GRAND GEDEH COUNTYHEALTH AND SOCIAL WELFARE PLAN

2011-2021

MINISTRY OF HEALTH & SOCIAL WELFAREREPUBLIC OF LIBERIA

28 June, 2011

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TABLE OF CONTENTS Executive Summary……………………………………………………………………………. iiiAcronyms……………………………………………………………………………………… ivForeword …………………………………………………………………………………….. viAcknowledgements …………………….……………………………………………………. vi1.0 Introduction and Background ………………………………………………………….. 1 1.1 Introduction………………………………………………………………………………. 1 1.2 County Population and Geography ……………………………………………………… 1 1.3 Administrative Structure ………...………………………………………………………. 2 1.4 Description of Current County Health System: …………………………………...….…. 2 1.5 Health Facilities …………………………………………………………………..……… 3 1.6 County Health & Social Welfare Team………………………………………………….. 3 1.7 Human Resource: ………………………………………………………………..……… 4 1.8 Coordination And Partnership: …………………………………………………………. 42.0 Summary Of Previous County Plan And Its Implementation ………………………… 6 2.1 Basic Package of Health Services………………………………………………………… 6 2.2 Evaluation of Basic Package Of Health Services………………………………………… 6 2.3 BPHS Proposed Strategies………………………………………………………………. 73.0 Expanded Package of Health Services …………………………………………………. 8 3.1 Mission and Vision………………………………………………………………………. 8 3.2. Service Provision………………………………………………………………………… 8 3.3 Brief Analysis of the Situation…………………………………………………………… 9 3.4 Strategies for Implementation of the EPHS ……………………………………………… 10

3.5 Priorities of The Essential Package For Health Services (EPHS) ……………………… 13 3.6 The County Hospital And The Referral Pathway ………………………………………. 154.0. Systemic Components Of The 10-Year CHWSP …………………………………….. 15 4.1 Human Resources Management and Development……………………………………… 15 4.2. Drugs/Medicines Distribution And Rational Use………………………………………. 16 4.3 Financing: Local Revenues and Use of Transfers………………………………………. 16 4.4. Network of Facilities and Service Delivery Points ……………………………………. 16 4.5. Supervision: …………………………………………………………………………… 19 4.6. Quality Improvement: …………………………………………………………………. 19 4.7 Sector Issues ……………………………………………………………………………. 205.0. EPHS Implementation …………………………………………………………………. 21 5.1 EPHS implementation…………………………………………………………………… 21 5.2 Implementation Schedule for the Upgrading Of PHC Facilities to Health Centers ….... 22 5.3 Implementation Schedule for the Rehabilitation of Existing Facilities ………………… 22 5.4 Implementation Schedule for New Service Delivery Points …………………………… 236.0 Monitoring & Evaluation ……………………………………………………………… 23Annex 1: EPHS Indicators (Grand Gedeh County) …………………………………………. 24Annex 2: ??????????????????????????? ................................................................................... 26

Tables and Figures:

Table 1: Calculation of Target PopulationsTable 2: Composition of County Health LeadershipTable 3: New SDPs to be establishedTable 4: EPHS Schedule of ImplementationTable 5: Upgrading PHC Facilities to Health CentersTable 6: Schedule for Rehabilitation of Existing FacilitiesFigure 1: The Grand Gedeh County Administrative StructureFigure 2: Grand Gedeh County Health & Social Welfare Team Organogram Figure 3: Map of Proposed Service Delivery Points

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Executive Summary - Grand Gedeh County Health Plan (2011-2021) Grand Gedeh’s, with a population of 130,000, has 18 health facilities, i.e., one hospital, two health centers and 15 clinics. 55% of its population lives within 5km (one hour walk) of a health facility, but only 31% of deliveries actually occur in a facility with skilled assistance. Due to the scattered nature of communities, OPV3/Penta3 coverage for children under one year is 51%, the lowest rate in the country.

The Grand Gedeh ten year health plan will increase access to the EPHS through the strategic addition of 16 Service Delivery Points including a combination of clinics, outreach and community-based strategies (see map). The plan will also reinforce systemic components to support services. Key objectives, baselines (2010) and targets (2021) include the following1: Increase the population living within 5 km of a health facility from 55% to 85%; Increase children under 1 year who received OPV3/Penta3 from 51% to 90%; Increase facility-based deliveries with a skilled birth attendant from 31% to 80%; Increase pregnant women provided with 2nd dose of IPT for malaria from 22% to 80%; Increase public facilities with a two star accreditation from 39% to 90%; Maintain timely, accurate and complete HIS reporting at more than 90%; and Increase facilities with no stock-out of tracer drugs to 95%.

