Project Components

Project Components:  The project is organized around three components which can be directly mapped into the next 5YPOW as well as the detailed 2007 POW: (i) institutional strengthening for coordination, implementation, and outcomes; (ii) community-based health and nutrition service delivery in target regions; and (iii) malaria prevention.  The project will promote and enhance: (i) a decentralized management system that favors flexibility to local conditions within a large-scale operation; and (ii) a learning-by-doing which allows Districts and communities to learn from innovative approaches developed under the decentralized flexible management system.

Component 1.  Institutional strengthening for coordination, implementation, and    outcomes

• This component supports the following elements of the 5YPOW of the MOH: good governance and sustainable financing to improve productivity, effectiveness, efficiency, equity, sustainability, and accountability in the sector.  The specific objectives are: (i) to develop effective inter-sectoral coordination, ownership, and accountability for nutrition towards the establishment of a coherent national program; and (ii) to strengthen the MOH and GHS to effectively coordinate implementation of the community-based health and nutrition program supported by the project. 

 

• This component will finance technical assistance, training and workshops, and incremental operating costs to:

• establish and/or build capacity of intersectoral coordination mechanisms (e.g. inter-ministerial committee,  technical committee, District Planning and Coordination Unit and Social Services Subcommittee of the District Assembly (DA), DHMT, and community health and development committees) as well as strengthen the linkages between communities and public services, particularly the convergence between the community-based, outreach and facility-based health service delivery system;
• develop and update various strategies and action plans that mainstream nutrition into the multisectoral development agenda at all levels (e.g. advocacy strategy, multi-sectoral nutrition policy, community-based service delivery strategy, school health and nutrition curriculum);
• develop strategies and mechanisms for reducing malnutrition and micronutrient deficiencies (e.g. development of public education models, development of small-scale fortification models, promotion of and the enforcement of salt iodization in intervention areas, and development of guidelines on appropriate mechanisms/strategies for twice-yearly distribution of vitamin A supplements in a post-NID era); 
• design performance-based incentive systems for community-based health and nutrition service delivery;  and
• support the MOH/GHS and the district assemblies to strengthen the M&E system for efficient planning and management (e.g. operational research) of community-based health and nutrition service delivery.

 

• The health sector has for a long time been unable to move forward the inter-sectoral agenda on health even though it has been recognized as an important element to achieve improved health outcomes. The MOH therefore decided in the National Health Policy and in the third 5YPOW to implement inter-sectoral action around issues based on a successful inter-sectoral action on guinea worm eradication. The MOH will use this project to establish an Inter-Ministerial Steering Committee on Nutrition and Child Survival.  The Committee, which will be chaired by the Minister for Health with the Chief Director, MOH providing secretarial support, will: (i) be responsible for the overall planning, management and coordination of nutrition and child survival activities in Ghana; and (ii) support implementation of the project.  The Committee representation will be at a level not lower than Chief Director of a Ministry, and comprise the Ministries of Health (MOH), Food and Agriculture (MOFA), Education, Science and Sports (MOE), Women and Children’s Affairs (MOWAC), Local Government Rural Development and Environment (MLGRDE), Finance and Economic Planning (MOFEP), Information and National Orientation, and the National Development Planning Commission.

• Many activities to strengthen coordination and implementation of a coherent national program will be achieved through carefully crafted advocacy and strategic communication strategies that will build on and interact with the program communication strategy (see Component 2).  Program interventions, outcomes and relevance (in terms of human development, MDGs and economic development) are important message elements for strategic communication, social mobilization and advocacy.  While advocacy aims at creating awareness, social mobilization and strategic communication is to build strong alliances, strengthen the commitment, and deepen the partnerships – in other words, enhance ownership, engagement and accountability.  This includes orientation and training of stakeholders with specific responsibilities such as best practices in community health and nutrition, financial management, procurement, and M&E.  The communication strategy has to be reviewed and enriched on a periodic basis to adapt to new circumstances, opportunities and challenges.  A performance-based incentive system (e.g. output-based disbursement system where disbursement from the Health Fund will be made to the implementing agencies based on agreed POW and achievement of certain outputs at the district level) will be developed and tested in the year two and three of the project before being extended to a wider range of intervention areas.

