plan to introduce a structured in-service training for the senior personnel of the MOH and Agencies in evidence-based policy making and programme monitoring has been on the drawing board for the second year running. It looks like the implementation of this priority activity has challenges. A re-evaluation of the need for this activity should be carried out and resources allocated to ensure that the necessary arrangements are made to bring the plan to fruition if it is still deemed necessary. 4.3 Health objective 3: Improve access to quality maternal, neonatal, child and adolescent services Reduce the major causes contributing to maternal and neonatal deaths The implementation of the MAF action plan has delayed. Delay in release of funds has been blamed for the slow process in implementing the MAF. The content and processes of MAF are not new. Indeed part of the MAF plan is being implemented at all levels. Whiles waiting for disbursement of the MAF money, the Ministry of Health should provide guidance and supervision to ensure there is synergy with on-going activities. Meanwhile, efforts aimed at minimising the delays should be made. The target of providing appropriate equipment to at least 25% of hospital blood banks nationwide to make them functional could not be met. However 34 health facilities were provided with cold chain equipment 36

37 such as deep-freezers, chest freezers, plasma freezers and cold boxes for storage and transport of blood and blood products. The basis for determining the 25% target is not clear. There is the need to establish a baseline for coverage to be estimated and efforts will be made in that direction. The emergency obstetric care equipment meant for the three remaining regions (Upper West, Greater Accra and Volta Regions) has not been delivered according information provided during the review process. It is not clear what the reasons are but subsequently it will be convenient for the M&E unit of the Ghana Health Service to monitor such important arrangements and report same at their management meetings for follow-up action to be taken by appropriate officers Reduce the major causes contributing to child morbidity and deaths. The pneumococcal, meningococcal and rotavirus vaccines including second dose of measles vaccines were successfully introduced. The recent study of Access, Bottlenecks, Cost and Equity (ABCE) shows a high capacity to treat Malaria at CHPS level but less than 25% of CHPS providers have the capacity to test for Malaria by Rapid Diagnostic Testing. Moreover, the implementation of the planned community case management of malaria, diarrhoea and acute respiratory disease is facing challenges. Community health workers face difficulties in recouping funds for the drugs they dispensed at the community level. This is because they are not recognized by the NHIS and thus are not reimbursed even when they treat insured clients in the communities. It is important to support community level initiatives to reduce child morbidity and mortality with adequate financial support. Discussions on how insured clients can benefit from close to client services like this should be pursued. Community interventions have the potential to reduce costs to NHIS due to the prompt treatment that prevents disease conditions from worsening to a state where children will need to be admitted Improve the health of adolescents and youth It was planned to implement standards for adolescent and youth friendly health services in Ghana. The adolescent health strategic plan and policy was disseminated to all stakeholders during the year Improve nutritional status of women and children It was planned to disseminate and implement the National Nutrition Policy. Although action was started on this, it could however not be completed. The Nutrition policy and strategy has been finalised. The Ministry of Health is working with the NDPC to prepare the document for submission to cabinet for approval. Most of the Scale Up Nutrition (SUN) activities are in the form of advocacy. There were interactions with media and a communication plan was also drawn. Nutrition, Malaria and Child Survival Program to improve the nutritional status of children using community based approaches is being implemented in districts in Upper West, Upper East, Volta and Central Region. Evaluation of the programme is being conducted. 4.4 Health objective 4: Intensify prevention and control of communicable and non-communicable diseases and promote healthy lifestyles Improve upon prevention, detection and case management of communicable diseases The implementation of strategic plans for HIV/AIDS, malaria and tuberculosis started during the year. However the range of years the plans cover should be clear and arrangements should be made to align and integrate all these plans into the new Health Sector Medium Term Plan (HSMTDP). 37

38 4.4.1 Improve upon prevention, detection and case management of non-communicable diseases In the 2012 POW, the Ministry was expected to facilitate or advocate for incorporation of healthy lifestyles into basic school and teacher training curricula and support the alcohol/substance abuse facility at Pantang. While healthy lifestyles were incorporated into the curricula, the ministry was not able to support the alcohol/substance abuse facility at Pantang. The scaling up of the detection and management of non-communicable diseases through the implementation of the national strategy for cancer control and expansion of screening program for hypertension, diabetes and sickle cell were also not done. Though the guidelines for the cancer programme have been developed they are yet to be printed. Screening is going on in the regions for hypertension, diabetes and sickle cell, but such routine screening is unstructured. The 2012 Programme of Work requires that screening centres for NCD be set up. This objective has not been achieved Implement national strategic plan to increase TB case detection and cure rate It was planned to increase the TB case detection and cure rate during the year. To achieve this, regional and district teams were trained on identifying cases among vulnerable groups. Capacity of laboratory staff was built in doing sputum microscopy. To improve outcome of treatment, Nutritional assessment, counselling, and food were provided for TB and HIV clients Implement national strategic plan to reduce malaria case fatality among pregnant women and children To reduce malaria case fatality for the vulnerable groups, ACTs for treatment were procured and distributed through the AMFm programme. LLINs Hang Up campaign was organized in all the regions. Indoor residual spraying was carried out in Ashanti and Northern Regions with some limited larviciding in Accra. Public education on malaria prevention was also continued Prevention, detection and management of diseases of epidemic potential and those targeted for eradication The plan for the year was to maintain the polio free status of the country and validate eradication of guinea worm and polio. To achieve this, surveillance activities including case searches were intensified; Public education was continued with monetary reward being advertised for anyone reporting a case of Guinea Worm. As at December 2012, no case of Polio or confirmed Guinea Worm was seen Increase coverage of community activities for Neglected Tropical Diseases (NTDs) especially onchocerciasis, lymphatic filariasis, trachoma, yaws and leprosy. The plan for the year was to increased case detection for NTDs. To achieve this, the Ministry finalized the NTD Master Plan for Ghana for the period 2011 to 2015 in collaboration with WHO. The plan was shared with the relevant stakeholders. Mass drug administration was conducted for Onchocerciasis, schistosomiasis and Lymphatic Filariasis in communities and schools. An Intra-Country Coordinating Committee (ICCC) for the NTD program was constituted and two meetings were held. Although some activities aimed at reducing the prevalence of yaws by 50% were performed, poor contact tracing and treatment still remain a major challenge for the yaws control programme Improve prevention, detection and management of non communicable diseases The plan for the year was to Implement the national strategy for cancer control and expand screening program for hypertension, diabetes and sickle cell in all regional hospitals. The cancer control strategic 38

39 plan was finalized and submitted to PPME (GHS) for printing and dissemination. Screening for the noncommunicable diseases is on-going. 4.5 Health objective 5: Strengthen institutional care, including mental health service delivery Enforce standards, guidelines and protocols to improve the quality of institutional care Under this priority the Ministry is to ensure the availability of equipment and infrastructure required for adherence to standards, guidelines and protocols. Most infrastructure projects, with the exception of the construction of the 5 polyclinics in the Upper West Region, are at various stages of completion. Most are encountering various degrees of financial challenges, which need to be resolved for the construction to be completed. Reporting on some of the projects is not comprehensive enough. The ministry needs to set up a reporting framework that clearly spells out information needed. This is to ensure consistency in reporting by various agencies Strengthen the system capacity for emergency response The Ambulance service exceeded its target of establishing 80 district functional ambulance stations by establishing 97 new stations Ensure commodity security of health technologies for medical products including traditional medicines Though a 5-year master plan for Supply Chain Management was completed there are disagreements from some sections regarding centralisation of procurement at the national level. Preparations are however going to operationalise the master plan with the appointment of a head for the new supply chain management Unit Increase access to mental health services Refer to above. 5.0 Agencies assessments and performance contracts 5.1 CENTRE FOR SCIENTIFIC RESEARCH INTO PLANT MEDICINE The Centre for Scientific Research into plant medicine was set up to conduct and promote scientific research relating to the improvement of plant medicine. As part of its mandate, it is to ensure the purity of drugs extracted from plants and collate, publish and disseminate the results of its research and other useful technical information. Total staff at post at the centre is 192 comprising a medical doctor, two (2) medical herbalists, three (3)l nurses, 13 medical herbalist interns and twenty three (23) research officers. It also has forty five (45) senior staff and One hundred and four junior staff. PLANNED ACTIVITIES FOR 2012: The centre planned to undertake among others the following activities in

40 Develop at least one herbal medicine for the ff. diseases conditions: malaria, diabetes, hypertension, HIV/AIDS: The centre screened and selected 4plants each for diabetes, hypertension and malaria respectively and 2 plants for prostate cancer. Preliminary analysis on 4 anti hypertensive plant extracts showed promise in decreasing blood pressure over a four week period in laboratory rats. Safety and efficacy evaluations of three out of four herbal products which not dose dependent showed considerable reduction in parasitemia. Disseminate research findings (4 research papers and 6 technical reports) on quality, efficacy and safety of herbal medicines; Two (2) papers were published Improve and expand access to herbal medicines Intensify program for the conservation & cultivation of medicinal plants Provide technical support services to herbal medicine manufacturers and Traditional Medicine Practitioners (TMPs) Collaborate with pharmaceutical industry in the manufacture of herbal medicines Collaborate with TMPs In the development of their products (aimed at building confidence between researchers & TMPs 5.2 ALLIED HEALTH PROFESSION The allied profession task force was set up as a stopgap to provide some regulatory functions whilst preparatory work in setting up a regulatory body to regulate the professional activities of the allied health professions are completed. Its mandate includes collaborating with relevant agencies to standardize training of allied health professionals in the country. It also works with other relevant organizations to provide accreditation to qualified training institutions providing allied health programmes. It regulates practice standards of professionals. Planned activities include among others the development of guidelines for accrediting training institutions and programs in collaboration with the National Accreditation Board. It also planned to initiate and institutionalise Continuous Professional Development activities, which will be a pre-requisite for renewal of professional license when registered. Data collection on existing training institutions and evaluation of e training programs including curricula, facilities and Faculty Members were major plans for the year. ACHIEVEMENTS A total of 34 applications were received from training institutions for accreditation. Twenty applications were reviewed and nine institutions were inspected. The board of the taskforce will meet to consider and grant accreditation to deserving institutions. A start up kit for training institutions was developed for new schools during the year. A workshop on curricula for allied health programs in the West African sub-region was held. Application of the curricula will start after it has been adopted by ECOWAS Ministers of Health.. The allied health professions Bill was passed by parliament and is awaiting presidential accent. 5.3 FOOD AND DRUGS AUTHORITY PLANNED ACTIVITIES The following activities were planned for 2012: Accreditation as per ISO requirement Public education on food and medicine safety issues Training of industry in Good Manufacturing Practices (GMP) and Food Safety Management Systems 40

41 Organization of training program on the regulation of controlled substances for the relevant importers Industrial Support for Street food vendors, Ghana School Feeding Program and local industries ACHIEVEMENTS One hundred and ten (110) food manufacturing industries were trained in Food Safety Management Systems and Street Food Vendors in 30 Food Service Establishments were trained in Basic Food Safety and Hygiene practices. Two hundred and ninety nine institutions were trained in drug safety monitoring and pharmaco-vigilance. The 4 th round of the United States Pharmacopeia quality monitoring (USP/FDA PQM) Anti-Malaria project was completed in the third quarter of the year. Three Hundred and Seventy samples of antimalarial preparations on the market were sampled and screened with Minilabs. One Hundred and Sixty-Five (165) of these samples were subjected to full monograph analysis. The observed failure rate of antimalarial preparations was 6.3%. The first phase of testing of Analgesics commonly prescribed during malaria was also carried out samples were analysed of which 22 (19.8%) failed. The first round of Quality Surveillance of Uterotonic preparations namely Oxytocin Injections and Ergometrine Maleate Preparations (Injections and Tablets) was carried out 279 samples were analysed of which 178 (63.7%) failed. The Final Draft of the National Food Safety Policy was completed The Public Health Bill, 2012, (Act 851) (which includes the Tobacco Bill, FDA Bill and Clinical Trials) was passed into law. CHALLENGES Inadequate operational vehicles. Limited border post-activities. High cost of radio programmes and TV advertisements, as well as adverts in the print media for consumer education, Increasing enforcement costs of joint police swoops, destruction of fake, unwholesome and substandard regulated products, press releases, and post market surveillance functions. High cost of reagents and equipment for the lab. OUTLOOK FOR 2013 Post-market surveillance functions will be enhanced to rid the market of fake, substandard and unwholesome regulated products. Dissemination of sections of the Public Health Act 851 which deals with the FDA. Increase the fleet of operational vehicles. Commence construction of Tema Port office complex. Increase presence at the Border Posts. Increase staff strength. Increase Consumer Education 5.4 GHANA COLLEGE OF PHYSICIANS AND SURGEONS The Ghana College was established to promote specialist education in medicine, surgery and related disciplines. It also promotes continuous professional development in medicine, surgery and related disciplines including research. The college in 2012 planned to publish a journal and a newsletter and install ICT infrastructure to aid in the colleges training programme. It also planned to have at least two continuous professional development programmes per faculty. The college has 24 faculties. Other key activities planned for the year include accreditation of training sites and medical knowledge fiesta. The college published one journal and 2 newsletters and organized 20 CPDs out of the expected 24. A knowledge fiesta was also organized for English speaking West Africa to exchange knowledge on current 41

42 happenings in the medical field. An ICT infrastructure sponsored by MTN was installed and commissioned during the year. CHALLENGES The major challenges of the college include; 1. Developing alternate funding arrangements for post graduate medical education. 2. Maintenance of College building 3. Accreditation for training. The colleges hopes to decentralize training sites but this is dependent on the state of the health facilities and the availability of relevant supervisors OUTLOOK FOR 2013 The College will continue with its core functions of producing specialists in medicine, surgery and related disciplines and develop options for funding post graduate specialist training. It will work with the Ministry to attract trainees into deprived specialties. Efforts will be made to develop sub-specialty training opportunities in all faculties and implement ICT based education and learning. The college will also support implementation of WAHO initiative towards harmonization of curricula and accreditation criteria with subregional Colleges. 5.5 GHANA HEALTH SERVICE The Ghana Health Service identified 8 main priority areas for improvement in 2012 under the various health sector objectives. The priorities are as follows: Health Objective 1: 1. Accelerate scaling up of the Community-Based Health Planning and Services (CHPS) under the close-to-client service delivery policy Health Objective 2 2. Support the finalization the staffing norms and implementing the Human Resource for Health (HRH) deployment plan in order to provide more skilled middle level health workers for deprived areas; 3. Increase the strategic use of Information Communication and Technology (ICT) for improved health outcomes, especially as it relates to deployment of DHIMS2 Health Objective 3: 4. Continue implementation of the MDG Acceleration Framework for achieving MDG5, and related emergency services. Health Objective 4: 5. Introduce three new vaccines (pneumococcal conjugate, meningitis group A conjugate and rotavirus) and a second dose of measles into the routine immunization programme; 6. Step up disease control activities, particularly surveillance Health Objective 5: 7. Support implementation of the Mental Health Bill 8. Improve quality of care in GHS facilities. 42

43 ACHIEVEMENTS HO1: Bridging the Equity gaps in access to health care and nutrition services and ensure sustainable financing arrangements that protect the poor The major priority activity under this objective is the scaling up of the Community-based Health Planning and Services (CHPS) as a close-to client policy to increase access to basic health services. The GHS made 551 CHPS zones functional exceeding its target (500) by 51 zones. This achievement was made possible by simplifying the community health community training manual and trainer of training programmes for the regional teams. The table below depicts the regional distribution and status of CHPS in the country CHPS IMPLEMENTATION STATUS BY REGION REGION Number of Demarcated CHPS Zones Functional CHPS Zones at Beginning of 2012 TOTAL No. of Functional CHPS at the End of 2012 ASHANTI BRONG AHAFO CENTRAL EASTERN GAR NORTHERN UPPER EAST UPPER WEST VOLTA WESTERN TOTAL 3,499 (100%) Table 8: CHPS implementation by Region 1675 (48%) 2226 (64%) One of the major challenges of the Ghana Health Service is the availability, distribution and appropriate mix of relevant health staff at the health facilities. Out of a total of 149 hospitals (including CHAG facilities), 84 (56.4%) of hospitals have between 1 and 3 doctors with 25 (16.8%) without a doctor. This may have implication for availability and quality of service. Objective: HO2: Strengthen governance & improve efficiency & effectiveness Leadership and Management capacity development and strengthening HMIS using ICT to improve effectiveness & efficiency in service delivery were the two key priorities under this objective. The GHS introduced the leadership and management capacity development as a capacity building effort in the Central region in Since then 161 health personnel have been trained. This comprises Greater Accra (35), Western (35),Volta( 41), Upper east (60) Upper West (44) and Northern(46) have been trained. A total of 150 personnel were trained in

44 As part of efforts to consolidate the achievements made, the GHS undertook training on DHIMS 2 in all the regions and held two high level meetings to address technical problems arising out of the implementation of the DHIMS 2. The GHS is also workinh with the NHIS on the Health Improvement Project to develop and deploy hospital software to improve data capture and claims. management. Other activities carried out during the year include: Scaling up a community health information system- the community e-register Evaluation EWS and development of plan for rolling out nationwide Expansion of mobile midwife pilot to provide health information for pregnant women and improve data collection, Piloting of Rapid Malaria Diagnostic Reader in some Districts in GAR. HO 3: Improve access to quality maternal, neonatal, child and adolescent health services Key priority activities under this objective include the following; 5. Implement the MAF country Action plan for improved maternal and neonatal care 6. Develop and implement National Nutrition Policy and strategy 7. Scaling up child and Adolescent Health 8. Advocacy and Capacity building for providing family planning and safe motherhood Under the MAF, a national assessment report were completed and incorporated into the MAF action plan. The regional MAF work and procurement plans have also been completed. The draft Nutrition policy was completed. A stakeholder meeting is planned for the first quarter of 2013 to collate views on the draft policy for finalisation and submission to cabinet for approval. The Adolescent Health policies and strategies were disseminated through several fora in collaboration with the paediatric society of Ghana. Training of trainers Workshops were held on Contraceptive Updates and Counseling, JADELLE and IMPLANON insertion training for Ten Regions. Regional training and orientation for the new maternal death audit guidelines were also held for three regions GAR CR WR HO4: Intensify prevention and control of communicable & non-communicable diseases and promote healthy lifestyles The GHS planned to introduce three new vaccines (pneumococcal conjugate, meningitis group A conjugate and rotavirus) and a second dose of measles into the routine immunization program and step up disease control activities, particularly surveillance. Two new New Vaccines Rotarix & Penvar and measles 2 nd dose at 18 months were introduced. All Districts (170) were also trained In Community Management Of Malaria (CMM)and & some districts commenced implementation of CMM. As part of effort to improve prevention and control of communicable diseases, the GHS planned to procure and distribute ICT equipment to support district level surveillance activities. Districts in three regions (UWR, BAR and CR) were supplied with ICT equipment. 44

