SMC in GHANA: current status & lessons learnt JAMES FRIMPONG, PROGRAMME OFFICER NMCP, GHANA

GHANA: operational map 2015 Implementation Upper West Region (11 Districts) Operational funds provided by the Global Fund Medicines provided by DFID Door-to-Door Approach Trained Community Volunteers 4 Rounds of dosing

GHANA: operational map 2016 Implementation Upper West and Upper East Regions (11+13 Districts) Operational funds provided by the Global Fund Medicines provided by DFID Door-to-Door Approach Trained Community Volunteers 2 Rounds of dosing

Ghana: Funding map Partner/Districts covered 2016 2017 2018 Comments Number Eligible Districts* 24 All the districts in UE&UW The Global Fund - GF provided operational funds and medicines DFID 11 Procured the medicines for 2015 and 2016 Govt Total funded Unfunded * By WHO criteria

Ghana: Targets & coverage Target number of children Administrative coverage results Severe Adverse Events reported 2015 2016 3-11 months 24,685 61,128 23,253 45,010 12-59 months 123,423 305,639 116,264 258,009 Total 148,107 366,767 139,517 303,019 152 313 Other comments: Specifically, this represents 70% of targeted children in 2016 as against 94.2 % in 2015

GHANA: Lessons learnt Training - I Numbers Trained 2015 2016 Comments Trainers 30 64 These include National, Regional and District level staff and it is cumulative for the two years. Training cascades Supervisors 280 652 Health Facility Workers 325 780 Community Health Workers 2500 5300 Public announcers and other mobilisation actors 14 Total trained 3,149 6,826

GHANA: Lessons learnt Training – II (max 1 page + 1 page with sample pictures if appropriate) Training was done in a cascading mode, national-regional-district-sub- district/community This helps to train more people in a shorter time However, the quality of training reduces down the line Impact of the training reflects in the volunteer performance Solution Supervision by national trainers helps to improve performance of trainers Use of pictorial job aides helps improve understanding Involvement of regional and district staff creates a sense of ownership staff Potential issues may include: - Minimum standards, coordination and harmonization - Key training levels / tools - Capacity gaps - Review and evaluation processes

GHANA: Lessons learnt Door-to-Door approach was used in all instances, fixed approach gives impression of the usual facility based services, care givers choose to go at will and may prolong dosing schedule- This helped to ensure maximum coverage in the given period It helps improve on other disease surveilance Community members did not have to travel, no excuses of raining, etc Volunteers chose flexible times to ensure they reach households For a fixed position, volunteers/health workers will have to wait without knowing if caregivers are coming or not Door to Door also helps to identify kids who are in the community and those who had travelled out Door-to-Door also helps to validate community population

GHANA: Lessons learnt Delivery approaches – II Protective clothing for the Volunteers-eg rain coats, wellington boots Torch lights, plastic bags, zip-locked plastic envelopes to hold medication etc These should be factored into the resource mobilization Need to be budgeted for Could be considered as part of volunteer motivation Potential issues for consideration may include: - Explanation about the choice for specific approach choices - Key constraints / challenges - Integration within existing networks / systems (CHWs / health workers) - Motivation issues - Review and evaluation processes (monitoring, supervision, daily coverage analysis)

GHANA: Lessons learnt Eligibility and referrals Age determination must be cross-checked with the child’s health record books (Road to Growth) There is the need to thoroughly question the child’s health status and medication history Complete explanation of the exercise and its benefits is very important The risk of taking the doses without considering existing medication should be well explained to caregivers Supervisors can play a leading role by reviewing the child health records if available Ineligible children due to ill health should be referred to identified facilities with relevant diagnostic tools and personnel to manage All health facilities were told to manage ADRs free of charge Potential issues for consideration may include: - How it worked in country - Issues with age-setting - Role of health facilities - Availability of RDT and treatment - How many children were ineligible (% of target) / Common reasons

PV and safety monitoring GHANA: Lessons learnt PV and safety monitoring Pharmacovigilance was implemented together with the FDA Teams were formed around FDA trained Institutional Contact Persons Volunteers were given instructions to report any ADR to their supervisors (HWs) who helped complete the ADR forms All ADR forms were sent to the Regional FDA office for transmission to Accra A major challenge is differentiating regular occurrences such as vomiting or spitting from real ADR Misunderstanding ADR to be only life threatening conditions These result in under-reporting of ADRs

GHANA: Lessons learnt Monitoring, supervision & evaluation of reach Tools provided in the WHO Field Guide were adopted, modified and used Periodic review was necessary to achieve final tools Daily meeting with volunteers was helpful in identifying difficult issues for addressing To ensure that each child receives the 4 cycle dose, the same register is used during a round To verify parents administer the dose, volunteers inspect the blister and conduct key informant interviews with neighbours District Malaria Focal Persons transmitted daily coverage to the Regional office, this helped identify areas in need of attention and additional support Potential issues for consideration may include: - Appropriateness of tools (provide summary of key monitoring and supervision minimum tools) - Fitness-for-purpose, challenges and constraints - In-process monitoring and how data are used / not used to inform implementation - Supervision processes and gaps Quality assurance: How do you make sure children are reached 4 times? How do you assess adherence to home doses? Cross-checking age targets - Existence and reliability of coverage surveys or other surveys - Impact assessment (is there any?) and evaluation gaps

Country XX: Lessons learnt Key messages / recommendations / conclusions (max. 2 pages) Social/community mobilization is essential for acceptance and success Early identification of key stakeholders is very important-partners go beyond actors in the health service; Procurement of SPAQ must be initiated early-8mths to 1 year ahead! Supervisors must be well trained and committed Volunteers should be sufficiently motivated-financially and morally The challenges of SMC implementation are enormous but the benefits make it worth the efforts Please consider: - Proxy measures of success (evidence of reduction of cases, feedback from health workers, etc.) - Beneficiary perceptions (positive, neutral, negative) (Quote from the end of cycle rapid surveys where available) - What key message from country on the future of SMC implementation? How to sustain financial investment? - Expected short-term and mid-term challenges - Other points to be raised / open questions / recommendations / points of advocacy

ACKNOWLEDGEMENT GFATM DFID GOG The WHO-Country Office Sub-Regional Partners-WAHO, W/CARN The Regional Health Directorates-UWR &UER FDA National and Regional Offices

THANK YOU