 

• In addition, this component will address bottlenecks of micronutrient deficiency control: this project will support the development of a post-NID strategy for vitamin A supplementation (VAS) that ensures adequate coverage in children 6-59 months, including the development and dissemination of new guidelines. This will be supported by UNICEF and the Micronutrient Initiative (MI) which are two principal agencies supporting the Ghana VAS program and have worldwide experience in designing post-NID VAS strategy as integral part of the child survival strategy.  The CBNFSC also tested household food production measures, such as planting of vitamin-rich fruit trees for the promotion of vitamin A intake in children, an experience that will be replicated in the intervention areas of this project emphasizing the importance of nutrition education to improve dietary intake in children.

• As for iron, the most feasible strategy to date is food fortification.  Efficient fortification models are needed to enhance iron intake of very young children.  New technologies regarding the direct addition of food fortificants are making this possible. This project, in collaboration with the MI and WFP, will support the development of small-scale fortification models, e.g. adding a premix of vitamin and mineral fortificants to the maize flour as part of the local milling process, and home-based sachets for direct addition to the young child’s meal.  WFP has been pilot testing small-scale fortification with local mills managed by women groups.  Although most local mills are managed by private entrepreneurs, the experience will answer key questions around training needs and dosage.  MI has valuable experience in testing similar strategies in other sub-Saharan African countries and will provide technical support to the developments in Ghana.

 

Figure 1.  Iodized salt coverage from 1997-2006

Source:  GHS; DHS; MICS/UNICEF.

• National legislation mandating the iodization of all salt for both human and animal consumption has been in place since 1996.  Progress towards universal salt iodization however has been slow (see Figure 1).  In collaboration with UNICEF, MI and WFP, the project will support law enforcement efforts such as training of the law enforcers and distributors, testing of salt by communities, and education of the public, within the target Regions.  This complements the work by UNICEF, MI and WFP which aims to increase the supply of iodized salt.  Although awareness campaigns have led to a relative high awareness level among the general public, trade in non-iodized salt still remains unacceptably high.  The project’s aim is to send a message back to producers that the market for non-iodized salt is limited through the social mobilization in the target Regions.

 

 

 

 

Component 2 : Community-Based Health and Nutrition Service Delivery

• This component supports the following elements of the 5YPOW of the MOH:  (i) healthy lifestyles and environment (regenerative health and nutrition); and (ii) health, reproduction, and nutrition services.  The objective is to scale up community-based health and nutrition services for children under two and pregnant women based on a community-level package of Essential Nutrition Actions (ENA).  A main thrust of the program to enhance child care and feeding practices is growth promotion through weighing of individual children and counseling of mothers and pregnant women. The ENA will be enriched with elements of: (i) maternal care (i.e. antenatal, delivery, and postnatal cares); (ii) the (community) Integrated Management of Neonatal and Childhood Illnesses, such as diarrheal disease control, prevention and control of acute respiratory infections and fever; and (iii) household food production strategies such as backyard gardening that promote the intake of micronutrient-rich foods.

 

• This component will finance technical assistance, training, workshops, and goods for community-based health and nutrition services and service providers, incremental operating costs, and sub-projects to:

• build capacity of relevant central, regional and district governments to plan, administer, and supervise the community based health and nutrition program;
• develop and implement effective program communication strategies for behavior change, a community-level package of ENA and training and supervision programs for community-based health and nutrition service providers (e.g. community growth promoters, traditional birth attendants (TBA), health care workers, etc); and
• implement community-based health and nutrition Sub-project, including pilot Sub-projects to verify the effectiveness of the performance-based incentive systems.