45 Under a programme to prevent, detect and manage of HIV/AIDS, TB & Malaria, 7,645,745 LLINs were distributed under the hang up campaign using volunteers. Household ownership of at least one ITN has improved to 96.7% of total population. The national HIV/AIDS strategic plan was implemented in all the regions. The Kick TB Ghana Project, an advocacy communication and social mobilization project was launched and TB Treatment success rate improved from 83.35% to 86.2% During the year under review, no case of Guinea Worm or wild poliovirus was reported. STOP GW teams were deployed to 16 districts in VR, NR and BAR as part of the surveillance efforts and preventive Yellow Fever mass vaccination in 15 districts was organised. Coverage of the population in these districts was 90.4%. SO5: Strengthen institutional care, including mental health service delivery The areas of emphasis under this objective included the improvement in quality of care, improvement of knowledge and skills of health personnel and development of guidelines for improved service provision. The GHS conducted evidence-based summary for selected medicines (Caffeine, Artemether, Amoxicillin, Artesunate, Zinc, Chlorhexidine, Rosiglitazone, insulin analogues) as part of efforts to improve quality of care in the service. It also conducted an Internal Lab Quality Audit Training based on ISO to improve the knowledge base of 15 lab based auditors. The following guidelines, policies and strategies were developed or reviewed; 1. Laboratory accreditation guidelines for clinical labs in hospitals 2. Laboratory Quality Control of Taylor & Taylor Analyzers in selected Laboratories in Greater-Accra Region 3. Antimicrobial policy for Ghana 4. Informed Consent Form 5. Community Mental Health Strategy 6. Guidelines for A and E units developed CHALLENGES The major challenge of the Ghana health Service, which tend to impede service provision and the achievement of set targets was inadequate & unpredictable funding. Out of an approved budget of 17.6 million, 4.5 million representing 25% was disbursed. Inequitable distribution and productivity of staff were also major constraints MITIGATING MEASURES The Ghana Health Service plans to re-prioritize the numerous activities, to ensure that the key ones are implemented. It will also explore non- traditional sources of funding for the Service e.g. responding to calls for proposals from funding entities. The service will as a matter of urgency help to finalize the staffing norms and use it to establish the basis for staff redistribution. OUTLOOK FOR 2013 Priorities for 2012 are still relevant for Strategies for their successful implementation will be reviewed and refined to ensure efficiency. Targets will also be reviewed to reflect existing capacities 45

46 5.6 Komfo-Anokye Teaching Hospital The Komfo-Anokye teaching Hospital in 2012 planned to undertake the following; 9. Continue with policies to widen the range of specialist services and improve quality of care 10. Sustain activities aimed at reducing mortality, (especially maternal mortality), and improving general care outcomes 11. Continue to support Nurses and Doctors to pursue training programme in Emergency Medicine & Nursing 12. Conduct operational research into emerging Diseases 13. Complete Maternity and Children block 14. Set up Blood Bank Unit within the Maternity Area 15. Complete construction of a new eye centre 16. Expansion of Radiotherapy & Nuclear Medicine services 17. Put in measures to improve supply of water and electricity 18. Provide infrastructure for clinical training of students from KNUST 19. Continue efforts in providing support to district and regional hospitals in the northern sector of Ghana, by way of providing outreach services 1. Continue with policies to widen the range of specialist services and improve quality of care The appointment systems in the various Directorates were reviewed and this ahs brought improvement in services provided to clients. Standard protocols for all procedures and emergencies were developed for the Surgery, Child Health and Obstetrics & Gynaecology Directorates. A patient satisfaction survey conducted during the year indicated that 62% of hospital clients were statisfied with the hospital s services. Customer Care Service Training was organised for staff during the period under review to improve services provided to clients. A Magnetic resonance Imaging (MRI) Centre was completed during the year and handed over to the hospital Services at the center commenced. Work on the uncompleted Maternity & Children s Block was reactivated whilst construction of Eye Centre is 95% complete. The hospital renovated and modified an existing building to a guest house. OPD attendance and services provided at the hospital either declined or remained stagnant over the period. With the exception of and emergency services which showed a discernible increase in service provision, OPD attendance declined by about..% and diagnostics also declined by.% 2. Sustain activities aimed at reducing mortality, (especially maternal mortality), and improving general care outcomes As part of efforts aimed at reducing mortality and general health outcomes, the hospital s Quality Assurance (QA) Committee as well as Directorates Quality Assurance Committees were strengthened and a Blood Bank Unit was established at the maternity area. Daily clinical meetings and monthly maternal mortality meetings were held to audit all Maternal Deaths. A total of 152 maternal deaths were recorded with an estimated institutional maternal mortality ratio of 1,255.37/100, LB. All neonatal deaths were also audited with Pre-maturity and Birth Asphyxia being the main causes of neonatal deaths 46

47 2010 N= N= N=165 1 Eclampsia/Pre- 29 Eclampsia /Pre- 41 HPT-Related diseases(eclampsia/pre- 45 Eclampsia Eclampsia Eclampsia) 2 Septicaemia/Septic 12 PPH/APH 17 Haemorrhage (PPH) 26 Abortion 3 Severe Anaemia 10 Septiceamia 5 Abortion Related Deaths 17 4 PPH 6 Malaria in 5 SCD Related 11 Pregnancy 5 HIV Infection 6 Anaemia 4 HIV Related 9 6 Ruptured Ectopic 5 Lobar Pneumonia 4 Hepatic Failure 9 Pregnancy 7 Lobar Pneumonia 3 Ruptured Uterus 4 Malaria in Pregnancy 6 8 Placenta Abruptio 3 HIV Infection 4 Puerperal Sepsis 5 9 Placenta Previa 2 Sickle Cell Crisis 3 Labour Pneumonia 5 10 Ruptured Uterus 2 Placenta Abruptio 2 Meningitis 5 Table 9: Top-ten causes of Maternal Deaths at Komfo-Anokye Teaching Hospital 3. Continue to support Doctors & Nurses to pursue training programme in Emergency Medicine There is an ongoing training programme for staff in Emergency medicine. 5 Doctors and 20 nurses qualified as Emergency Physician and emergency nurses respectively. 4. Continue efforts in providing support to district and regional hospitals in the northern sector of Ghana. The Hospital embarked on several outreach programmes in eye screening and surgeries, ENT, Cleft, Child Health and Infectious Diseases during the period under review. The Hospital visited One Teaching Hospital and Eight Districts. 5. Conduct operational research into emerging Diseases Twenty-five (25) research activities initiated by directorates during the period are on-going. Two (2) research reports were completed and disseminated: Endoscopy findings in patient with upper GIT bleeding at KATH) Prevalence of diabetic nephropathy in patients attending the diabetic clinic at KATH CHALLENGES Late referrals of patients from lower level institutions Congestion, especially at maternal & children s wards (eg. Bed occup. Ranges b/n 120%-156%) Inadequate clinical staff, particularly Nurses Accommodation for House Officers & Residency Drs Delays in the payment of health insurance claims and unrealistic tariff. Old & Non-functional Oxygen Plant Rent Expenditure for House Officers & Residents The hospital will continue to put in measures to improve qaulity of services to the general public. 5.7 KORLE-BU TEACHING HOSPITAL The hospital has a total staff strength of 4419 with clinical staff constituting 72% (3,184) and Non clinical staff 28% (1,235). The composition of the clinical staff is as follows: 47

48 Doctors 597 Consultants (KBTH) 8 Consultants (UGMS) 96 Doctors (Specialist, MO s & HO s) 278 Residents 215 Nurses/HCA 1,899 To improve maternal health outcomes and general clinical outcomes, a number of projects and programmes were initiated. A Blood bank established at the Maternity Block Laboratory and the renovation of the Maternity OPD, 4 th and 6 th Floors which was started at the beginning of the year are 80 to 90% complete. Outreach programmes were held to educate hospital locality staff and general public on dangers of unsafe abortion. The emergency department is being refurbished to improve emergency medicine services. Capacity building in Client/Patient care aimed at addressing Staff attitudes was initiated. About 50% of staff have undergone the training. Training in Basic Life support skills for all staff was also started Achieved 2011 Achieved TOTAL PATIENTS SEEN 412, ,132 OUT PATIENTS 362, ,122 IN PATIENTS 50,189 50,010 DEATHS 3,800 5,069 BED CAPACITY ,912 TOTAL SURGERIES 11,570 19,889 MAJOR 5,003 (43.2 %) 11,419 (57%) MINOR 6,567 8,470 Obstetric and Paediatric indicators Total live births 10,103 10,455 Total Caesarean Sections 4,063 4,040 Total deliveries 10,278 10,503 Caesarian Section rate (%) Maternal deaths Maternal mortality ratio 841 1,138 (per 100,000 live births) Under-5 deaths Under-5 Mortality Ratio (per 1000 live births) Table 10: Clinical indicators for Korle-Bu Teaching Hospital 48

49 2012 Achieved 2011 Achieved Patient days 370, ,912 Crude mortality (%) Occupancy rate (%) Average length of stay 8.3 days 7.8 Bed Turnover rate (%) Discharges 41,023 41,960 Table 11: Service Utilization indicators, Korle-Bu Teaching Hospital Ranking Conditions No. Cases % of Total 1 Pregnancy 11, Diabetes Mellitus 3, Cerebrovascular Accidents 3, Hypertension 2, Congestive Heart Failure 2, Appendicitis 1, Pneumonia 1, Fractures 1, Inguinal Hernia 1, Intestinal Obstruction Table 12: Top-ten causes of admission, Korle-Bu Teaching Hospital Ranking Conditions No. Of Cases % 1 Cerebrovascular Accidents Congestive Heart Failure Diabetes Hypertension Pneumonias Renal Failure Intestinal Obstruction Anaemias Pregnancy Meningitis 69 4 Table 13: Top-ten causes of death, Korle-Bu Teaching Hospital CHALLENGES High level of indebtedness to our Creditors/ Suppliers and Staff. (GH 4,243,171.31) High proportions of deductions & delay in payment of NHIS claims. High cost of incentives to attract and retain critical staff. High maternal and child mortality. Weak logistical and infrastructural support. Inadequate capacity and funds to support research work. The major challenges of the hospital include unstable power supply, old cabling and wiring. Overcrowded Clinics and Wards and lack of IT supported bed management. 49

50 5.8 Tamale Teaching Hospital The objectives for the hospital in 2012 were; Strengthen and improve governance and efficiency of the TTH s management systems. Provide excellent quality Maternal and Child Health Service. Provide excellent tertiary health care. Attract and retain health staff. Improve and coordinate the TTH s research/m&e activities. To improve governance and efficiency of the TTH s management systems, a clinical governance team was set up and Sub BMC managers were appointed and given orientation. A financial management improvement plan was also developed and operationalized during the year. In an effort to improve general hospital management through informed decision-making, an ICT Firm commissioned to develop a Health Management Information System. The hospital introduced measures aimed at improving maternal and neonatal outcomes. To ease the severe congestion at the wards, improved logistics, new born services (PPP) new delivery equipments were acquired. The programme aimed at attracting and retaining specialised staff and building capacity of existing staff was intensified through the provision of financial and training incentives. Five Doctors are currently in Specialist Training. With the acquisition of improved clinical equipments, new sub specialties are being created. Radiology/Endoscopy/Urology services including new and improved imaging services have been introduced. There is regular availability of oxygen due to completion of new Oxygen Plants. Medical Outreaches services have been enhanced Staffing Trends STAFF CATEGORIES Permanent Staff Casual/Temporary Workforce NYEP TOTAL Table 14: Staffing trends, Tamale Teaching Hospital 5.9 NATIONAL AMBULANCE SERVICE The Service opened 97 new ambulance stations during the year bringing the total number of ambulance stations in the country to 121. This was made possible with the acquisition 161 ambulances earlier. The distribution of the stations is indicated in the table below. Thirty-five emergency medical technician basic (EMTB) were upgraded to emergency medical technician advance (EMTA) during the year. Although the training schools are yet to receive any major refurbishment, the schools is about 30% functional. DISTRIBUTION OF AMBULANCE STATIONS BY REGIONS 2011 New stations 2012 Greater Accra

51 Ashanti Eastern Central Volta Western Brong Ahafo Northern Upper East Upper West TOTAL Table 15: Distribution of ambulance stations by regions CHALLENGES Inadequate Budgetary Allocation and late release of funds hampered the programme and activities of the service. Lack of dedicated training facility leading to delays in training schedules Pass and implement mental health bill Training of MAPs, CMOHs, CPNs Improve the Mental Health Information Systems Establish alcohol and drug rehabilitation centre Formalize community psychiatric nursing training to degree level Strengthen international collaboration with Essex, Hampshire and Kaduna Mental Health Act enacted Training of MAPs, CMOHs on course Epilepsy Initiative started with WHO 8 Physician Assistants in Psychiatry produced at Kintampo College of Health Collaboration with Yale University Global Health Leadership Institute, US, continued Collaboration with South Essex in UK continued 5.10 NHIS Objectives of the scheme at the beginning of the year include: 1. To mobilize 100% of receivable funds by end of To increase efficiency in the financial operations of the scheme 3. To increase active membership to 45% of population by December To increase active membership of the poor and indigent to 50% of their population be December, To provide support to increase access to quality basic health care services in all districts 6. To strengthen governance system and improve human resource capacity 7. To improve the quality of service accessed by members in the NHIS Resource mobilisation The National Health insurance authority was able to access 48% of all receivable funds during the year and this had implication for timely reimbursement to providers. An analysis by the NHIA showed that the scheme cannot be sustained at the current level of operation. A policy paper including sustainability analysis was submitted to the government for consideration. To strengthen premium collection scheme level, a consolidated premium account was established. This initiative raked-in additional GHc28m. Efforts aimed at reviewing the premium upwards to between GHc10 to GHc 50 received some resistance and had 51

52 to be abandoned. The authority however has received some support and is in talks with other development partners for further support. The World Bank is supporting the Health Insurance Project (HIP) whiles DANIDA is supporting the authority with an M&E advisor. Discussions are underway with the USAID and the Royal Netherlands Embassy. Efficient financial operations Until recently, returns from investment formed a substantial part of the total funds of the scheme. However due to recent financial difficulties, the authority had not been able to invest and have had to plough back its savings to keep the scheme afloat. To reverse this trend, the authority developed an investment policy and guidelines to provide guidance to the authority. The authority realised 6.5% real rate of returns on investment exceeding its target of 4%. Its investment income for the year was GHc27.67m as against a target of GHc18m. The NHIA intensified clinical audit of the district schemes and providers. During the year, 157 providers were audited and 128 schemes visited. An amount of GHc20.1 was recommended for recovery for the period with GHc7.5m recovered in A uniform prescription form was piloted in the Greater Accra Region and systems for linking treatment to diagnosis were developed. These were meant to increase technical efficiency. The authority also hoped to improve efficiency by diversifying provider payment mechanism. As a result Capitation was piloted in the Ashanti region for which a mid-term evaluation was conducted. Preliminary findings of the evaluation was presented and discussed with stakeholders. Membership Drive Active membership of the scheme stood at 34% short of the target of 45%. The indigent definition was revised and the common targeting developed. With these revisions some categories of persons with disability and mental health patients would be covered under the exemption policy for services within the benefits package. The Common targeting mechanism is being piloted in 90 districts. Fifty three thousand two hundred and seventeen out of 200,000 LEAP beneficiaries were covered Support to public health About 46% of earmark funds for the ministry of health was released whiles 94% of expected funds was released to members of parliament. As part of efforts to Implement electronic claims management system 46 providers have been selected for pilot. Challenges INTERNAL Financial sustainability of the scheme Identification of the poor in the informal sector Delays in ID card management chain ICT Challenge Claims Management EXTERNAL Moral hazard Ability to pay premium Renewal challenges Rights and responsibilities of subscribers 52

53 Quality of care challenges Attitude towards subscribers Waiting times Clinical Audit findings Wrong application of Tariffs Irrational Prescription of medicines Inflation of quantities of medicine supplied Unauthorized co-payment Provision of services above accreditation level No record of attendance Overbilling of medicines 5.11 NURSING AND MIDWIFERY COUNCIL The nursing and midwifery Council, which is concerned with practice standards of nurses and midwives established 3 new regional offices and researched into low performance of students in nursing and midwifery. The research, which is aimed at identifying factors affecting performance of trainees and finding solutions to them is yet to be disseminated. During the year, the bill aimed at revising the law governing the operations of the council was passed into law. This will it is hoped will sharpen the mandate of the council and improve on its regulatory activities to ensure improved nursing and midwifery standards. As part of its continuing professional development programme, training workshops were organized during the year to upgrade the knowledge and skills of 210 Nurses and Midwives. Seminars and workshops on test construction and practical assessment for examiners, clinicians, tutors and invigilators were organized for 785 nurses and midwives nationwide. Rules and regulations for the conduct of licensure examination were also reviewed and disseminated to all training schools. Challenges The main challenges of the council include; 1. Inadequate office accommodation at the Head office 2. Inadequate staff: difficulty in securing financial clearance to employ 3. Inadequate conduct of support supervision 5.12 PHARMACY COUNCIL Planned activities for the year were under the following broad headings Education & Training Licensing & Registration Inspections & Monitoring Enforcement Public Education 53

54 A total of 137 interns started 9 attachments to various hospital pharmacies throughout the country whilst 1262 pharmacists were trained as part of its continuing professional education. Similarly, 1500 licensed chemical sellers (LCS) were trained. Pass rate for the year s General Pharmacy Practice Qualifying Exams (GPPQE) was 89% (130/146). Approval was given for the establishment of 246 pharmacies out of a total application of 334. Similarly, the council received 565 for the establishment of chemical shops out of which 421 were processed. A thousand five hundred and forty three (1543) licenses were renewed representing 86.4% of target for the year and 7678 LCs renewed their licenses representing 83.4% of expected. One hundred and twenty six (126) new pharmacists were registered and 188 licenses were issued to pharmacies. The council in collaboration with the national malaria control programme, is mmonitoring the sale of copaid ACTs by pharmacies & LCS. It is also training LCS in the management of diarrhoea in children in collaboration with USAID, SHOPS and Ghana Health Service. Over 6000 LCS have been trained. Budget Execution SOURCES OF FUNDING APPROVED BUDGET (GH ) TOTAL RECEIPTS (GH ) TOTAL EXPENDITURE (GH ) GOG 76, , , (Goods & Services) IGF 1,836, ,770, ,695, SBS 59, , , TOTAL 1,971, ,828, ,752, Table 16: Budget Execution by Pharmacy Council 2012 Total expenditure for the year amounted to GHc 1,752, representing 95.9% of total receipt. Internally generated funds constitute 96.7% of total expenditure. CHALLENGES Inadequate funds & budgetary allocations to execute line-up programmes High cost of Rental accommodation for offices and staff Emerging channels of distribution of Medicines (Unregulated and clandestine) Inadequate information among consumers Limited and skewed distribution of facilities Limited and ageing fleet of vehicles Inadequate staff (both in numbers and specialties) 5.13 CHRISTIAN HEALTH ASSOCIATION OF GHANA (CHAG) The Christian Health Association of Ghana is a Network of 19 Christian health services with 182 health facilities. The facilities comprises 58 hospitals (31%), 77 clinics (42%), 19 health centers (10%), 15 PHC programmes (8%), 10 training institutions (6%) and 3 specialist clinics (2%9. CHAG facilities accounts for about 5.3% of all health infrastructures in the country and are spread all across all 10 regions. CHAG Priorities for 2012 include 54

55 The improvement in service outputs [outpatients, inpatients, deliveries, outpatient insured clients, 15 additional hospital emergency service units] The improvement in organizational capacity of CHAG secretariat and member institutions The improvement of service outcomes [reduction in institutional mortality, community morbidity and increase in community wellness] Outpatient attendance increased by almost 17% from 4,867,252 in 2011 to in However, inpatient attendance increased just marginally from 394,442 in 2011 to 397,240. CHAG s contribution to the total OPD and inpatient attendance was 29% and 19% respectively. Deliveries in CHAG institutions increased by 25.8% from 93,855 in 2011 to 118,040 in About 88% of outpatients attended by CHAG institutions were insured. CHAG Service Outcome A total of 13 hospitals were trained to establish hospital emergency units bringing the total to 22 since Similarly, 55 CHAG staff were trained and certified in basic life support skills. Table 17 below shows details of both trainings. Training Planned Hospitals trained to establish Hospital Emergency Units 2012 Actual Staff trained and certified in Basic Life Support skills Table 17: Training in emergency skills, source CHAG Overall Total Challenges 55

56 The major challenge of the CHAG is Having to make changes to implementation design and content on account of observed results of the interventions (both desirable and undesirable). 56

57 6.0 Follow-up on Aide Memoire recommendations The Aide memoir to a large extent was adequately implemented except for some few activities that were either not implemented or progress not known. Table 18 below indicates some of the activities that are outstanding. Activity Complete the nutrition policy Finalise a detailed implementation plan and costing of the nutrition policy Launch the nutrition policy Disseminate the nutrition policy Finalise HRH policy Finalise Norms Zero draft of comprehensive health financing policy and strategy to be completed by end July 2012 for presentation and discussion Establish a small team including NHIS, Teaching Hospitals, CHAG and private sector to tease out all the issues and define an implementation plan.(institutional and organisational assessement) Provide office accommodation to solve the repository problem (Public Financial Management, flow of funds) MOH to contact MOFEP and agree on how to take forward the study recommendations Table 18: Outstanding Aide Memoire Recommendation as of 31 st December Progress/Remarks Nutrition policy could not be completed on schedule. The road map fro completion was reviewed. A new deadline for completion was set for the end of the first quarter of 2013 These activities are dependent on the completion of the nutrition policy A draft policy was circulated. A stakeholder meeting was scheduled for the first quarter of Tools for determining staff requirement at the institutional level have been developed. A norm that standardises staff numbers and mix is yet to be developed. The health financing policy has not been developed. Roadmap for completion has been rescheduled to The process to implement the recommendations of the institutional and organisational assessment is on-going. Committees and sub-committees have been formed to look at various aspects of the recommendations. New developments such as decentralisation process warranted the revision of the TOR for the various sub-committees The CHIM offices, which was earmarked as the centre for the data repository has been awarded for refurbishment. The refurbishment is progressing rather slowly. A temporary repository has however been established at the rrsim directorate of the Ministry of Health An agreement was reached with MoFEP to hold regular meeting to track and ensure funds for the Ministry of health are released on time. It has been difficult to organise this meetings. The convenor of the meeting (MoFEP) has not been able to organise the meetings. A suggestion for MOH to be proactive in ensuring the meetings are held have been made. The ministry of health hopes to carry the suggestion forward in the new year. 57

58 7.0 Conclusion MDG4 With twice as many under-fives dying per 1,000 live births in the poorest wealth quintile compared to the richest, the under-five mortality inequality gap between richest and poorest children is widening. Exclusively breastfed has significantly worsened since 2008, and the current performance at 45.7% is below 2003 levels and far below the target of 70%. Factors external to the health sector are also likely to have influenced the trend, e.g. increased number of women engaged in the workforce and behavioural changes as a consequence of economic growth and attainment of middle-income country status. The under-five prevalence of low weight for age has reduced slightly to 13.4% and the target of 8.0% is far from being achieved. The Ministry expected to disseminate and implement the National Nutrition Policy in The Nutrition Policy and Strategy has been finalised and being submitted to cabinet for approval. The pneumococcal, meningococcal and rotavirus vaccines including second dose of measles vaccines were successfully introduced. Community health workers implementing the community case management of malaria, diarrhoea and acute respiratory disease face difficulties in recouping funds for drugs. This is because they are not recognized by the NHIS and thus are not reimbursed even when they treat insured clients in the communities. Hang-up campaigns were completed for the whole country, and with 7,645,745 distributed LLINs household ownership of ITNs stands at above 95%. The MICS survey 2012 showed that only 15.9% of children under five with fever were tested for malaria. The Ministry is concerned about the access to and quality of diagnostic services related to malaria. MDG5 The total fertility rate has worsened from 4.0 to 4.3, meanwhile, the contraceptive prevalence rate for the same period has improved significantly, and unmet need for family planning reduced. Over the past 3 years, supervised delivery coverage has increased by 28.2%, and over the past 5 years by 66.5%. Coverage of supervised deliveries in 2012 was 58.5% (based on expected delivery being of 4% of the population) and 77.9% (based on the 3% estimate). All regions were above 50% except Volta Region at 46.5% and Northern Region at 49.9%. The good performance may be attributed to improved financial access from the free maternal health care policy, and improvement in the data collection. Institutional Maternal Mortality (immr) dropped significantly from 211 maternal deaths per 100,000 live births in 2011 to 193 in While immr at Komfo-Anokye Teaching Hospital continued to be high, Korle- Bu Teaching hospital reduced institutional maternal mortality ratio significantly from 1,133 in 2011 to 841 in Investigations by Foods and Drugs Authority revealed that almost 70% of all 279 samples of Oxytocin failed the quality test. 58

59 OPD The number of outpatients per capita reached 1.17, more than doubling 2006 figure. Citizens may choose to register with NHIS only when they anticipate a need for health services and subsequently discontinue their membership. This can lead to adverse selection that potentially creates challenges for the financial sustainability of NHIS. With the increase in OPD visits across the regions, there has not been equally significant improvement in infrastructure of most of the facilities to accommodate these increases. It is now more important than ever to ensure good service and clinical quality. Non-communicable diseases Detection and management of non-communicable diseases continued to provide challenging to the sector. Guidelines for the cancer programme have been developed they are yet to be printed. Screening is going on in the regions for hypertension, diabetes and sickle cell, but such routine screening is unstructured. The total number of mental health nurses in the three psychiatric institutions was 1,068. This comprises both community psychiatric nurses and registered mental nurses. No formal training exists for training community psychiatric nurses and the current crop are registered nurses converted to practice as community psychiatric. Financing In 2012, Government of Ghana contribution increased by 126.9% from GH 771 million in 2011 to GH 1,750 million in The Ministry recorded a total expenditure of GH 2,613.4 million for the period under review. Out of this amount, 63.4% was for Employee Compensation as against 53.9% for the same period of Employee Compensation increased significantly from GH 754.7million in 2011 to GH 1,655.7 millon as a result of the movement from the Health Sector Salary Scale (HSS) to the Single Spine Salary Pay Policy (SSSPP). HRH The poorest staffed region is Northern Region with one nurse to 1,601 population compared to the national average of one nurse to 1,251 population. Other regions, especially Northern Region, should also adopt the approach of Upper East Region to strictly implement the policy of retaining nurses that train in the region. Twenty-five government Hospitals in Ghana are without doctors. Eight of them are found in the Northern Region. The doctor to population ratio did not change much and with 11 times less doctors per population in Upper West Region compared to Greater Accra Region equitable distribution of doctors remains a major challenge to the health sector. The Ministry expanded CHPS coverage with over 500 new functional zones during the year. Deploying close to 9,000 CHOs into the zones or communities is a challenge. Due to inadequate funding, districts are unable to provide the basic package to facilitate the deployment of the CHOs. The absence of staffing norms, deployment plans and a final HRH policy continues to affect the management of human resource in the sector resulting in inequity in the distribution of critical staff in terms of numbers and mix. 59

60 Leadership Performance contracts were signed with the Ghana Health Service and the three teaching hospitals, but contract management in terms of supervision, reporting and evaluation was not adequate. Bills have been passed into law and require development of legal instruments. The Ministry of Health should lead the process to facilitate the development of the various legal instruments on time. Regions of Excellence Central and Upper East Region performed excellent in The two regions had access to extra budgetary funding, which they are obviously using very efficiently compared to Regions like Northern and Upper West Region who although benefiting from similar extra budgetary funding are not performing equally well. The three Regions Volta, Ashanti and Brong-Ahafo do not have any significant extra-budgetary support and depend only on the dwindling GOG funding possibly accounting for their lower than average performance on these specific indicators. 60

61 Annex 1: Sector Wide Indicators and Targets POW 2012 Indicators Base-line Targets Health Objective 1 Bridge equity gaps in access to health care and nutrition services and ensure sustainable financing arrangements that protect the poor 1 % children 0-6 months exclusively breastfed 62.8% N/A N/A 70.0% 70.0% 2 Equity Index: Poverty (U5MR by highest/lowest wealth quintile) 1:2.18 N/A N/A 1:1.5 1:1.5 3 Equity Index: Geography - Services (Supervised deliveries by 1:1.97 1:1.90 1:1.80 1:1.70 1:1.60 region) 4 Equity Index: Geography - Resources (Nurses:Population by 1:2.03 1:2.00 1:2.00 1:1.95 1:1.90 region) 5 Equity Index: NHIS Gender (Active members by gender) 1: Equity Index: NHIS Poverty (Active members by lowest quintile - N/A N/A N/A - to whole pop) 7 Outpatients attendance per capita (OPD) Access to Health facility N/A N/A N/A N/A N/A 9 Doctor:population ratio 1:13,400 1:11,500 1:10,500 1:9,700 1:9, Nurse:population ratio 1:1,353 1:1,100 1:1,000 1:900 1:800 Health Objective 2 strengthen governance and improve efficiency and effectiveness in the health system 1 % total MTEF allocation to health 14.9% 11.5% 15.0% 15.0% 15.0% 2 % non-wage GOG recurrent budget allocated to District level 49% 50% 50% 50% 50% and below 3 Per capita expenditure on health 23 US$ 26 US$ 28 US$ 30 US$ 31 US$ 4 Budget execution rate (Item 3 as proxy) 97% 95% 95% 95% 95% 5 % of annual budget allocations to items 2 and 3 (GOG and 23% 40% 42% 50% 50% SBS) disbursed to BMCs by end of year 6 % of population with valid NHIS membership card 45.0% 60.2% 65.0% 70.3% 75.0% 7 Proportion of NHIS claims settled within 12 weeks N/A 40% 60% 70% 80% 8 % of IGF from NHIS 66.5% 70.0% 70.0% 75.0% 75.0% Health Objective 3 Improve access to quality maternal, neonatal, child and adolescent health services 1 Maternal mortality rate per 100,000 live births 451 N/A N/A N/A Total fertility rate 4.0 N/A N/A Institutional Maternal Mortality rate per 1000 live births % of pregnant women attending at least 4 Antenatal visits 62.4% 70.0% 74.6% 80.1% 85.7% 5 Infant Mortality Rate (IMR) per 1, N/A N/A <30 <30 6 Under 5 Mortality Rate (U5MR) per 1, N/A N/A <50 <50 7 % deliveries attended by a trained health worker 39.4% 50.3% 55.6% 60.0% 65.0% 8 Under 5 prevalence of low weight for age 13.9% N/A N/A 8.0% 8.0% Health Objective 4 Intensify prevention and control of communicable and non-communicable diseases and promote a healthy lifestyle 1 HIV+ prevalence among pregnant women years 2.2% <1.9% <1.8% <1.7% <1.6% 2 % of U5s sleeping under ITN 40.5% 50.0% 65.0% 70.0% 75.0% 3 % of children fully immunized by age one - Penta % 87.9% 89.0% 91.4% 93.5% 4 HIV+ clients receiving ARV therapy[5] 23,614 51,814 65,914 80,014 94,114 5 Incidence of Guinea Worm 501 <100 <70 < % of households with improved sanitary facilities 11.3% N/A N/A 21.3% 21.3% 7 % of households with access to improved source of drinking 77.3% N/A N/A 80% 80% water 8 Obesity in adult population (women aged years) 30% N/A N/A N/A 28% 9 TB treatment success rate 84.7% 86.0% 88.0% 89.0% 90.0% Health Objective 5 Strengthen institutional care, including mental health service delivery 1 Equity Index: Ratio of mental health nurses to patient population N/A 5% 10% >b.l. 25% >b.l. 30% >b.l. >b.l. 2 Number of community psychiatry nurses trained and deployed N/A 5% >b.l. 10% >b.l. 25% >b.l. 30% >b.l. 3 % tracer psychotropic drug availability in hospitals N/A 70% 70% 75% 80% 4 Institutional Infant mortality rate Basket equipment functioning in hospitals N/A 80% 80% 80% 85% 7 % Tracer drug availability in hospitals 68% 80% 85% 90% 90% 8 % of hospitals assessed for quality assurance and control N/A 70% 80% 90% 100% 61

62 9 Institutional under five mortality rate Institutional Maternal Mortality rate per 1000 live births

63 Annex 2: Sector wide indicator trends based on 3% proportion Table 19 below presents sector wide indicator trends recalculated for the previous years on basis of the 2010 census projections for expected pregnancies (3%), expected children under one year (3%) and WIFE (25.8%). POW Performance Source Health Objective 1: Bridge equity gaps in health care and nutrition services and ensure sustainable financing arrangements that protect the poor 1 % children 0-6 months exclusive breastfed 62.8% % MICS 2 Equity: Poverty (U5MR) MICS 3 Equity: Geography - Services (supervised deliveries) * 1.66* 1.48 GHS 4 Equity: Geography - Resources (nurse: population) * 1.73* 1.75 MOH 5 Equity: NHIS Gender MICS 6 Equity: NHIS Poverty 0.82 (F) (F) MICS 7 Outpatients attendance per capita (OPD) * 1.04* 1.17 GHS /TH 8 % population living within 8 km of health infrastructure Doctor: population ratio 1:13,499 1:11,698 1:11,833* 1:10,217* 1:10,452 MOH 10 Nurse: population ratio 1:1,353 1:1,494* 1:1,516* 1:1,262* 1:1,251 MOH Health Objective 2: Strengthen governance and improve efficiency and effectiveness in the health system 1 % total MTEF allocation on health 14.9% 14.6% 15.1% 15.8% 15.4% MOH 2 % non-wage GOG recurrent budget to district level and below 49.0% 62.0% 46.8% 55.3% 38.5% MOH 3 Per capita expenditure on health MOH 4 Budget execution rate (Item 3 as proxy) 115.0% 80.4% 94.0% 82.1% 86.8% MOH 5 % of annual budget allocations disbursed to BMC by end of year 23.0% 39.0% 31.0% 89.8% % of population with valid NHIS membership card % 33.4% 34.0% NHIA 7 Proportion of claims settled within 12 weeks % IGF from NHIS 66.5% 83.5% 79.4% 85.0% - - Health Objective 3: Improve access to quality maternal, neonatal, child and adolescent health services 1 Maternal Mortality Ratio (MMR) per 100,000 live births Total Fertility Rate MICS 3 Contraceptive Prevalence Rate 16.6% % MICS 4 % of pregnant women attending at least 4 antenatal visits 81.1% 81.6% 71.1% 71.3% 96.4% GHS 5 Infant Mortality Rate (IMR) per 1,000 live births MICS 6 Under 5 Mortality Rate (U5MR) per 1,000 live births MICS 7 % deliveries attended by a trained health worker 56.3% 60.8% 65.0% 73.0% 77.9% GHS/TH 8 Under 5 prevalence of low weight for age 13.9% % MICS Health Objective 4: Intensify and control of communicable and non-communicable diseases and promote a healthy lifestyle 1 HIV prevalence among pregnant women years GHS 2 % of U5s sleeping under ITN 40.5% % MICS 3 % of children fully immunized by age one - Penta % 119.1% 114.5% 115.3% 117.1% GHS 4 HIV+ clients ARV treatment 23,614 33,745 40,575 59, NACP 5 Incidence of Guinea Worm GHS 6 % households with improved sanitary facilities 12.4% % MICS 7 % households with access to improved source of drinking water 83.8% % MICS 8 Obesity in population (women aged years) 9.3% TB treatment success rate 84.6% 85.4% 87.0% 85.3% 86.2% NTP Health Objective 5: Strengthen institutional care, including health service delivery 1 Psychiatric patient treatment and rehabilitation rate % Chief Psy. 2 Equity index: Ratio of mental health nurses to patient population :63 Chief Psy. 3 Number of community psychiatric nurses trained and deployed Chief Psy. 4 % tracer psychotropic drug availability in hospitals % Chief Ph. 5 Institutional infant mortality rate GHS 6 Basket equipment functioning in hospitals % tracer drugs availability in hospitals % 85.7% Chief Ph. 8 % of hospitals assessed for quality assurance and control Institutional under-five mortality rate GHS 10 Institutional MMR GHS /TH Table 19: Sector wide indicators based on both 3% of children under 1-year/expected pregnancies, greyed out indicators are not measured on annual basis. 63