 

• The needs and opportunities for scaling up community-based health and nutrition services vary by District.  Hence, a significant portion of this component will be allocated to supporting District-level ‘sub-projects’, which refer to strategies and activities in the District Plan of Action that promote the utilization of community-based health and nutrition services. Working on the basis of District-level sub-projects has the advantage of helping Districts to focus on specific areas while allowing the flexibility inherent to the decentralization policy.  The health sector has, as part of the SWAp, been disbursing a large portion of budget to the district level structures called Budget Management Centres to implement planned activities.  This project will use the existing structures to implement sub-projects.  Sub-projects will support purchasing minor goods (e.g. bicycle, community promoter identification package), training and workshop services, and incremental operating cost.  A detailed description of the operational arrangements of ‘sub-projects’ including contracting mechanism, fund flow and reporting is provided in Annex 6.

• A key parameter in rolling out the community-based interventions is the cost per child per year, based on recurrent costs incurred at District level.  A maximum of US$12.00 per child per year will serve as a guide to estimate coverage, although it is expected that the cost per child per year will be closer to US$8.00 or less including training of community growth promoters.  Based on an annual review of unit costs, coverage estimates will be adjusted yearly.  In addition, information on the transfer and use of funds for the implementation of sub-projects will be made public on a regular basis for a transparent management of funds at the district level to ensure the confidence and commitment of participating communities.

 

• The principal change agents are community growth promoters and TBAs who will be supported by community committees under the overall management oversight of the DHMT and DA.  Supportive supervision will be ensured by the district level through CHO and sub-district CHN for the health aspects (see Annex 6).  Facilitation by NGOs will be sought particularly in areas where capacity is low.  The community growth promoters will carry out weighing of the children, plot the weight chart and interpret the results, fill in the necessary data in the collecting tools for analysis and reporting to sub-DHMT and assist in counseling mothers on feeding their children, hygiene and environmental sanitation. The community growth promoters will also undertake home visits to follow up on children who failed to gain weight and counsel their caregivers or refer them to the health officer for appropriate action. Furthermore, these promoters will identify and follow up children who failed to turn up at growth monitoring sessions. 

• TBAs will be mobilized and trained to enhance pregnancy and delivery care, for which they will closely collaborate with the sub-District midwife and the community growth promoters.  Like growth promoters they will undertake home visits to: (i) counsel pregnant women on nutrition during pregnancy; (ii) teach them to recognize danger signs; (iii) encourage them to seek timely antenatal care; (iv) adhere to iron/folic acid supplementation and malaria prophylaxis schemes; and (iv) prepare the expecting mother for the immediate post-partum issues, including early initiation of breastfeeding, colostrum feeding, and exclusive breastfeeding for the first six months.  As part of improved delivery care, TBAs will ensure that new mothers receive a high-dose vitamin A supplement soon after birth, start breastfeeding within the first hour after birth, and facilitate birth registration.  Finally, TBAs and community growth promoters participate in monthly meetings with the CIC and CHO and quarterly community durbars to review progress of the growth promotion program.  Through these community based activities, the project will enhance the efficiency of existing Community-based Health Planning and Services (CHPS) activities.  The project will also support the expansion of CHPS initiative in the target Districts where there are no CHPS activities by facilitating the process of communities to elaborate and submit proposals for funding which will further ensure adequate coverage of essential health services.

 

• Providing program support for the above activities implies development of a program communication strategy for behavior change, including the development of key messages and communication tools; a community-level package of ENA and other key actions; a training and supervision program; and an efficient monitoring system.  The program communication strategy’s objective is effective change of behaviors around maternal and child care and feeding practices and is therefore aimed at specific target groups.  Various communication methods will be applied, including: (i) growth promotion counseling for the mother or principal caretaker of the child and pregnant women; (ii) group education on selected key messages directed at decision makers in the household and community (e.g. mothers, fathers, grandmothers, mothers-in-law, and religious leaders); and (iii) mass communication involving a few key messages targeted at a broad audience.  The key messages will be developed based on recommended practices, but will also take into account specific needs and circumstances of the local population. 