64 Annex 3: Holistic Assessment Tool and Analysis The holistic assessment tool was developed during the 5YPOW to provide a brief but wellinformed, balanced and transparent assessment of the sector s performance and factors that are likely to have influenced this performance. Most of the indicators from the 5YPOW have been carried over to the HSMTP and used in the 2011 POW. The indicators have been clustered under Health Objectives 1 to 5. The review team has performed the initial assessment based on the holistic assessment methodology. The purpose of the initial assessment is to form a basis for a balanced discussion between the Ministry of Health, its agencies and development partners to reach a common conclusion of the sector s performance. During this discussion, the final sector score can be modified if the initial assessment has either over- or underestimated the performance. Methods The assessment is based on indicators and milestones specified in the operational annual POW. More specifically, the analysis underlying the holistic assessment is based on the following elements: 1. Annual POW including budget 2. Annual Performance Review Reports and presentations from MoH and its Agencies 3. Annual MoH Financial Statement 4. National survey reports (Ghana DHS, MICS etc.) 5. Health Sector Medium Term Development Plan As part of the annual health sector review process, the review team has conducted an initial assessment of milestones realization and indicator trends. The assessment was guided by a predefined methodology that ensured full transparency of calculations. The assessment will be presented at the April Health Summit where overall performance of the sector and possible factors, which may have influenced the performance, can be discussed. The purpose of the initial assessment is to form a basis for a balanced discussion between the Ministry of Health, its agencies and development partners to reach a common conclusion of the sector s performance. The initial assessment has three steps: First, each indicator and milestone is assigned a numerical value of -1, 0 or +1 depending on realization of milestones and trend of indicators. While indicators which normally are measured on annual basis are included in each year s assessment, indicators which are not measured on annual basis (e.g. survey based information like MICS, DHS etc.) are only included in the assessment if new information is available. Milestones are assigned the value +1 (colour coded green) if the review team is provided with evidence from the relevant authority that documents the realization of the milestone; otherwise it is assigned the value -1 (colour coded red). Indicators are assigned the value +1 (colour coded green) if The indicator has attained the specified annual target regardless of trend, or 64

65 The indicator has experienced a relative improvement by more than 5% compared to the previous year s value Indicators are assigned the value -1 (colour coded red) if The indicator is below the annual target and has experienced a relative deterioration by more than 5%, or No data is available (only applies to annually measured indicators and not to survey indicators) Indicators are assigned the value 0 (colour coded yellow) if The relative trend of the indicator compared to previous year is within a 5% range, or The indicator was not reported the previous year (for annually measured indicators) or the previous survey (for survey indicators) Second, the indicators and milestones are grouped into Health Objectives as defined in the HSMTDP and the sub total of indicators and milestone values are calculated for each group. Health Objectives with a positive score are assigned a value of +1, -1 if the total score is negative and 0 if the total score is 0. Third, after assigning a numerical score to each of the Health Objectives the scores are added to determine the sector s score. A positive sector score is interpreted as a highly performing sector, a negative score is interpreted as an underperforming sector and a score of zero is considered to be sustained performance. Assessment of indicators and milestones Health Objective 1: Bridge equity gaps in health care and ensure sustainable financing arrangements that protect the poor Milestone: Review of CHPS undertaken with stakeholders and re-zoning of CHPS completed 2012 Performance: no information Source: MOH Outcome: 0 The Ministry of Health organised a joint monitoring visit to five regions, namely Central, Greater Accra, Ashanti, Northern and Upper East Region to ascertain the status of Implementation of the Communitybased Health Planning and Services (CHPS). The findings of the joint monitoring visit were presented at the November business meeting in form of a policy brief. The process of rezoning of CHPS into zones coterminous with the District Assembly electoral areas was initiated. Since the review was performed but the rezoning was not completed, the Ministry proposes that this milestone is given the score of 0. % children 0-6 months exclusively breastfed 2012 Performance: 45.7% 2012 Target: 70% Source: MICS % 54.0% 62.8% 45.7% 65

66 Outcome: -1 Result: The proportion of children below the age of 6 months exclusively breastfed has significantly dropped since 2008, and the current performance is below 2003 levels. Discussion: At district level, health activities to promote good nutrition including exclusive breastfeeding have received decreasing attention and priority over the past years. Because of limited financial and human resources and since these activities are less integrated into the routine district level activities than for example EPI, the tendency has reportedly been to give preference to other activities. Moreover, head quarter s monitoring and support to regions and districts in the area of nutrition has reduced. The ministry is concerned about this trend and will work with its agencies to strengthen nutrition activities and promote exclusive breastfeeding. Equity Poverty (Poorest/Richest U5 mortality rate) 2012 Performance: Target: 1.5 Source: MICS 2011 Outcome: -1 Wealth Quintile Lowest Second Middle Fourth Highest Ratio Result: The under-five mortality inequality gap between lowest and highest wealth quintile is widening, and the poorest children a significantly worse of than children from any other quintile. Moreover, it is evident that children from the richest quintile are significantly better of the any other quintile. The reduction of under-five mortality since DHS 2003 is also highest among children from the richest quintile (41%) and lowest among the poorest children (17%). Discussion: While children of the richest quintile seem to be on track to meet the MDG target of reducing under-five mortality rate, children from other quintiles and especially the poorest children are faring much worse. The same widening of inequity is observed for infant and neonatal mortality rates. Since 2003 there seems to have been no reduction of infant mortality and only slight reduction in neonatal mortality among the poorest children while reduction of infant and neonatal mortality among the richest was 34.5% and 42.9%, respectively. The ministry whish to perform further analysis of these trends to isolate the determinants of high mortality among children, e.g. urban/rural dwelling, socio-economic status, education status of parents, child gender etc. in order to device strategies to ensure more equitable health development for children in Ghana. Wealth Quintile Reduction since 2003 Lowest % Second % Middle % Fourth % Highest % Table 20: Infant Mortality Rates by wealth quintile, Source GHS 2003/2008 and MICS 2006/

67 Wealth Quintile Reduction since 2003 Lowest ,4% Second ,0% Middle ,6% Fourth ,6% Highest ,9% Table 21: Neonatal Mortality Rates by wealth quintile, Source GHS 2003/2008 and MICS 2011 (no information about neonatal mortality rate in MICS 2006) Equity Geography (Supervised Deliveries) 2012 Performance: 1: Target: 1:1.7 Source: GHS Outcome: +1 Result: The equity index for supervised deliveries by region is improving and reached the target of being below 1:1.7. In 2012, there was improved CR 74.0% % - - UER % % 66.3% 68.6% BAR % - WR % NR 25.1% % 36.1% - VR % 39.9% 45.0% Ratio 1:2.95 1:2.47 1:2.17 1:1.49 1:1.89 1:1.66 1:1.53 performance among both the best and worst off regions. Almost all regions performance was above 50% except VR at 46.5% and NR at 49.9%. Three regions were above 60%, namely UER (68.7%), BAR (65.9%) and CR (60.1%). Discussion: Coverage of supervised deliveries continued to increase in all regions except for AR, which experienced a drop of 2.1%. Over the past 3 years, the highest improvement in coverage is observed in UWR with an impressive 53.7% increase since The national increase for the same period was 28.2%, while the national increase over the past 5 years has been 66.5%. While some of this increase can be contributed to improved data collection, the ministry considers this also to be the consequence of specific policy interventions to improve access to maternal services, e.g. HIRD and the Free Maternal Health Care Policy introduced in When linking the regional figures for supervised deliveries to neonatal mortality reported in the MICS 2011, there seems to be a relation between low coverage of supervised deliveries and high level of neonatal mortality. The causes of neonatal mortality are multifaceted, and the relation is not without exceptions, which raises the question about quality of the provided maternal services and their impact on both neonatal and maternal mortality and morbidity. Since 2010, VR has been the poorest performing region. While the region has improved supervised deliveries with close to 50% since 2010, the region should still receive special attention and support to catch up with the other regions. Results: Equity for supervised delivery improved for the year under review. The performance was better than the target of 1:1.7 for the year There is an overall improved performance for supervised delivery for all the regions. All regions are above 50% except VR at 46.5% and NR at 49.9%. Three regions are above 60%: BAR (65.9%), CR (60.1%) and UER (68.7%). 67

68 Discussion: The good performance may be attributed to Improved financial access from the free maternal health care policy. Although Volta region is showing an improvement in supervised delivery, it has consistently been the lowest performer with regards to supervised delivery for the past three years. Volta, Northern and Western Regions have high midwife WIFA population ratio compared to the other regions. Of the three regions with few midwives in relation to their WIFA poulation, only Western Region had supervised coverage above 50%. This is due to midwives in the Western Region doing averagely more deliveries per midwife than in any other region(204 deliveries/midwife).this is above the WHO recommeded 175 deliveries/midwife. Upper East Region continues to improve its supervised delivery coverage over the years. It will be of benefit to the whole health sector to look at the strategies that have been put in place for them to achieve this consistent results. The performance of Volta Region with regards to skilled delviery needs to be addressed. There are various reasons for this performance which came up in the Joint monitoring visit report to the Region in 2011, among the issues are inadequate infrastructure, ageing and inadequate numbers of midwives and the fact that Volta Region is one of the regions with very few maternal and child health interventions outside the regular budget provided by the Ministry of Health. The region will need to be targetted for special attention. AR WR NR BAR CR VR UER ER UWR GAR Ghana % 34.8% 25.1% 47.4% 74.0% 35.4% 38.4% 38.7% 28.8% 42.2% 44.5% % 17.6% 27.7% 34.5% 22.3% 33.3% 43.5% 43.1% 32.9% 43.1% 32.1% % 39.1% 26.0% 49.8% 56.3% 37.5% 40.4% 48.0% 40.6% 50.2% 42.2% % 42.6% 36.1% 53.7% 52.5% 39.4% 52.6% 52.1% 36.7% 47.9% 45.6% % 46.6% 36.3% 53.1% 48.2% 31.1% 58.8% 47.1% 44.8% 50.1% 48.7% % 53.5% 42.8% 62.4% 56.9% 39.9% 66.3% 52.0% 51.3% 54.5% 54.8% 12 50,3% 57,6% 49,9% 65,9% 60,1% 46,5% 68,7% 55,3% 56,4% 57,2% 58.5% Table 22: Coverage of supervised deliveries by region, , Source GHS 68

69 Figure 15: Supervised deliveries by region , source GHS Equity Geography (Nurses/Population ratio) 2012 Performance: 1: Target: 1:1.95 Source: HR MoH Outcome: +1 Result: Ratio did not improve over 2011 performance, but reached target of being below 1:1.95. The poorest staffed region is NR with 75% more citizens per GAR - 1:952-1:1,043 1:918 1:917 AR 1:1,429 1:1,932-1:2,077 1:1,586 NR 1:1,934 1:1,601 UER 1:3,225-1:1,069 - Ratio 1:2.26 1:2.03 1:1.81 1:1.99 1:1.73 1: and 2008 figures include midwifes. nurse than best performing region and 28% more citizens per nurse compared to the national average. Equity has however improved significantly overall since Discussion: The improvement over the years has been due to the establishment of new nursing training schools in all the regions. The recent stagnation is probably due to the high failure rate among the nursing students over the past two years that has reduced the number of nurses who are passing out of the schools. ( Pass rate from Nurses and Midwife Council Report) Equity Gender (Female/Male NHIS Card Holder ratio) 2012 Performance: Target: Target not specified in POW 2012 Source: MICS 2012 Outcome: Ratio

70 Result: NHIS cardholders became slightly more equal between the sexes. Trend below 5% and no target established, therefore neutral outcome. Discussion: Women have higher need for health care services (including maternal care) over the life span. Until NHIS reaches universal coverage, the ministry both expect and desire relatively higher female enrolment. Equity Poverty (Poorest/National NHIS Card Holder ratio Women only) 2012 Performance: Target: Target not specified in POW 2012 Source: MICS 2011 Outcome: -1 Wealth Quintile Poorest 27.9% 28.7% National 34.1% 41.6% Ratio Result: The socio economic inequity of NHIS coverage has significantly worsened since The MICS survey demonstrates a modest increase in cardholders among the poorest, but this increase is largely overtaken by a national increase in cardholders of 22.0%. Discussion: The observed inequity indicates that there continues to be a financial access barrier for Ghana s citizens from the lowest wealth quintile to enrol onto NHIS and/or maintain a valid card. Reports from the district hospitals suggest that the poorest citizens choose to register with NHIS when they need health services and subsequently discontinue their membership. This leads to adverse selection, which potentially can create challenges for the financial sustainability of NHIS. The above findings contrast the recent evaluation of the Free Maternal Health Care Policy that concludes that equity in NHIS membership provided by the policy is improving. The study also reports an unanimous agreement among all respondents that the introduction of the free maternal health care policy has increased the level and the equity in the utilisation of health facilities for delivery. Out Patient Visits 2012 Performance: Target: 0.88 Source: GHS Outcome: Results: OPD per capita continue previous years increase. In 2012, the relative increase was 11% and OPD pre capita reached 1.17, more than doubling 2006 figure. The OPD per capita of Ashanti Region dropped significantly. Discussion: The National Health Insurance since its introduction has led to increase in utilization of OPD services across all the regions. 80.1% of total Outpatients seen were insured. Regions like Upper East Region and Brong- Ahafo Regions which share borders with neighbouring countries and have old and well known facilities close to the border, has OPD per capita above 1.5 with some of their patients coming from the neighbouring countries. Volta Region however because of inadequate facilities especially in the Northern 70

71 parts of the region has not benefitted greatly from the influx of patients from the neighbouring countries compared to the other two regions. 61.4% of those attending outpatient were females. For the males children 1-4years were seen more at the OPD than any age group. For the females those between 20-34years were seen more at the OPD compared to the other age group. Overall women between the ages of 20-34years were seen more at the OPD than any other age group for males or females Figure 16: OPD visits by gender and age-group 2012, source GHS Ashanti region like all the regions was showing an increase in OPD attendance till 2012 when it experienced a drop in OPD per capita. It was the year also that the capitation was piloted in the Ashanti Region. It is not clear whether this reduction in OPD was due to reduction in inappropriate utilization by insured clients or reduction in access on account of the capitation. Discuss possible relation between AR capitation pilot and reduced OPD/capita. Ashanti Region was also the only region where the proportion of OPD clients with insurance fell( from 82.6% to 76.9%). Northern Region OPD per capita might be a reflection of poor geographical access in the Region. Although finacial access has been facilitated with the health insurance with 88.9% of their total OPD being insured clients, their overall OPD per capita remain low compared to the other regions. With the increase in OPD visits accross the regions, there has not been significant imporvement in infrastructure of most of the facilties to accomoodate these increases. It is now more important than ever to ensure good service and clinical quality. Strategies for quality assurance for clinical care services should be developed for inclusion in new HSMTDP. 71

72 Figure 17: OPD per capita by region, , Source GHS AR WR NR BAR CR VR UER UWR ER GAR Ghana Table 23: OPD per capita by region, , Source GHS % population living within 8 km of health infrastructure 2012 Performance: N/A 2012 Target: N/A Source: N/A Outcome: N/A N/A Survey data not available for 2012 POW review. Doctor:Population Ratio 2012 Performance: 10, Target: 9,700 Source: HR - MOH Outcome: :15,423 1:13,683 1:13,499 1:11,649 1:11,698 1:10,217 1:10,452 Result: Doctor: population ratio did not change much. Neutral outcome. Large regional variances with 11 times more doctors per population in GAR compared to UWR. Almost 4 times higher population per one doctor in UWR compared to national average. Discussion: 72

73 Greater Accra continue to be the Region with the highest number of doctors per capita. Fifty percent of all Ghana s doctors are in Greater Accra Region and another 20% are in Ashanti Region. The number of doctors in training in Greater Accra Region might be accounting for this high numbers. The proportion of female doctors in Greater Accra is higher than for the other Regions, indicating that some of these doctors are in Greater Accra Region because of domestic reasons. Northern Region has consistently improved its doctor population ratio over the past three years, however this increase has only benefitted the Teaching Hospital. Of the 25 Hospitals in Ghana without doctors 8 of them are found in the Northern Region. There is the need for establishment of clear staffing norms for faciltiies and the Ministry of Health need to have a strategy to address the inequitable distribution of doctors Figure 18: Doctor: population ratios (lower is better), , Source MOH AR WR NR BAR CR VR UER UWR ER GAR Ghana No. of docs ,082 No. of docs ,108 No. of docs ,085 2,475 No. of docs ,204 2,481 Pop. / 1 doc ,715 27,775 19,163 15,705 22,505 24,728 39,697 40,502 19,748 3,540 10,452 Table 24: Total number of doctors 2009 to 2012 and doctor/population ratio for 2012 (lower is better), source HR - MoH Nurse:Population Ratio 2012 Performance: 1, Target: 1:900 Source: HR MOH :1,497 1:1,489 1,240 1:1,251 Outcome: 0 73

74 Result: Nurse:population ratio has remained stagnant. This has resulted in a neutral outcome for this indicator. The highest concentration of nurses are in Greater Accra Region and Upper East Region. Lowest are in Northern Region and Ashanti Region. Discussion: The decision of Upper East Region of implementing strictly the policy of retaining nurses that train in their Region appear to be yielding fruits. Regions like Northern Region should also adopt this approach. Numbers of midwives are reducing across all the regions with the exception of Ashanti Region which showed a marginal increase in numbers of midwives. The training and deployment of midwives is not keeping pace with those going on retirement. There is the need to get more nurses into training, this can be accelerated if the community health nurses can be given diplomas instead of certificates when they undertake the post-basic midwifery course. Most of them are reluctant to enrol in the post-basic midwifery course because they are awarded certificates. AR WR NR BAR CR VR UER UWR ER GAR Ghana Total no. of nurses ,325 1,422 1,191 1,214 1,373 1, ,994 3,698 16,228 Total no. of nurses ,397 1,376 1,194 1,207 1,370 1, ,914 3,846 16,268 Total no. of nurses ,096 1,712 1,645 1,562 1,655 1,733 1, ,259 4,502 20,031 Total no. of nurses ,253 1,739 1,640 1,645 1,873 1,789 1, ,219 4,649 20,734 Pop. / 1 nurse ,550 1,422 1,601 1,470 1,250 1, , ,251 Table 25: Total number of nurses 2009 to 2012 and nurse/population ratio for 2012 (lower is better), source HR - MoH AR WR NR BAR CR VR UER UWR ER GAR Ghana Total no. of midwifes ,794 Total no. of midwifes ,780 Total no. of midwifes ,034 Total no. of midwifes ,863 WIFA/1 midwife ,553 2,142 2,300 1,649 1,911 1,763 1,354 1,336 1,461 1,260 1,611 Table 26: Total number of midwifes 2009 to 2012 and midwife/population ratio for 2012 (lower is better), source HR - MoH Health Objective 2: Strengthen governance and improve efficiency and effectiveness of the health system Milestone: System for performance contracting introduced 2012 Performance: no information Source: MOH Outcome: +1 In 2012, the ministry introduced performance contracts with four agencies, the three teaching hospitals and Ghana Health Service. The ministry will sign performance contracts for 2013 with all its agencies. % MTEF on Health 2012 Performance: 15.4% 2012 Target: 15.0% Source: MoH Outcome: % 14.9% 14.6% 15.1% 15.8% 15.4% % Non-wage GOG recurrent budget allocated to district level and below

75 2012 Performance: 38.5% 2012 Target: 50% Source: MoH Outcome: % 49.0% 62.0% 46.8% 55.3% 38.5% Per capita expenditure on Health (USD) 2012 Performance: Target: 30 USD Source: MoH (draft financial statement exhibit B, p. 5) Outcome: Budget Execution Rate of Item Performance: 86.8% 2012 Target: >95% Source: POW 2011 and draft financial statement Outcome: % 115% 80% 94% 82.1% 86.8% % of annual budget allocations to item 2 and 3 disbursed by end of December 2012 Performance: 2012 Target: 50% Source: MoH Outcome: Disbursed by end June n/a 23.0% 39.0% 31.0% - Disbursed by end December % % Population with valid NHIS card 2012 Performance: 2012 Target: 70.3% Source: NHIA Outcome: Members 36.2% 44.7% 50.0% - - Active Card holders % 32.8% 34% Result: The number of cardholders increased to 8,645,483 providing an NHIS coverage of 33.3%. There are significant regional variances with UWR and UER leading. A significant drop by over 25% was observed in AR. Discussion: 75

76 % of claims settled within 12 weeks 2012 Performance: 2012 Target: 70% Source: NHIA Outcome: -1 % of IGF from NHIS 2012 Performance: 2012 Target: 75% Source: MOH Outcome: n/a n/a n/a n/a n/a n/a 66.5% 83.5% 79.4% 85% - Health Objective 3: Improve access to quality maternal, neonatal, child and adolescent health and nutrition services Milestone: Pneumocococcal and rotavirus vaccines successfully introduced 2012 Performance: Source: GHS Outcome: +1 Vaccines were introduced to the EPI programme in Maternal mortality ratio 2012 Performance: No new data for Target: N/A Source: N/A Outcome: N/A Survey indicators are not measured on annual basis. 76

77 Total fertility rate 2012 Performance: Target: 3.8 Source: MICS 2011 Outcome: Result: The total fertility rate worsened in 2012, and at 4.3 it is now almost back to the 2003 rate. Discussion: While total fertility rate has worsened, the contraceptive prevalence rate for the same period has improved significantly. Moreover, unmet need for family planning reduced from 34.0% in 2003 to 26.4% in the 2011 MICS. These factors indicates that access to family planning is improving and raise concern that the increase in fertility may be a statistical variation that is not a true reflection of performance. Contraceptive Prevalence Rate (for modern methods women years married or in union) 2012 Performance: 23.4% 2011 Target: No target specified Source: GHS Outcome: % 18.7% 13.6% 16.6% 23.4% Results: The contraceptive prevalence rate has markedly increased since The positive trend observed in the survey, is supported by routine information, which shows a significant increase in short-term CYP and minimal increase in long-term CYP. Discussion: Survey figures are consistently showing increased use of modern family planning methods and reducing unmet need for family planning. This is consistent with routine figures from the public sector. Analysis by GHS shows that an increasing proportion of family planning clients are accessing the services from the private sector including pharmacy shops, since this is more convenient for the clients. This leads to incompleteness of the data collected by GHS. Some of the long-term methods can only be administered by midwifes and doctors. Since both midwives and doctors are likely to be occupied with other activities, these methods cannot be administered to meet the demand. The ministry currently considers the possibility for task shifting administration of these long-term family planning methods to other health personnel. Results: Contraceptive prevalence rate from the MICS showed a significant increase from 16.6% to 23.4%. The routine Family planning Acceptor rate however reduced slightly. Couple Year protection has similarly increased compared to the previous year Upper West Region recorded a family planning acceptor rate of 43.8% while Ashanti Region reported a low coverage of 15.8%. Discussion: The increase in Total Fertility rate as recorded in the MICS is not consistent with the increase in CPR found in the same survey. There might be the need to investigate this further. The completeness of data on Family planning from the traditional facility sources, both Public and private has improved with a reporting rate of 93.9% from these facilities. 77

78 From the MICS unmet need for Family planning has reduced to 26.4% indicating an improved access to family planning services, which is also reflected in the routine service data. CYP AR WR NR BAR CR VR UER UWR ER GAR Ghana ,281 78,945 29,155 58,837 56,880 47,027 19,831 25,163 80,879 54, , ,796 47,268 74, ,181 96,635 51,093 28,048 19, ,566 30, , ,922,289 Table 27: CYP by region , source GHS % of pregnant women attending at least 4 antenatal visits 2012 Performance: 72.3% 2012 Target: 80.1% Source: GHS Outcome: ANC visits 62.8% 60.9% 66.6% 66.6% 70.7% 72.3% AR, BAR, VR and GAR were excluded from national figure due to unreliable data Results: ANC 4+ increased, but the relative increase of 2.2% was below the 5% threshold for a positive indicator outcome. Discussion: The programme definition of ANC4+ is based on its use as a proxy quality indicator rather than a coverage indicator. It is defined as the number of ANC registrants making the fourth visit. The definition used in this review and previous reviews makes it a coverage indicator by looking at those expected to get pregnant how many made the fourth visit. This is more aligned to the survey definition that asks for the women interviewed who were pregnant the previous year how many had attended ANC at least four times by any provider. For the 2011 MICS report this was 86.6%. The definition of this indicator presents challenges for some of the Regions with their figures being consistently above 100%. In the previous review the figures from Ashanti, Brong-Ahafo Volta and Greater Accra were ommitted from the Analysis because of these errors. It is only in 2012 that all the regions have been able to get reasonable coverage for this indicator. This shows an improvement in the data quality. Figure 19: Antenatal care registrants and 4+ visits , source GHS ANC 4+ AR WR NR BAR CR VR UER UWR ER GAR Ghana % 54.4% % 35.7% 55.0% 47.3% 45.7% 86.0% 60.9% 78

79 % 78.2% % 46.9% 71.8% 70.2% 59.0% % % 71.9% 81.4% 80.7% 46.7% 72.5% 63.5% 55.3% % % 70.9% 68.4% 67.4% 90.8% % 59.2% 59.3% % % 71.6% 70.8% 66.9% 88.2% 60.2% 84.7% 54.4% 62.9% 82.6% 72.3% Table 28: ANC 4+ by region , source GHS Infant mortality rate 2012 Performance: 53 Target: 30 Source: MICS 2011 Outcome: Results: The infant mortality rate was 53 and increased by 6% over the DHS 2008 figure. Discussion: The national IMR increased only slightly since 2008, but this national average does not show some large regional variations. While IMR is highest in Volta Region, the infant mortality rates of Upper West, Northern and Brong-Ahafo Region are nearly as high. The reported trend in VR and BAR is worrying with significantly worsening of IMR. Since 2003, UWR has made an impressive effort to bring IMR down from 105 to 67. With the scale-up of CHPS, increased utilisation of ITNs, high EPI coverage and improving coverage of skilled deliveries (have we forgot other important initiatives?) since 2008, the ministry did expect to see an improvement of both IMR and U5MR. The ministry plans to analyse the underlying data thoroughly to identify reasons for the observed stagnation in child mortality indicators. AR WR NR BAR CR VR UER UWR ER GAR Ghana DHS MICS DHS MICS Table 29: Infant mortality rate , source DHS (2003 and 2008) and MICS (2006 and 2012) Under-five mortality rate 2012 Performance: Target: 50 Source: MICS 2011 Outcome: Results: The under-five mortality rate remained stagnant since Discussion: Despite stagnation of national average of under-five mortality rate, significant regional variations occurred. Northern Region and Upper West Region have since 2003 had relatively high U5MR. While UWR was able to bring down U5MR by 50%, the U5MR in NR saw only limited improvement. 79

80 AR WR NR BAR CR VR UER UWR ER GAR Ghana DHS MICS DHS MICS Table 30: Under 5 mortality rate , source DHS (2003 and 2008) and MICS (2006 and 2012) Figure 20: Under 5 mortality by region , source DHS (2003 and 2008) and MICS (2006 and 2012) % Deliveries attended by a trained health worker 2012 Performance: 58.5% 2012 Target: 60.0% Source: GHS and THs Outcome: % 35.1% 42.2% 45.6% 48.7% 54.8% 58.5% Results: Coverage of supervised deliveries has steadily increased since 2007 to 58.5% in 2012, a relative increase of 6.7% over Discussion: The MICS gave the country a skilled attendant at delivery coverage of 68.4%. With improvement in the data collection on skilled attendant delivery the routine data will be aligning reasonably well to the survey data from MICS or DHS. Under-five prevalence of low weight for age 2012 Performance: 13.4% 2011 Target: 8.0% Source: MICS 2011 Outcome: % 13.9% 13.4% Results: Under-five prevalence of low weight for age reduced by 3.6% to 13.4%. 80

81 Discussion: The slow reduction in the under-five prevalence of low weight for age is a reflection of the low performance of the sector in nutrition in general. The target of 8.0% is far from being achieved. The coverage of nutrition intervention in the country is not high. Most of the interventions like community management of acute malnutrition and community growth promotion cover only few districts and regions. There will be the need to fully integrate nutritional interventions into the activities of all the Districts in Ghana. The child nutrition campaign launched in May 2012 with the theme Eating Healthy for Goodlife, brought child nutrition to the attention of the general public Health Objective 4: Intensify prevention and control of communicable and non-communicable diseases and promote a health lifestyle Milestone: Healthy lifestyle integrated into basic school and teacher training curricula 2012 Performance: Achieved Source: RHN, PPME, MOH Outcome: +1 Results: In 2012, healthy lifestyle was integrated into basic school and teacher training curricula. Milestone: 50% reduction in Yaws prevalence achieved 2012 Performance: Not achieved Source: GHS Outcome: -1 HIV prevalence among pregnant women years 2012 Performance: 2012 Target: <1.7% Source: NACP - GHS Outcome: -1 Information from sentinel survey not yet available % 2.6% 1.9% 2.1% 1.5% 1.7% %U5s sleeping under ITN 2012 Performance: 39.0% 2012 Target: 70% Source: MICS 2011 Outcome: % 28.2% 39.0% Results: Use of ITN has improved by almost 50% since 2008 reaching 41.5%. Discussion: Since the MICS 2011, ITN use is expected to have increased further, because only Volta and Eastern regions had completed their universal coverage campaigns prior to MICS 2011 data collection. Seven other regions had their campaigns during or after the data collection. While the total number of expected malaria cases among children has not dropped significantly the recent years, the case-fatality of malaria has improved. The MICS survey showed that only 15.9% of children under five with fever had blood 81

82 taken from finger or heel for testing. Based on the, the ministry is concerned about the clinical quality of services, especially diagnostic services related to malaria, and expects that a significant proportion of expected malaria cases are in fact not caused by malaria infection. The national prevalence of malaria parasitaemia in children aged 6-59 months based on microscopy was 27.5% with the highest prevalence in UWR (51.2%) and NR (48.3%). Lowest prevalence was recorded in GAR (4.1%). Despite no clear evidence of causality, it is obvious to relate the high under-five mortality rate in UWR and NR to high prevalence of parasitaemia, and intensify malaria control activities in these two regions. Results: Use of ITN has improved by almost 50% since Discussion: The MICS survey measuring this indicator was done when only two Regions have completed their hang-up campaigns. With the completion of the hang-up campaigns for the whole country, 7,645,745 LLINs have been distributed and household ownership of ITNs stands at 96.7%. It is likely that the percentage of under five sleeping under ITN will be higher than 41.5% The under five malaria case fatality rate for the country has dropped from 1.2 to 0.6. % children fully immunized by age one - Penta Performance: 87.7% 2012 Target: 91.4% Source: GHS Outcome: 0 Results: EPI coverage has been stable close to 90% since Insignificant improvement over Discussion: The Penta 3 coverage over the years has remained consistently above 80%. This is a demonstration of the strength of the EPI programme. The effect of low and erratic flow of funds to the district level which is an issue of great concern appear not to have had much impact on delivering of immunization service. A lot more effort and input however will be needed to move the coverage to 90%. The MICS gave a coverage of 92.1% for Penta 3. The Penta 3 coverage in Upper West Region has been going down over the years but the MICS gave a coverage of 97.4%, so possibly the reduction being seen might be due to low reporting. The same situation pertains in Greater Accra Region with a low routine coverage for Penta 3 but relatively high MICS coverage. There is the need to improve data collection especially from the private facilities in the major Metropolitan areas like Accra and Kumasi % 87.8% 86.6% 89.3% 85.9% 86.5% 87.7% 82

83 Figure 21: Penta 3 coverage by region , source GHS AR WR NR BAR CR VR UER UWR ER GAR Ghana % 89.0% 114.5% 97.3% 92.2% 83.8% 94.8% 93.0% 87.5% 68.3% 86.6% % 88.6% 123.0% 95.0% 96.6% 82.9% 105.9% 94.5% 90.1% 72.7% 89.3% % 96.3% 110.4% 83.3% 85.6% 66.4% 87.3% 79.9% 86.9% 77.9% 85.9% % 98.4% 105.3% 94.3% 82.7% 76.4% 87.4% 78.3% 86.8% 70.0% 86.5% % 94.2% 107.5% 97.4% 86.0% 78.5% 87.1% 72.1% 90.3% 76.5% 87.7% MICS & 98.1% 91.7% 97.5% 85.3% 83.4% 97.7% 97.4% 94.5% 89.1% 92.9% Table 31: Penta 3 by region , source GHS and MICS 2011 HIV Clients receiving ARV therapy 2012 Performance: 73, Target: 80,014 Source: NACP Outcome: ,338 13,429 23,614 33,745 40,575 59,007 73,339 Results: HIV Clients receiving ARV therapy continues to increase. Discussion: The increase in the number of HIV clients receiving ARV therapy is encouraging, however with the uncertainty surrounding the continuous supply of ARVs there are concerns about the interruption of treatment of clients. This development if not addressed promptly can result in development of resistance of the HIV virus to the drugs that are currently being used by the programme. There is an urgent need with the lost of the Global Fund funding to look at how the country is going to ensure continuous supply of ARVs for the increasing clients. Guinea Worm 2012 Performance: 0 cases 2012 Target: <50 Source: GHS Outcome: ,136 3,

84 Results: There has not been a single case of Guinea Worm in Ghana since May Discussion: Transmission of guinea worm has been interrupted. The country continues to maintain surveillance for Guinea worm. 875 of rumours of guinea worm cases were investigated within 24hours. Stop Guinea worm teams have been deployed in 16 previously endemic districts in Brong-Ahafo, Northern Region and Volta Region. A team from WHO visited the country and raised concerns about the surveillance system. The surveillance system need to be improved to ensure the country is certified as guinea worm free. % households with improved sanitary facilities 2012 Performance: 15.0% 2012 Target: 21.3% Source: MICS 2011 Outcome: Not shared 12.4% 15.0% Total 60.7% 71.2% 60.9% Results: The sector wide indicator is defined as coverage of sanitary facilities that are not shared, which increased by 21% to 15% of the population covered. Discussion: While the proportion of the population with access to improved sanitary facilities that are not shared increased, the access to all improved sanitary facilities, shared and not shared, reduced. Actions to improve coverage are done in cross-ministerial collaboration with other ministries. % households with access to improves source of drinking water 2012 Performance: 79.3% 2012 Target: 80% Source: MICS 2011 Outcome: % 83.8% 79.3% Results: The access to improved sources of drinking water worsened since 2008 and came slightly under the set target of 80%. Discussion: Obesity in adult population (women age years) 2012 Performance: No new data 2012 Target: n/a Source: Outcome: n/a Survey indicator not measured in % 9.3% - TB treatment success rate 2012 Performance: 86.2% (2011 cohort) 2011 Target: 89% % 84.6% 85.4% 87.0% 85.3% 86.2% 84

85 Source: National TB Programme Outcome: 0 Results: TB treatment success rate improved slightly over 2011, but the increase was within the 5% margin of sustained performance. Discussion: Treatment success rate continues to improve although the target of 89% was not achieved. The adverse outcomes reduced from 16.7% to 13.8%. The fieldwork to determine the prevalence of tuberculosis was started. Health Objective 5: Strengthen institutional care including mental health service delivery Milestone: Functional ambulance stations in 60% of district capitals 2012 Performance: Achieved Source: National Ambulance Service Outcome: +1 NAS expanded significantly in 2012 opening 97 new stations in Total number of stations is 121 in 120 districts. With 172 district capitals, 70% of districts are covered, and the milestone of covering 60% of these with ambulance stations was achieved. Psychiatric patient treatment and rehabilitation rate 2012 Performance: 84.8% 2012 Target: 25% over 2009 baseline Source: Chief Psychiatrist Outcome: % Result: Total Number of patients treated during the year was 67,732 and the total treated and discharged and number of outpatients treated was 57,404. The rehabilitation rate is calculated as 84.8%. Since this is the first year rehabilitation rate is reported and since there is no figure specified as target, the outcome for the holistic assessment is zero. Discussion: The standard definition of rehabilitation is that treated patients are integrated and able to leave a normal life again. Measuring this indicator under present circumstances is difficult considering the human resource and capacity constraints of the psychiatric sector. The indicator was therefore calculated bas the proportion of patients treated and discharged who are seen at outpatient departments on regular basis. The psychiatric patient treatment and rehabilitation rate was calculated as 84.8%. The M&E Unit of the Ministry of health should enter into discussion with the Chief psychiatrist to refine and sharpen this indicator to ensure appropriate preparations are made to collect the appropriate and agreed data subsequently. The issue of contention is the contextual definition of rehabilitation. Equity index: Ratio of mental health nurses to patient population 2012 Performance: 1: Target: 25% over 2009 baseline Source: Chief Psychiatrist :63 85

86 Outcome: 0 Result: The total number of mental health nurses in the three psychiatric nurses was This comprises both community psychiatric nurses and registered mental nurses. Total number of patients seen during the year was 67,732. The ratio therefore calculates to 1 nurse per 63.4 patients. Discussion: There is an issue of the appropriateness of the denominator. The chief psychiatrist would expect the denominator to reflect the estimated number of people with psychiatric disorder in the community, which is estimated as 10% of total population of the country. Such estimate would amount to 2.59 million patients. However we looked at the intent of the indicator, which is to measure the workload of nurses in the psychiatric sector of the Ministry of Health. The ratio of mental health nurses to patient population was therefore estimated as 1:64. Number of community psychiatric nurses trained and deployed 2012 Performance: Target: 25% over 2009 baseline Source: Chief Psychiatrist Outcome: Result: Current crop of community psychiatric nurses amount to 400. Discussion: No formal training exists for training community psychiatric nurses. All community psychiatric nurses are registered nurses, which have been converted to practice as community psychiatric nurses. For this reason, the indicator is problematic. How is community psychiatric nurse defined? This is a question the team want answered to support future decision regarding training and capacity building. % tracer psychotropic drug availability in hospitals 2012 Performance: 85% 2012 Target: 70% Source: Chief Pharmacist Outcome: % 64% 85% Institutional infant mortality rate 2012 Performance: Target: No target specified in POW 2012 Source: GHS Outcome: Results: Institutional IMR improved significantly in 2012 with more than 50% reduction. Discussion: There are issues with the data quality and accuracy of this indicator, especially with regards to the capture of all deaths occurring in children under one year in the health facilities need to be recognised. The consistently high immunization rate and the drop in vaccine preventable diseases like measles can result in the low Institutional infant mortality that we are seeing. The county has not recorded any deaths due to measles since