• Three of the five selected regions, Volta, Upper East and Upper West, are known to have high levels of moderate-severe malnutrition (> 10 percent of children 6-24 mo).  The risk of death in undernourished children with a severe, moderate or mild weight deficit for age is 8.4, 4.6, and 2.5 times higher relative to the risk of death in normal children.  Children with severe undernutrition need to be treated immediately as they are at a much higher risk of death than children with mild-to-moderate undernutrition.  In-patient therapeutic care of acute undernutrition is expensive and coverage in the three regions concerned is low compared to the sheer numbers of acutely malnourished children.  The new technology of ready-to-use-food (RTUF), for example Plumpy’nut, has made possible the treatment of severe acute malnutrition without complications at the community level.  This is a safe and cost-effective way of treating severely malnourished children in the community, which can be easily managed by community growth promoters.  In the Upper West Region, UNICEF in collaboration with Catholic Relief Services is beginning an intervention program to treat severe malnutrition at the community level using RTUF, with the possibility of rolling it out to other areas after an impact evaluation. If found to be effective, and if a local production of RTUF can be set up, a similar intervention will be implemented in the Upper East and Volta Regions by the UNICEF.

Component 3.   Malaria prevention 

• This component supports the communicable disease control of the 5YPOW of the MOH.  The objective of component 3 is to increase utilization of LLINs in order to reduce malaria related morbidity and mortality among children under five and pregnant women.  Component 3 would finance technical assistance, goods, and incremental operating costs to:

 

• procure and distribute LLINs to pregnant women and target children through campaigns and/or through various community outreach programs as well as during antenatal clinics and Child Welfare Clinics;
• improve utilization of LLINs; and
• improve the M&E capacity of the National Malaria Control Program (NMCP) including insecticide resistance monitoring and key operational research

• The distribution of LLINs will follow two distinct patterns. In year one of the project, free LLINS would be distributed nationwide as part of a national campaign.  Distribution would be aimed at about 900,000 pregnant women and children under one. The project would provide 700,000 nets and the remainder to be financed from other available sources (e.g. Global Fund)

 

• During year two to four, the project would provide for 200,000 nets per year to pregnant women und children under five in the selected regions through the regular facility based channels (e.g. antenatal clinics, child welfare clinics) and various community outreach services. The nets would be distributed in line with the co-payment and subsidy policy prevailing in the specific regions.

•  The project aims by 2011 to achieve in the target areas a target of two bed nets per household for 80% of all households. This coverage, in addition to the individual protection effect, is expected to show a moderate community effect reducing malaria prevalence. The NMCP will establish baseline data and undertake regular surveys to monitor availability and utilization of bed nets.  IEC/BCC activities associated with the distribution of nets will be funded by the NMCP from other existing sources.

 

Figure 2.  Areas of interventions and modality of child survival strategy to be supported by the Project
Approach	Essential Nutrition	High Impact Rapid Delivery
		Accelerated Child Survival				Safe Motherhood	Roll Back Malaria
		Action
Interventions	Intensive child health/nutrition education/ promotion; growth monitoring; community therapeutic care	Vit A supplementation; basic health/N education C-IMCI	Expanded program on immunization; Antenatal care		Integrated Management of Childhood Illnesses (IMCI) - Case management skills of first level health staff; health system required for effective management of childhood illnesses  and severe acute malnutrition	Antenatal/ postnatal care; safe delivery; referral system; family planning	Insecticide treated bed nets; Intermittent preventive & anti-malarial treatment
Delivery Modality	Communities	CHPS*; CHPW; Health Center; District Hospital
Delivered by	Community growth promoters Community committees			Community Health Officers Sub-District Community Nurses District Health Professionals
Note: The project will directly support the interventions and modalities in bold under the overall government strategy of child survival.  The project will also support other areas of child survival indirectly by generating demand and improving uptake (e.g. vitamin A supplementation, immunization). * CHPS:  Community based Health Planning and Services; CHPW:  Child Health Promotion Week