87 Basket of critical equipment functioning in hospitals 2012 Performance: No data 2012 Target: 80% Source: No data Outcome: Result: No information available to MOH % tracer drugs availability in hospitals 2012 Performance: 85.7% 2011 Target: 90% Source: Chief Pharmacist Outcome: % 94.1% 85.7% % of hospitals assessed for quality assurance and control 2012 Performance: No data 2012 Target: 90% Source: No data Outcome: Result: No information available to MOH Institutional under-five mortality rate 2012 Performance: Target: No target specified Source: GHS Outcome: Results: Institutional under five mortality has improved significantly in 2012 with more than 50% reduction overall. All the districts experienced reduction with Upper West having a reduction of 91%. Discussion: The non-inclusion of Northern and Central Region in the analysis shows that there are data quality issues. Although there are concerns about the completeness and accuracy of the mortality data, the observed drop in the institutional under-five mortality rate may be a reflection of the improvement in access to care that ensures that children are treated promptly. Health Insurance and community management of malaria, diarrhoea and acute respiration are the main interventions that have improved access to care in the districts. The introduction of community management of malaria, diarrhoea and acute respiratory infection is addressing the major causes of deaths in children under five years. This may also be contributing to this decline. The community interventions for the three diseases are being implemented nationwide, but in Upper West Region, Northern Region and Upper East Region almost all the districts are now implementing the community based treatment for malaria, diarrhoea and acute respiratory infection. 87

88 Figure 22: Under-five deaths by region Not adjusted for population sizes. CR and NR excluded because of unreliable data. Institutional MMR 2012 Performance: 2012 Target: 160 Source: GHS Outcome: GHS (incl. TBAs) GHS (incl. TBAs) + THs MMR at Teaching Hospitals is based on number of supervised deliveries as proxy of live-births Results: Institutional Maternal Mortality dropped significantly from 2011 to At Komfo-Anokye Teaching Hospital the immr continued to be high with 1,252 deaths per 100,000 deliveries. Korle-Bu has reduced immr from 1,133 in 2011 to 841 in Discussion: Korle-Bu Teaching hospital has reduced institutional maternal mortality ratio significantly from 1,133 maternal deaths per 100,000 deliveries in 2012 to 841 in During the year, Korle-Bu initiated and strengthened several interventions to improve maternal services, including education of hospital staff and general public on unsafe abortion, renovation of maternity OPD, addressing staff attitude, training in basic life support and establishment of blood bank at maternity lab. These initiatives appear to have had a positive impact on maternal mortality in the hospital. During 2012, Komfo-Anokye Teaching Hospital established a blood bank at the maternity area and all maternal deaths were audited. Despite these initiatives to improve maternal services, the hospital continued to have a high maternal mortality ratio of 1,252 maternal deaths per 100,000 deliveries in 2012 compared to 1,199 of the previous year. In average, every second day a pregnant woman dies at KATH. The top-causes of maternal death at KATH were conditions related to high blood pressure, i.e. eclampsia and pre-eclampsia. Post partum haemorrhage was the second highest cause and abortion was third. The continuous high maternal mortality ratio at the teaching hospitals calls for stronger and more structured collaboration between the teaching hospitals and the referring hospitals and clinics Recent investigations by Foods and Drugs Authority have revealed poor quality of the investigated medicines, which are potentially life saving in case of maternal emergencies. Almost 70% of all 279 samples of Oxytocin failed the quality test. Sub-standard medicines are likely to have a negative impact on maternal 88

89 mortality ratio at all levels of the health care system. The ministry finds it highly concerning that women die because of substandard medicines and critical for the sector to analyse and address causes of the problem. Step 2: Grouping of indicators and milestones Health Objective 1: Bridge equity gaps in health care and nutition services and ensure sustainable financing arrangements that protect the poor 1 % children 0-6 months exclusive breastfed -1 2 Equity: Poverty (U5MR) -1 3 Equity: Geography - Services (supervised deliveries) +1 4 Equity: Geography - Resources (nurse:population) +1 5 Equity: NHIS - Gender (Female/Male cardholder ratio) 0 6 Equity: NHIS - Poverty (Ratio lowest wealth quintile to whole population who wholds NHIS cards) -1 7 Outpatients attendance per capita (OPD) +1 8 % population living within 8 km of health infrastructure n/a 9 Doctor: population ratio 0 10 Nurse: population ratio 0 Milestone: Review of CHPS undertaken with stakeholders and re-zoning of CHPS completed 0 Total Health Objective 1 0 Health Objective 2: Strengthen governance and improve efficiency and effectiveness in the health system 1 % total MTEF allocation on health +1 2 % non-wage GOG recurrent budget allocated to district level and below -1 3 Per capita expenditure on health +1 4 Budget execution rate (Item 3 as proxy) +1 5 % of annual budget allocations to items 2 and 3 (GOG and SBS) disbursed to BMCs by end of year -1 6 % of population with valid NHIS membership card 0 7 Proportion of claims settled within 12 weeks -1 8 % IGF from NHIS -1 Milestone: System for performance contracting introduced +1 Total Health Objective 2 0 Health Objective 3: Improve access to quality maternal, neonatal, child and adolescent health services 1 Maternal Mortality Ratio (MMR) per 100,000 live births n/a 2 Total Fertility Rate -1 3 Contraceptive Prevalence Rate +1 4 % of pregnant women attending at least 4 antenatal visits 0 5 Infant Mortality Rate (IMR) per 1,000 live births -1 6 Under 5 Mortality Rate (U5MR) per 1,000 live births 0 7 % deliveries attended by a trained health worker +1 8 Under 5 prevalence of low weight for age 0 Milestone: Pneumocococcal and rotavirus vaccines successfully introduced +1 Total Health Objective 3 +1 Health Objective 4: Intensify and control of communicable and non-communicable diseases and promote a health lifestyle 1 HIV prevalence among pregnant women years -1 2 % of U5s sleeping under ITN +1 3 % of children fully immunized by age one - Penta HIV+ clients ARV treatment +1 5 Incidence of Guinea Worm +1 6 % households with improved sanitary facilities +1 7 % households with access to improved source of drinking water -1 8 Obesity in population (women aged years) +1 9 TB treatment success rate 0 Milestone: Healthy lifestyle integrated into basic school and teacher training curricula 89

90 Milestone: 50% reduction in Yaws prevalence achieved Total Health Objective 4 +3 Health Objective 5: Strengthen institutional care, including health service delivery 1 Equity index: Ratio of mental health nurses to patient population 0 2 Number of community psychiatric nurses trained and deployed 0 3 % tracer psychotropic drug availability in hospitals 0 4 Institutional infant mortality rate +1 5 Basket equipment functioning in hospitals -1 6 % tracer drugs availability in hospitals -1 7 % of hospitals assessed for quality assurance and control -1 8 Institutional under-five mortality rate +1 9 Institutional MMR +1 Milestone: Functional ambulance stations in 60% of district capitals +1 Total Health Objective 5 +1 Table 32: Health Objective group scores Step 3: Sector score The outcome of the holistic assessment based on the HSMTDP indicators and cluster in 2012 is positive with a score of +3, which is interpreted as a highly performing sector. Health Objective 1 0 Health Objective 2 0 Health Objective 3 +1 Health Objective 4 +1 Health Objective 5 +1 Sector score +3 Table 33: Holistic Assessment Tool Sector score 90

91 Annex 4: Indicator definitions and calculations Indicator Numerator Denominator Source Calculation 2012 (4%) % children 0-6 months exclusive breastfed Equity Index: Poverty (Richest/Poorest U5 mortality rate) Equity Index: Geography (supervised deliveries) Equity Index: Geography (nurses:population) Number of children 0-6 months exclusively breastfed U5MR among children of lowest wealth quintile Proportion of deliveries attended by a trained health worker in best performing region Number of nurses by total population in best performing region Number of children 0-6 surveyed MICS 2011 Rate stated in report U5MR among children of highest wealth quintile Proportion of deliveries attended by a trained health worker in poorest performing region Number of nurses by total population in poorest performing region MICS 2011 GHS HR Ministry of Health. Population data from GHS 106 per 1,000/52 per 1,000 Equity Index: Gender (NHIS registration) Number of women being active NHIS Number of men being active NHIS MICS 2011 members members Equity Index: Poverty (NHIS registration) Number of women being active NHIS Number of women being active NHIS MICS 2011 members in lowest wealth quintile members in the whole population Outpatient attendance per capita Number of OPD encounters (GHS, CHAG, Teaching Total population provided by GSS GHS Hospitals) % population living within 8 km of health infrastructure Doctor:Population ratio Number of doctors registered at IPPD/MoH Total population provided by GSS HR MoH. Population data from GSS Nurse:Population ratio Number of nurses registered at IPPD/MoH Total population provided by GSS HR MoH. Population data from GSS % total MTEF on Health MTEF allocated to health. Sources: GOG + Donor + Total MTEF for GOG GHS IGF + HIPC + NHIS % non-wage GOG recurrent budget APOW allocation to districts Total allocation GHS allocated to district level and below N/A Per Capita Expenditure on Health Budget Execution Rate of Item 3 Total expenditure on health in Ghana Cedis * Cedit to USD exchange rate (Bank of Ghana per ) Item 3 disbursements from GOG + SBS + HF + HIPC + NHIS (subsidies + distress + MoH allocation) Total population provided by GHS - GHS POW item 3 budget (same sources). GHS GHS % of annual budget allocations to items 2 and 3 disbursed by end of December Disbursements for item 2 and 3 by end of December. Sources: GOG and SBS. Total budget allocations for item 2 and 3 (same sources) GHS % Population with valid NHIS Membership Proportion of claims settled within 4 weeks Total number of active NHIS members (valid NHIS card holders) Number of claims reimbursed (disbursed from DMHIS accounts) within 4 weeks of reception by Total population provided by GHS Proportion provided by NHIA Total number of claims received by DMHIS No information - 91

92 DMHIS % IGF from NHIS IGF from NHIS Total IGF No information - Maternal Mortality Ratio (MMR) per No information - 100,000 livebirths Total Fertility Rate MICS 2011 Rate stated in report Contraceptive Prevalence Rate MICS 2011 Rate stated in report % of pregnant women attending at least 4 antenatal visits Number of pregnant women with 4 or more ANC visits Expected number of pregnancies GHS (based on 4% pop.) Infant Mortality Rate (IMR) per 1,000 livebirths Under 5 Mortality Rate (U5MR) per 1,000 livebirths % deliveries attended by a trained health worker Number of deliveries supervised by trained health worker Number of expected deliveries MICS 2011 MICS 2011 GHS and Teaching Hospitals (based on 3% pop.) Rate stated in report Rate stated in report (based on 4% pop.) (based on 3% pop.) Under 5 prevalence of low weight for Children under 5 years Weight for age % below -2 MICS 2011 Rate stated in report age sd HIV Prevalence among pregnant women n/a n/a National AIDS Control n/a years Programme. Sentinel Surveillance report. % U5s sleeping under ITNs Number of surveyed U5s sleeping under ITN the Number of surveyed children MICS 2011 Rate stated in report previous night % Children receiving Penta 3 Number of children who received Penta 3 Expected number of children 0-12 months GHS (based on 4% pop.) (based on 3% pop.) HIV positive individuals receiving ART Number of HIV positive individuals receiving ART n/a NACP n/a Incidence of Guinea Worm Number of new cases n/a GHS n/a % households with improved sanitary MICS 2011 Rate stated in report facilities (NOT SHARED) % households with access to improved MICS 2011 Rate stated in report source of drinking water Obesity in population (women aged years) No information 92

93 TB success rate Psychiatric patient treatment and rehabilitation rate Equity index: Ratio of mental health nurses to patient population Number of community psychiatric nurses trained and deployed % tracer psychotropic drug availability in hospitals Number of patients proven to be cured of TB after completion of therapy Number of patient commencing anti-tb therapy National TB Programme annual report Rate provided by NTP Number of OPD patients at psychiatric facilities Number of patients discharged from mental Mental Health Authority facilities Number of mental health nurses Number of OPD patients at psychiatric Mental Health Authority facilities Number of community psychiatric nurses trained Mental Health Authority n/a Chief pharmacist Chief pharmacist provided the rate Institutional infant mortality rate Number of institutional deaths among children 0- Number of institutional live births GHS 11 months Basket equipment functioning in No information hospitals % tracer drugs availability in hospitals Chief pharmacist Chief pharmacist provided the rate % of hospitals assessed for quality No information assurance and control Institutional under-five mortality rate Number of institutional deaths among children 0-59 months Number of institutional live births Institutional MMR Number of maternal deaths at government and CHAG institutions, including deaths recorded by GHS supervised TBAs Number of live births in government and CHAG institutions, including deliveries by GHS supervised TBAs GHS 1,188/615,388 93

94 Annex 5: Analysis framework for POW 2012 implementation HO1: Bridging equity gaps in access to health care and nutrition services, and ensure sustainable financing arrangements that protect the poor Strategies Priority actions Activities Expected Output s Status of implementation and comments 1.1 Strengthen district health system with a particular emphasis on primary health care Improve coverage of PHC services at subdistrict level through community health systems Continue to expand CHPS coverage to achieve 500 new functional zones 500 new CHPS zones functional 1. Achieved 516 new functional CHPS zones 2. Training and deployment of newly qualified Community Health Nurses has been carried out. 3. Monitoring and support visits carried out specifically by public heath teams at regional and district levels Difficulty embedding CHOs in community. Relate to Costing Study of 8 staff per CHPS in average. Inadequate equipment. Improve local government support for CHPS through providing orientation to regional and local government staff on the revised CHPS policy and strategy Staff in 10 regional and 170 district local government offices oriented on revised CHPS policy and strategy to support implementation Construction of increased number of CHPS compounds initiated using MMDA funds Activities carried out not available to PHD at HQ. Process initiated but not completed due to lack of funds. Very important that must be coordinated and done. 1.2 Develop sustainable financing strategies that protect the poor and Develop comprehensive health financing framework Develop a comprehensive Health Care Financing Strategy A comprehensive health financing strategy developed and disseminated This activity was not achieved 94

95 vulnerable Update National Health Accounts and initiate institutionalisation National Health Accounts II completed National health accounts updated. Draft report presented to the Ministry of Health. Will be discussed at health summit. Arrangements are made to incorporate data collection tools into already existing surveys like GLSS and DHS. Piloting of capitation payment in Ashanti region Pilot project in progress Capitation piloted. Mid-term evaluation conducted and preliminary findings presented and discussed with stakeholders. Draft report will again be discussed at health summit. The ministry should provide leadership in monitoring the roll-out to other regions Develop comprehensive health financing framework Pilot project on identification of the poor using the common targeting instrument Improved mechanisms for identification of very poor for NHIS coverage Some categories of persons with disability to be covered under the exemption policy Mental health patients to be covered under the exemption policy for services within the benefits package Common targeting mechanism developed and being piloted in 90 districts 1.3 Increase availability and efficiency of human resource Revise and implement the human resource strategy Develop and implement Human resource deployment plan. New HRH deployment plan available and implementation started Scaling up human resource information system by the end of first quarter. This will form the basis for the HRH deployment plan. A tool was developed to guide individual institutional staffing norms. A draft HR policy was circulated. 95

96 HO2: Strengthen Governance and improve the efficiency and effectiveness of the health system Strategies Priority action Activity Expected Output Status of implementation and comments 2.1 Develop capacity to enhance the performance of the National Health system Leadership and management capacity development at all levels Train and equip DHMTs and sub-district teams in managerial and leadership skills (LDP) in 50 deprived districts to improve quality service delivery 50 deprived districts trained and equipped 150 participants from 44 districts in UER, UWR and NR were trained. MOH should strengthen the DHMTs and SDHTs through technical and managerial capacity building. Introduce a structured inservice training for the senior personnel of the MOH and Agencies in evidence-based policy making and programme monitoring Training programme developed and senior officers trained in evidenced-based policy and programme monitoring This activity could not be undertaken. This is the second year running. MOH PPME responsible in POW. Use technical assistance to strengthen capacity in priority areas, including M&E and Public Financial Management (PFM) Improved capacities in priority areas Two long-term advisors embedded in Ministry of Health PPME, M&E and PBU Performance Contracting Implement performance contracting for all agencies and training institutions Performance contract signed with all agencies and training institutions and implemented Performance contract was signed with the Ghana health Service and the Three Teaching hospitals. Performance contracts will be signed with all agencies in the coming year Enforce adherence to sound PFM practices Prepare agencies in readiness for decentralization (composite budgeting etc) and for full implementation of PBB All agencies familiar with composite budgeting PBB being implemented A three-member committee was established to work towards engaging stakeholders to discuss options and implication. Committee has been working in-house and intends to start serious engagement in No clear guidelines on how the health sector should be involved in composite budgeting at district level. 96

97 Some district assemblies organized meetings to integrate health into the composite budget. With the evolving decentralization the role of national level in implementing PBB at district level is unclear. Flow of funds to districts not clear. In 2012, some funds flowed through GHS, some through district treasuries. 2.2 Strengthen the regulatory framework Support the implementation of the revised health sector regulation Development of Legislative instruments (LI) for Acts that were passed in 2011 LIs developed for the health Acts passed in 2011 LIs for Health Institutions and facilities Act (Act 829), Specialist Health Training and Plant medicine Research Act (Act 833), Mental Health Act (Act 846), Public Health Insurance Act (Act859) will be developed in First two are in the ongoing. MOH should lead the process and invite a working group to develop LIs. Establish Health Facilities Regulatory Authority, Ambulance Agency and the Mental Health Authority Health Facilities Regulatory Authority, Ambulance Agency, and Mental Health Authority established Laws for Health Facilities Regulatory Authority, and Mental Health Authority have been passed. Development of Legal instruments is underway to operationalise the laws. The passage of the ambulance agency is outstanding 2.3 Strengthen intersectoral collaboration and public-private partnership Finalize and implement private sector policy Complete the revision of the private sector policy and disseminate same Revised Private Sector Policy disseminated and implemented Private sector policy has been developed. Printing and disseminating of policy is outstanding Promote intersectoral collaboration Develop and implement a plan for strengthening intersectoral collaboration Plan developed and being implemented Plan developed through the creation of cross sectoral working group on health with NDPC providing leadership 97

98 2.4 Strengthen systems for improving the evidence base for policy and operations research Develop a national monitoring and evaluation framework for the sector Finalise and implement the expanded National M&E Framework for the sector National M&E Framework finalized and implemented The draft M&E framework was completed and circulated for comments. It has however been agreed to align the framework with the forth coming HSMTDP II Strengthen health information management Establish the national health sector data repository National health sector data repository established (including private sector data) Refurbishment of CHIM for National Data repository is almost complete Furnishing and equipment yet to be in place. Temporary repository set up with online service data HO3: Improve access to quality maternal, neonatal, child and adolescent services Strategies Priority action Activity Expected Output Status of implementation and comments 3.1 Reduce the major causes contributing to maternal and neonatal deaths Implement the MAF Country Action Plan for improved maternal and newborn care Evaluate the free maternal care policy, disseminate report, and implement recommendations Report available and recommendations taken on board The terms of Reference and contracting of consultants have been done. Study is expected to be undertaken in the first quarter of 2013 Implement the MAF and activities that will address the gaps identified in the EmONC assessment At least 50% of identified health centres provided with basic obstetric care equipment A national assessment report was completed and incorporated into the MAF action plan. The regional MAF work and procurement plans plan have been completed and implementation of some aspects of the plan have started in all the regions Provide blood safety equipment to selected hospitals At least 25% of hospital blood banks nationwide appropriately equipped and made functional 34 health facilities were provided with cold chain equipment: deep freezers, chest freezers, plasma freezers and cold boxes for storage and transportation of blood and blood products. Provide emergency obstetric care equipment to three remaining regions namely Upper West, Greater Accra EmOC equipment provided and in place for the three regions These three regions are still outstanding. 98

99 and Volta 3.2 Reduce the major causes contributing to child morbidity and deaths Implement the Child Health policy and strategy Establish the baseline and introduce pneumococcal, meningococcal and rotavirus vaccines including second dose of measles vaccines Baseline for new vaccines established Three new vaccines and a second dose of measles introduced All activities fully implemented. All vaccines introduced following the establishment of baseline incidence All activities including national launching, public education/social mobilization, training and actual vaccination exercise have been carried. AEFI monitoring also conducted and still ongoing. Pneumococcal, rotavirus, meningococcal and second dose of measles vaccinations are now part ongoing routine EPI programme activities. Mass meningitis vaccination for age group 1-29 years was successfully carried out in the three northern regions MenAfriVac (Coverage 98.1%). Surveillance including use of PCR for diagnosis is ongoing Implement community case management of malaria, pneumonia and diarrhoea Community case management services in a number of districts Following activities carried out: 1. Training and re-training (over 6,000 trained) 2. procurement and distribution of logistics (bicycles, toolboxes, wellington boots, raincoats etc 3. Funds released to regions to implement HBC activities 4. National wide monitoring carried out A total of 136 districts are implementing community case management A total of 136 districts implementing strategy. Challenges including stock-outs of ACTs, poor commitment of some HBC and supervisors, and 99

100 inadequate logistics for all training HBCs. Home-based treatment is currently not covered under NHIS. This challenge needs to be sorted out. Scale up national nutrition interventions in support of Scaling Up Nutrition (SUN) National nutrition interventions scaled up Draft policy for scaling up nutrition developed. Stakeholder consultation is yet to be undertaken for policy to be finalised. Strategic plan will be developed after the policy is approved. 3.3 Improve the health of adolescents and youth Implement the Strategic Plan for adolescent health and development Implement standards for adolescent and youth friendly health services in Ghana Standards implemented in a number of regions / districts 3.4 Improve nutritional status of women and children Develop and implement National Nutrition Policy and Strategy Disseminate and implement the National Nutrition Policy Nutrition policy and strategy disseminated in 10 regions Draft policy for scaling up nutrition developed. Stakeholder consultation is yet to be undertaken for policy to be finalised. Strategic plan will be developed after the policy is approved. HO4: Intensify prevention and control of communicable and non-communicable diseases and promote healthy lifestyle Strategies Priority action Activity Expected Output Status of implementation and comments 4.1 Improve upon prevention, detection and case management of communicable diseases Prevention and control of communicable diseases Prevention, detection and management of HIV/AIDS, TB and malaria Provide ICT equipment support to 86 district level disease surveillance units Implement national strategic plan to reduce new HIV cases 86 districts provided with ICT equipment New HIV cases reduced A total of 180 computers and accessories were procured. Distribution is still ongoing. Malaria Control programme procured 150 and International Association of Public Health Institutes procured 30 with moderns. Implementation of national strategic plan has started. Some of the activities conducted include: 1. HIV Counselling and Testing including Know Your Status campaign 2. PMTCT Services- testing of pregnant women, ARVs for positive mothers 100

101 Implement national strategic plan to increase TB case detection and cure rate Implement national strategic plan to reduce malaria case fatality among pregnant women and children TB case detection and cure rate increased Case fatality reduced 3. ART services at all the centres 4. Sentinel surveillance carried out and data being analysed Analysis of Sentinel Survey carried out is ongoing. Results will indicate extent of progress with respect New HIV infections etc Implementation of national strategic plan has started. Some of the activities conducted include: 1. Training of regional and district teams for case detection among vulnerable groups 2. Capacity building for laboratory staff 3. Active case findings in Accra Metro areas 4. Routine screening of TB among health care providers established (KATH and KBTH) 5. Regional Referral clinicians identified and managing referred cases 6. Nutritional assessment, Counselling, and support with provision of food for TB patients, and PLHIV with support from FHI 360 These activities have significantly improved TB outcomes. 1. Case notification as at June 2012 was 6,500 as against 8,104 for the Jan-Dec. 2011) 2. Treatment success = 86.2% Implementation of national strategic plan has started. Some of the activities conducted include: 1. Procurement and distribution of ATs through AMFm programme 2. Diagnosis using RDTs and microscopy 3. LLINs Hang Up campaign in all regions 4. IPT-P 5. IRS in Ashanti and Northern Regions 6. Limited larviciding 7. Public education There has been improvement in most of the process indicators including IPT-P2 coverage, household ownership, proportion of confirmed cases etc. 101

102 Malaria Case Fatality among all malaria cases admitted was 0.6%. Surveillance activities including case searches were intensified; Public education ongoing. No case of Polio or confirmed Guinea Worm seen. Eradication status, i.e. zero cases maintained throughout the year. 1. Conducted one integrated round of community based Mass Drug Administration (MDA) for LF, Oncho in 121 districts (Coverage 73.6%) 2. Conducted one integrated round of school and community based MDA for SCH in 120 districts and STH in 170 districts (Coverage 80%) 3. Supported TF surveillance activities in 29 districts where Trachoma transmission has been broken. 4. Constituted and held two Intra Country Coordinating Committee (ICCC) for the NTD program 6. Finalized 2011 to 2015 NTD Master Plan for Ghana in collaboration with WHO and share with stakeholders 1. MDA coverage for (Oncho and LF)=73.6% 2. School based Schisto treatment=80% 3. Prevalence of Oncho in 34 villages surveyed: 0-32% with 5 of the villages above threshold of 5%. 4. Entomological surveyed showed infections at Sissili and Mo river basins 50% reduction was not achieved. Yaws logistics were distributed to all regions Monitoring visits conducted Yaws programme launched Some regions have not completed their simplified yaws baseline mapping, implementation of MDAs and monitoring of endemic communities. Poor contact tracing and treatment means poor yaws elimination activities. All districts are below the target of: - Contact: Case Prevention, detection and management of diseases of epidemic potential and those targeted for eradication Maintain polio free status and validate eradication of guinea worm and polio Increase coverage of community activities for Neglected Tropical Diseases (NTDs) especially onchocerciasis, lymphatic filariasis, trachoma, yaws and leprosy Guinea worm and polio eradication status maintained Increased case detection for NTDs 50% reduction in yaws prevalence achieved 102

103 ratio of Improve prevention, detection and management of non communicable diseases Implement Regenerative health and nutrition programme Incorporate healthy lifestyles into basic school and teacher training curricula Healthy lifestyles incorporated into curricula Healthy lifestyles incorporated into curricula of 1 st and 2 nd cycle institutions. Textbooks and practical guide developed for tertiary institutions and health training institutions. Training of lecturers of health training institutions to be conducted soon Not done, however, a proposal to set up alcohol support centre at the Accra psychiatric hospital and Pantang was developed and sent to Chief Director. Cancer control strategic finalized and submitted to PPME (GHS) for printing and dissemination. No funds secured yet for printing. Document not printed for dissemination due to lack of funds. Not done. 1. Guidelines were developed in collaboration with ICD. 2. Routine screening of patients who attend facilities is however ongoing. Information on status of dissemination of guidelines to be ascertained from ICD; Routine unstructured screening ongoing. Support the alcohol/substance abuse facility at Pantang Implement the national strategy for cancer control and expand screening program for hypertension, diabetes and sickle cell in all regional hospitals Improved functioning of the Pantang alcohol/substance abuse services National Strategy for Cancer Control disseminated in all regional hospitals Scale up detection and management of non communicable diseases Screening centres for hypertension, diabetes and sickle cell established in all regional hospitals HO5: Improve Institutional care, including mental health service delivery Strategies Priority action Activity Expected Output Status of implementation and comments 5.1 Enforce standards, guidelines and protocols to improve the quality of institutional care Ensure the availability of equipment and infrastructure required for adherence to standards, guidelines and protocols Complete and commission the Tarkwa District hospital Tarkwa District hospital completed and commissioned Civil Works for Tarkwa District Hospital is at 98% completion. Bidding for Tarkwa Hospital Equipment has commenced Bidding Documents for Tarkwa furniture finalized Construct District hospital at Bekwai District hospital 50% Construction of Bekwai District Hospital commenced 103

104 Bekwai completed in August 2010 and at 52% Completion Bidding Documents for Bekwai Equipment and furniture finalized Completion of 5 Polyclinics at Babile/ Brefo, Wechau, Ko, Lambuse and Han 5 Polyclinics at Babile/ Brefo, Wechau, Ko, Lambuse and Han completed and commissioned Construction of five (5) Polyclinics at Wechau, Babile, Lambussie,Ko and Hain in the Upper West Region were completed and commissioned. Construct 30 CHPS compound in 6 regions Completion of Offices for the Nurses and Midwives Council (NMC) at Okponglo, Accra 30 CHPS compound constructed in 6 regions and commissioned Offices for the NMC at Okponglo, Accra completed and commissioned 8 compounds completed. Another 11 compounds are at various stages of completion. Project has been reactivated. Contractor has moved to site. Works ongoing Expansion of 6 Health Training Institutions at Goaso, Nandom, Agogo, Pantang, Hohoe and Wa Major Rehabilitation and upgrading of Tamale Teaching Hospital (TTH) including housing programme for staff 6 Health Training Institutions expanded Upgrading and rehabilitation of TTH completed and commissioned 75% of housing programme for staff at Tamale Teaching Hospital completed Works at Agogo and Hohoe nearing completion. Procurement Procedure completed for award of contract(goaso, Nandom, Pantang) First phase of the upgrading and rehabilitation completed in the following areas(new building, block E,8theartres, ICU, CSSD, Radiology, A&E Department, Paediatric block, Mothers block, Medical gas, underground water storage 75% of Tamale Teaching Hospital housing component completed Major Rehabilitation and upgrading of Phase 3 of Phase 3 rehabilitation of Bolgatanga regional hospital Still at the pre-contract phase. All necessary documentations have been prepared. Awaiting no 104

105 Bolgatanga Regional Hospital about 50% completed objection from the Saudi s who are the financiers. Upgrade Radiotherapy and Nuclear Medicine project at KBTH and KATH Upgrading of radiotherapy and nuclear medicine project in KATH and KBTH about 80% completed Supply of equipment for KATH and KBTH is expected in the Country by May, Supply and Install Medical equipment in 8 regional, 3 teaching and 90 District hospitals nationwide First phase of medical equipment supplied and installed in 8 regional, 3 teaching and 90 district hospitals nationwide MRI/CT installed and are being tested Pediatric surgery theatre completed. First phase of kitchen completed Laundry installations on-going Pre-installation works on-going in main radiology department 260 new beds, 70 patient trolleys, 140 BP apparatus, 35 weighing scales delivered and distributed across wards in the hospital CT scan buildings on-going in Ridge, Koforidua, Sunyani, Cape Coast, Effia-Nkwanta hospitals Deliveries to PML, Tema General Hospital, Castle Clinic Supply and install digital X- Ray equipment for 23 hospitals Digital X-Ray equipment for 23 hospitals supplied and installed 5.2 Strengthen the system capacity for emergency response Develop and strengthen framework for emergency response Expand coverage of ambulance service 80 operational district ambulance stations established 97 new operational district ambulance stations established 105

106 Expand access to safe blood and blood products Develop systems for blood safety and availability in health facilities Systems developed for effective and efficient blood services nationwide A National blood collection plan was developed. Process for recruitment and training of 10 professional blood donor recruiters initiated with HRDD of GHS. A training workshop was organised in November for 10 Blood Donor recruiters by TA consultants of Safe Blood for Africa foundation under the CDC/PEPFAR task order 5.4 Ensure commodity security of health technologies for medical products including traditional medicines Finalize and implement guidelines for health technologies for medical products including traditional medicines Implement the commodity security recommendations Recommendations of commodity security report implemented 1 The Technical Working Group completed the preparation of the 5 Year Master Plan for Supply Chain Management. Consultations with relevant stakeholders were completed. A cabinet memo was signed by the Hon. Minister of Health for onward submission to cabinet. The Head of the SCMU has since been appointed. The RDHS and Regional DDPS Groups have separately protested against the attempt to centralize procurement 5.5 Increase access to mental health services Establish mental health services in all regional hospitals Develop community mental health strategy Community mental health strategy developed and disseminated A community mental health strategy have been developed and awaiting printing. 1 Director of P&S to provide 2 critical activities 106

107 Annex 6: Capital Investment Update POW 2012 sn Facility Type Locations Name of Contractor Source of Funding Cost Status Agreement Town Region Date ONGOING PROJECTS 1 District Hospitals Konongo Odumase Ashanti Euroget de- Salaga Northern Invest/Subcontractors Tepa Twifo Praso Nsawkaw Adenta/Madina Ashanti Central Brong Ahafo Greater Accra 2 Regional Hospitals Wa Upper West Euroget de- Kumasi Ashanti Invest/Subcontractors Euroget de-invest Euroget de-invest US$339,000,000 All the necessary technical agreements have been reached between MOFEP and Barclays Bank PLC on one hand and Euroget De- Invest for the take-off of the project. All the design works and preliminary site clearing and hording have been completed on all the 8 sites 3 Polyclinics Odumase/Kwatire Brong Ahafo VAMED VAMED 8,650, Site handed over. Works have Wamfie Brong Ahafo commenced Nkrankwanta, Bomaa Takyimantia Brong Ahafo Brong Ahafo Brong Ahafo Total Disbursement Undisbursed Balance 15/11/12 $19,040, $319,959,940 1/11/11 2,162, ,487, Upgrading of Teaching Hospitals Tamale Northern SIMED/CONSAR LTD. ORET/Fortis Bank 39,300, Sectionally completed including 26/01/ ,479, ,820, New Buildings Block E,8 Theatres, ICU,CSSD, Radiology, A&E Department, Peadiatric Block, Mothers Hostel, Medical GAS, Underground Water Storage etc. 5 Housing Tamale Northern CONSAR LTD. GOG GHC10,834, Construction works about 75% GHC7,869, GHC2,965, complete Consultancy Osei Kuffuor, Sohnes & Partners 1,077, /1/10 1,050, , Supply and Installation of 5MVA, 34.5/11 KV Bulk Power 7 Radiotherapy & Nuclear Medicine Centre 8 Health Services Rehab Project III Tarkwa Western Region 9 Rehab and expansion of Bolga hospital project phase III 10 Health Services Rehab III Blood Transfusion Centre 11 construction of Trauma and Acute Care Centre for Korle-Bu Teaching Hospital Tamale Northern IESL LTD. GOG $ 1,336, GHC 874, Works ongoing and about 75% complete 13/3/12 $1,013, GHC750, $322, GHC124, KATH Ashanti OFID US$13,500, *Contract awarded for Supply of 3/4/09 $414, $743, KBTH Greater Accra BADEA equipment. 1st batch of equipment expected by end of March. * Designs and estimates of the civil works have been submitted by Consultants for review. $329, African Development UA17,640, construction and equipping of 6/4/03 Bank District Hospitals in Tarkwa and Bekwai Ashanti Ecowas Fund UA 5,199, Bekwai would be completed by April, The civil works are completed awaiting the equipment installations 18/06/2010 Bolgatanga Upper East GOV'T OF SAUDI SAR 45,000, ARABIA Accra, Kumasi and Nordic Development 8,300, /08/2003 Tamale Fund Korle Bu Greater Accra SAUDI, OPEC & BADEA US$45,000, The Ministry has got both cabinet and parliamentary approvals. The process for the selection of consultants is currently under way 12 Rural Health Services Project II Nationwide Nationwide OPEC Fund $8,500, District Hospitals and 19 out of 21/12/

108 the 21 healthcentres have been completed and handed over. Outstanding works currently ongoing on 3 uncompleted ones. 13 Laundry Project Nationwide Nationwide KBC Bank of Belgium 2,867, Parlimentary and Cabinet Approved, doc. sent to MOFEP for VFM audit 14 Ongoing Capital Projects Nationwide Nationwide General Capital Corporation of USA 300,000, Awaiting Parliamentary Approval 15 Installation of Xray Equipment in Selected District Hospital St. Peter's Hosp. Jacobu Mankranso Dist. Hosp. St. Patrick Hosp., Offinso Atebubu Dist. Hosp. Dormaa Muni Hosp. Holy Family Hosp, Duayaw Nkwanta Abura Dist. Hosp. Ajumako Dist. Hosp. Assin North Muni. Assembly Mfantsiman Muni. Hosp. St. Martins Hosp. Enyiresi DH Weija Hosp Maamobi Polyclinic Pantang Psychiatry St. Joseph Hosp, Nkwanta Adidome Hosp Dodi Papasi Hosp Ashanti FSC 4,970, Equipment supplied and installed in all beneficiary hospitals Ashanti Ashanti Brong Ahafo Brong Ahafo Brong Ahafo Central Central Central Central Eastern Eastern Greater Accra Greater Accra Greater Accra Volta Volta Volta 16 Ambulances NAS KFW 10,000, Ambulances received and allocated by NAS 17 Accelerating TB Case Detection in Ghana 18 Cons. & Equi. Of 597-Bed University Hosp. In Legon, & additional works in Ho Regional & Hohoe Dist. Hosp. Nationwide Nationwide ORIO Dev. Stage complete, awaiting cabinet approval. yet to commence implementation Accra Ho Hohoe Greater Accra Volta Bank Hapoalim B.M. of Israel $359,000, The supply contract has been signed and sod has been cut for works to commence in November, Finalisation of pre-contract works. This is a turnkey project which is scheduled to be completed within 24 months 28/11/11 3,712, ,257, /8/10 9,500, , Polyclinics Odumase/Kwatire Brong Ahafo VAMED VAMED 8,650, Site handed over. Works have 1/11/11 2,162,500 6,487,500 Wamfie Brong Ahafo commenced Nkrankwanta, Brong Ahafo Bomaa Brong Ahafo Takyimantia Brong Ahafo 20 Supply of Equipment Selected Institutions Nationwide OPIC/Deutsche Bank Of New York $267,000, The Project is ongoing, 1/11/11 $193,040, $73,959,

109 21 1 Regional Hosp., Ridge Greater Accra Bouygues Batiment Int. HSBC Bank & Exim Bank, USA 22 Construction of 7 District Hospitals and Intergrated IT systems Sekondi Abetifi Garu Kumawu Fomena Western Eastern Ashanti Ashanti NMS Infrastructural Limited/ Barclays Bank PLC and Barclays Bank Ghana Limited Dodowa Greater Accra Takoradi Western US$250,000, $ 175,000, Cabinet and Parliamentary approvals have been gotten and currently Value for Money Assessment is on-going. The completion of the VFM assessment will culminate into the signing of the supply contract The VFM assessment and negotiations have been completed. The Contract has been signed and ready for take off upon the final review of the designs 23 Supply of 200 Ambulance Nationwide Big Sea Stanbic Bank $15,800, Executive and Parliamentary Approval Received. Awaiting VFM 24 Maternity and Children's Block KATH Ashanti S. K. Mainoo & Co. Ltd./Cymain (GH) Ltd. (Civil Works) Consultancy Services for Maternity and Children's Block GOG GH 49,921, Works ongoing. Civil works about 55% complete 19/11/12 $9,287, GH 8,825, US$250,000, AESL (Consultancy) GH 997, GH 345, GH 652, Maternity and Children's Facility Tema Greater Accra Proko (GH) Ltd. GOG GHC 1,687, Works ongoing. Civil works about 45% complete Consultancy Services for the Maternity and Children's Facility Izmatrix Architects & Dev. Consultants GH 153, Upgrading of Old Tafo Hospital Tafo Ashanti Konneh Ent. Ltd. GOG GH 2,380, Project reactivated. Works ongoing 2012 GH 2,380, Construction of OPD at Manhyia Kumasi Ashanti GH 800, Project has been reactivated for 2012 GH 800, Hospital completion 28 Remodelling of existing structures to classrooms, Staff Accomodation and kitchen for CHNTS, Fomena Consultancy Services for the Remodelling of Existing Structures to classrooms, Staff Accomodation and kitchen for CHNTS, Fomena 29 Construction of Wards, CSSD a& Laundry, Theatre, Mortuary and Block of flats for Akatsi District Hospital 30 Completion of Classroom, Hostel and External works at NTC, Agogo Construction of 4-Unit Classroom Block at Agogo Consultancy Services for the Construction of 80 capacity Hoste and 4-Unit Classroom Block at Agogo 31 Construction of Classroom and External works at NTC, Cape coast Fomena Ashanti M. Barbissotti & Sons Co. Ltd. GH 689, GH 997, GOG GH 3,082, Project reactivated. Works ongoing Feb GH 136, GH 2,945, AESL (Consultancy) GH 2,691, Akatsi Volta Maripoma Ent. Ltd. NHIS GHC 12,356, Approval received from CTRB, Award notification given and contract sign. Awaiting site handing over GHC 12,356, Agogo Ashanti Paafcons GH. Ltd. GOG GHC1,265, The project which is about 70% was 1/4/05 GH 424, GH 526, stalled for about 2years has been reactivated and the contractor has Gecam Superior Co. Ltd. GH 229, moved site to complete the works. GH 182, GH 46, Sufficient provision has been made Design Habitat GH 85, in the 2013 budget to make sure GH 32, GH 52, the project does not lack funds until it s completion Cape Coast Central Kofi Essuman Ent. Ltd. GOG GH 3,764, Contractor on site to complete the additional external works (Power supply, sanitary area, cooking area, retaining wall, etc.) The project is GH 2,237, GH 1,679, Consultancy Services for the Bows Consortium Ltd. GH 165, GH

110 Construction of Classroom and External works at NTC, Cape coast about 80% complete 32 Rehabilitation of Offices for Ghana National Drugs Programme and Procurement Unit 33 Rehabilitation of Offices and Workshop for Tema Mechanical Workshop 34 Construction of Office complex for St John Ambulance and National Ambulance Service 35 Construction of New facilities in 13 Health Training Institutions Accra Greater Accra Philiyanco Co. Ltd. GOG GHC772, Work is ongoing and progressing steadily. The roof beams have been cast and waiting for the concrete to cure before erecting the roof trusses to receive the roofing. This project was initiated after the GNDP office was gutted by fire in The project is about 48% complete Tema Greater Accra Philiyanco Co. Ltd. GOG GHC1,356, Contractor has already moved to site and the works are progressing steadily Accra Greater Accra Prime Star Ltd. GOG GHC1,660, Work is ongoing and progressing steadily about 95% complete. The Ministry s inability to honour claims or certificates has caused so much delay in the completion of the project. The last certificate for instance was received in September, 2012 but is yet to be honoured. Goaso MTS - Classroom Block Lot 1A Goaso MTS -Hostel Block Lot 1B Pantang HATS- Classroom Block Lot 2A Pantang HATS-Hostel Block Lot 2B Kokofu HATS Classroom Block Lot 3 Hohoe MTS Classroom Block Lot 4 Nandom MTS Classroom Block Lot 5 Asankragua HATS Classroom Block Lot 6 Wa HATS Classroom Block Lot 7A Wa HATS Hostel Block Lot 7B Tarkwa MTS Classroom Block Lot 8 Korle Bu POCCN Classroom Block Lot 9 Brong-Ahafo Akate Farms & Trading Co. Ltd. GOG/NHIS GH 2,107, a Approval received from CTRB. Contracted Awarded and signed. FB Telmax Investment GH 2,788, Ltd Greater Accra Asaric Co. Ltd GH 1,989, Hardwick Ltd. GH 2,918, Ashanti Survivor Ltd. GH Volta Alnort Co. Ltd GH Upper West K. A. Estates GH 2,137, Western Akalifa Ltd GH 2,385, Upper West Shamrock Ent. GH 2,143, Ahms world Ltd GH 2,881, Western Malsons Ltd GH 2,400, Greater Accra Philiyanco Ltd GH 3,489, GH 502, GH 407, GHC1,544, GH 269,

111 Dua Yaw Nkwanta PATS Classroom Block Lot 10 Brong-Ahafo Samaward GH Ltd GH 2,306, Nadowli MTS Upper West Yunrams Ltd. GH 2,450, Classroom Block Lot 11 Nadowli MTS Hostel High Trust GH. Ltd. GH 2,355, Block Lot 12 Sampa HATS Brong-Ahafo Barnes-Say Ltd. GH 2,233, Classroom Block Lot 13 Kete-Krachi MTS Volta Bawahuud Ltd. GH 2,475, Classroom Block Lot Completion of Shama Polyclinic Shama Western Bremu Const. Ltd. GOG GH 2,332,110.4 GH 267, GH 2,064, Consultancy Service for the Cost Plan Consult GH 438, Nil GH 438, Completion of Shama Polyclinic 37 Completion of Reconstructive KBTH Accra F. F. Const. Ltd. GOG GH 831, GH 823, Plastic Surgery and Burns Centre Consultancy Service for the Bows Consultium Ltd. GH 83, Completion of Reconstructive Plastic Surgery and Burns Centre 38 Refurbisgment/Upgrading of the Kaneshie Polyclinic to District Hospital Accra Greater Accra Sambros Complex Ltd. GOG Consultancy Service for the Refurbisgment/Upgrading of the Kaneshie Polyclinic to District Hospital 39 Completion of office complex for Nurses and Midwives council Consultancy Services for the Completion of office complex for Nurses and Midwives council 40 Water Improvement programme Various Upper East, Northern & Brong Ahafo 41 Refurbisgment/Upgrading of the Kaneshie Polyclinic to District Hospital Consultancy Service for the Refurbisgment/Upgrading of the Kaneshie Polyclinic to District Hospital 42 Rehabilitation of Bechem Hospital 43 Construction of 59 CHPS Compounds and Equipping of Renovation of the Centre for Health Information Management Optimum Shelter Partnership Okponglo Greater Accra GOG/IGF GH 1,319, GH 70, In the process of putting together all the necessary documentation leading to the reactivation of the project. The Contractor is however, at the site doing some minor works awaiting the Consultants directives. The project is about 40% complete GHC 531, GH 55, Accra Greater Accra Sambros Complex Ltd. GOG Sambix Ltd. GOG GHC1,898, The Contractor has already moved to the various sites since June, 2012 and the works are progressing steadily Optimum Shelter Partnership Bechem Brong Ahafo SAGES CONSULT GHANA GOG GHC 210, LIMITED North West Consortium Various Upper West JAICA Korle-Bu Sch. Of Hygiene Greater Accra Maruks Contract Work GOG GH 97, Work is ongoing and progressing steadily about 75% complete. GHC 569, GH 60,

112 Offices at Korle-Bu School of Hygiene GHS PROJECTS 1 Proposed Construction of Catering & Support Services and External Works at GHS Learning Centre at Pantang Lot 1C Pantang Greater Accra Malsons Ltd. GOG GH 1,972, Work in progress and about 89% complete GH 2,553, Proposed Construction of Conference Facility at GHS Learning Centre at Pantang Lot 1A Rich Bebe Agencies Ltd. GOG GH 2,873, GH 3,118, Consultancy Services for the Proposed Construction of GHS Learning Centre at Pantang FAB Arch Consult GOG GH 631, GH 634, Completion of Outpatient Department at Pantang Psychiatric Hospital, Accra Pantang Greater Accra Micador Const. Wks. Ltd. GOG GH 397, Work in progress and about 97% complete 2011 GH 397, Refurbishment of Children s Block for Korle-Bu Teaching Hospital, Accra KBTH Greater Accra Rich Bebe Agencies Ltd. GOG/IGF GH 3,499, Contractor has moved to the sites and waiting for the payment of Aadvance Mobilization Remodeling of 4-Storey Office Block for Disease Control Unit KBTH Greater Accra Rich Bebe Agencies Ltd. GOG GH 2,428, Work in progress and about 75% complete 1/3/12 GH 1,652, PIPELINE PROJECTS 1 Regional Hospitals Wa Upper West China Shanghai $200,000, Awaiting Cabinet and Parliamentary Approval 2 Five Healthcare Projects (Cape Coast Hospital, KATH, KBTH, 10New District Hosp & Supply of Equipt SYMEX Healthcare Corporation/ Infrastructure Logistics $590,000,000 Awaiting Cabinet Approval. The project has been reprioritised to construct 2 regional hospitals and 5 District Hospitals. 3 Construction of staff housing for Tema General Hospital Tema Greater Accra Canadian Commercial Corperation Proposal and terms sheet have been forwarded to MoFEP for review and advise 112

113 4 Boosting Reproduction and Child Health in 31New Districts & Municipalities ORIO Development phase yet to commence 5 Ambulances Exim Bank (NMEIEC) $ 530,680, Yet to seek Parliamentary Approval District Hospitals Polyclinics Accomodation Units 6 District Hospital Akontombra Western ORIO Development stage-feasibility studycompleted, awaiting Polyclinics Bogoso Western implementation stage Mpoho Western Ellubo Western Nsuaem Western Wassa Dunkwa Western 7 Const. Of 10DH, Supply of 350 Ambulance,Medical Devices and setting up of National Training Centre International Commercial Bank, China/NORINCO $432,000, Yet to seek Cabinet Approval Bed Trauma Hospital in Takoradi & Additional works on Effia Nkwanta Hospital and 3 District Hospitals Deutsche Bank, London $380,000, Draft loan agreement received from funding agency, yet to proceed to cabinet 9 Development of Additional Services and Infrastructure for the Tamale Teaching Hospital Tamale Northern Canadian Commercial Corperation Awaiting technical briefing on way forward from CCC. Discussions on MOU which is yet to be signed 10 District Hospitals International Finance & Development Corporation $126,000, Loan agreement under review by MOFEP 11 Supply of 100 Ambulance Nationwide Turkish Government $7,000, Evaluation for selection of supplier Bed District Hosp. At Kumawu Kumawu Ashanti Belstar Group $100,000,000 Proposal Submitted to MOH 13 District Hospitals TECHNOFAB Eng. Ltd $100,000,000 Signed MOU, Financial Terms Submitted to MOFEP for Review 113

114 Bed Teaching Hosp PP-Pettersen & Partners Ltd $825,000,000 Signed MOU, yet to submit firm offer 15 Construction of 4 District Hospitals, 4 Polyclinics with 120 Units of Staff Accommodation Univeral Hospital Group Limited, Ghana $135,000, Signed MOU 16 Construction of 10 District Hospitals Sonomed Limited, Israel $350,000, Signed MOU 17 Construction of Affordable Housing for Doctors, Nurses and other Medical BATTIS CO. LTD Request sent to MOFEP for annual budget provision of GHC 1.5m as repayment 18 Urology Centre at Korle Bu Teaching Hospital with PPP Accra Greater Accra VAMED Proposal has been sent to PPP Desk at MOFEP for way forward 19 Construction of 12No bed Hospital Various Sites Nationwide Anyinam,Tumu, Buipe,Nyinahin, Wassa Akropong,Dam bai Alliance International Partners $260,100,000 Cabinet memo sent to Mofep for onward transmission to Cabinet. 20 Supply of 400 Ambulance Nationwide Tanink Group $31,500, Executive Approval Received awiating Parliamentary approval 114

115 Annex 7: Procurement plan Draft 2012 Procurement Plan: MOH HQTS Budget Period: January - December,2012 Ref No. Procurement Package (Description) Estimated Need Gh Source of Funding Procurement Method Start Date Expected Contract Completion Date 1 Procurement of Pharmaceuticals 12,000, Drug Revolving Fund ICB 30/11/2011 7/08/2012 2a Procurement of Non Drug Medical Consumables 6,000, CMS Non-Drugs A/C RT 23/05/ /03/2012 2b Procurement of Non Drug Medical Consumables 6,00, CMS Non-Drugs A/C ICB 23/01/ /09/2012 3a Expanded Programme on Immunization (EPI) Vaccines 18,000, GAVI UNICEF 29/10/ /07/2012 3b Expanded Programme on Immunization (EPI) Vaccines 3,537, GOG UNICEF 23/01/ /04/2012 4a Procurement of Contraceptives 3,250, GOG ICB 01/02/ /07/2012 4b Procurement of Contraceptives 4,478, GOG ICB 26/12/ /07/2012 4c Procurement of Contraceptives 1,400, WAHO ICB/UNFPA 26/12/ /04/2012 4d Procurement of Contraceptives 9,943, USAID USAID 06/02/ /09/2012 4e Procurement of Contraceptives 2,445, UNFPA UNFPA 23/01/ /08/ Procurement Psychotropics Drugs 4,043, GOG ICB 10/02/ /07/2012 6a Procurement of HIV/AIDS /Antiretroviral Drugs 2,400, GOG ICB 10/02/ /07/2012 6b Procurement of HIV/AIDS /Antiretroviral Drugs 22,350, Global Fund ICB 10/02/ /07/ Procurement of Opportunistic Infection (Ois) 175, Global Fund Medicines 8 Procurement of Rapid Diagnostic Test Kits 4,219, Global Fund ICB 10/02/ /08/ Procurement of other Diagnostic products, supplies 5,982, Global Fund ICB 10/02/ /08/2012 and equipment 10 Procurement of Insecticde Treated Nets (ITNs) (Global 150, GOG ICB 10/02/ /07/2012 Fund) 11 Procurement of Artemisinin Combination Therapy 23,409, Global Fund ICB 8/03/ /09/2012 Tablets 12 Procurement of other Antimalarial Medicines 1,376, Global Fund ICB 8/03/ /09/ Procurement of Rapid Diagnostic Test Kits 8,066, Global Fund ICB 10/02/ /08/ Procuremt of Anti-Rabies Vaccines 500, SBS ICB/NCB 27/01/ /06/ Procurement of Tatanus Immuniglobulin 600, SBS ICB/NCB 02/02/ /07/ Procurement of Anti-Snake Venom Serum 1,000, SBS ICB 27/01/ /06/ Procurement of CSM Vaccines & Drugs 1,000, SBS ICB 27/01/ /06/ Procurement of Hospital equipment,beds &other 1,800, GOG ICB 8/03/ /09/2012 Accessories 19a Printing Material and other, Publications 790, GoG NCT 27/01/ /12/ b Printing of Medical Forms, Publications (CHR,Imm.Cards,etc) 2,400, Gap RT 19/12/ /06/

116 20 Procurement of Office Equipment & Stationery for the 1,000, Gap NCT 27/01/ /12/2012 Various Directorate 21 Procurement of Medical Consumables/Office 1,120, GOG NCT 16/03/ Sanitation Items for NAS 22 Supply of Logistics for Cholera 79, GOG RT 27/01/ / Extention of Contracts: Clinical Laboratory 16,765, GOG Contract 12/07/ /06/2012 Strengthening Project. Phases 1 and 2 Extension 24 Procurement of 1000 Saloon Cars Under MOH, SVHPS 37,852, Car Revolving Fund ICB 23/06/ /05/2012 (Health Workers) 25 Procurement of Hand Sanitizer 2,640, Gap RT 10/11/ /05/ Procurement of Dental Equipment 114, Gap NCT 26/12/ /06/ Procurement of Supplies and Printing of forms for 400, SBS RT 28/11/ /05/2012 Buruli Ulcer Programme 28 Capital Investment Projects 717,347, GOG/SBS/EM GRANTS/MIXED NCT 27/01/ /12/2012 GRANTS/IGF/SIP/NHIL Grand Total 921,534,

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