1 Baselines and targets will be refined and adjusted as more reliable data become available.

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ACRONYMS

AFRR Accreditation Final Results Report ANC Antenatal CareARI Acute Respiratory InfectionART Anti-Retroviral TherapyBCC Behavoir change CommunicationBPHS Basic Package of Health ServicesCHC Community Health CommitteeCHDC Community Health Development CouncilCHDD Community Health Development DirectorCHV Community Health VolunteerCHO County Health OfficerCHSA County Health Services AdministratorCHSWB County Health and Social Welfare BoardCHSWO County Health and Social Welfare OfficerCHSWP County Health and Social Welfare PlanCHSWT County Health and Social Welfare TeamCA County AdministrationCKC Christ The King ClinicDHS Demographic and Health SurveyDOT Directly Observed TreatmentEMOC Emergency Maternal and Obstetric CareEPHS Essential Package of Health ServicesEPI Expanded Program on ImmunizationFBO Faith-Based OrganizationgCHV General-purpose Community Health CommitteeGDP Gross Domestic ProductGOL Government of LiberiaHCT HIV Care and TreatmentHIV Human Immunodeficiency VirusHMIS Health Management Information SystemHRCR Human Resources Census ReportHSW Health and Social WelfareIEC Information, Education and CommunicationIMCI Integrated Management of Childhood IllnessesITN Insecticide Treated NetsLDHS Liberia Demographic and Health SurveyLIGIS Liberia Institute for Geo-Information ServicesLMIS Liberia Malaria Indicator SurveyM&E Monitoring and EvaluationMCH Maternal and Child HealthMOHSW Ministry of Health and Social WelfareMTMH Martha Tubman Memorial HospitalNACP National AIDS and STD Control ProgramNCD Non-Communicable DiseasesNGO Non Governmental OrganizationNHPP National Health Policy and PlanNTD Neglected tropical DiseasesOIC Officer-in-Charge

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TTM Trained Traditional MidwifeNPHS National Population and Housing CensusPHC Primary Health CareRED Reach Every District outreach strategyREP Reach Every Pregnant Woman outreach strategySDP Service Delivery PointTB TuberculosisUN United NationsUNDP United Nations Development ProgramVCT Volunteering Counseling and TestingWASH Water, Sanitation and Hygiene Promotion WHO World Health OrganizationWFP World Food Program

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II. Foreword

I. Acknowledgement: will be done later

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1.0 INTRODUCTION AND BACKGROUND

1.1 Introduction

Development of the Grand Gedeh County 10-year strategic plan began with a stakeholder’s workshop (held 14th to 17th February 2011) bringing together NGO sector, marketers, civil society representatives, local government officials, county health and social welfare officials, health workers from all districts and health facilities and the training institution. Input from the stakeholders meeting was fine tuned in a technical workshop which was held in April 2011 in Zwedru bringing together facilitators from central MOHSW and county health technicians. A first draft was developed and sent to Monrovia for comments. Partners in Zwedru then worked to produce the final draft.

This planning process is an improvement over the Five-Year (2007-2011) Health and Social welfare Plan which was done in 2007. Since then a number of surveys have been conducted by central government and the central office of the Ministry of Health and Social Welfare to inform the planning process. Apart from these the routine county and national HMIS data has greatly improved thus enabling us to take into consideration our immediate past experiences when setting targets. The other sources of information include the:

- 2007 Demographic and Health Survey (DHS); - 2008 National Population and Housing Census (NPHC); - 2009 Liberia Malaria Indicator Survey (LMIS); - 2009 National Census of Health and Social Welfare Workers; and- 2009, 2010 and 2011 Basic Package of Health Services (BPHS) Accreditation Final

Results Reports;

1.2 County population and geography

Grand Gedeh County was originally established in 1964 when Tchien, Webo and Gbepo Districts merged to become a County. They were formerly a part of the eastern province of Liberia which had its headquarters in Harper, Maryland County. In 1999, Webo and Gbepo were separated to become River Gee County. Currently, Grand Gedeh covers 10,276 square kilometers, which represents 9.22 % on the total land mass of Liberia.

Presently, the County is divided into three statutory districts: Gbarzon, Konobo and Tchien. The statutory districts are subdivided into eight (8) administrative districts:

Gbarzon District: B’Hai, Gbao, Gboe/ploe; Konobo District: Putu, Glio/Twarho and Konobo Tchien District: Cavalla and Tchien;

Zwedru, the seat of the county government, is located 315 miles (504 kilometers) from Monrovia. It serves as a major commercial center for the Southeastern Region of Liberia. Grand Gedeh is bounded on the North and East by Ivory Coast, on the West by Nimba and River Cess Counties and on the South by Sinoe and River Gee Counties. Grand Gedeh has three official border entry points (B’hai Joezon (near Toe Town), Ghai-Blor (Garley town) and Tempo) and several unofficial ones with the Ivory Coast.

The 2008 census puts the county’s population at 126,134 while the 2011 projected population is 134,288 (using an annual population growth rate of 2.1%). The Krahns are the dominant ethnic group, comprising 90% of the County’s population. Other groups constituting the remaining 10% include: Sapo 4%; Grebo 2.5%; Mandingo 1%; Bassa 1%; Kpelle (0.5%);

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Gio 0.5% and Kru 0.5%. Even though, Krahn is the dominant local language in the county, English is as well widely spoken. Over a quarter of the population also speak French.

Socioeconomic

The major economic activities consist of mining (mainly gold and iron ore,), logging and agriculture. Currently the county hosts the Putu Iron Ore Mining Company – one of the largest mining investments in post-conflict Liberia. Traditionally, farming is the major source of sustenance in this county. Petty trading, elicit small scale mining and hunting are other common occupations. Many of the population are in hard to reach areas (and subsequently, underserved areas.

Grand Gedeh is endowed with arid land and swamps, tropical rain forest and a mountain range offering tremendous natural resources. The county is a major hub for logging activity which contributes greatly to Liberia’s GDP. Presently, prospecting for iron ore and other minerals is ongoing. Two oil palm plantations are in Gbarzon and Konobo Districts respectively.

Demography

Based on the 2011 population projection, the target groups for health interventions are as followed.

Table 1: Calculation of Target PopulationsDistrict Total pop Under

1 yearUnder5 yrs

Womenof child

bearing agePregnant women

Konobo 33,401 1,336 5,678 7,682 1,670Tchien 32,433 1,297 5,514 7,460 1,622Gbao 22,053 882 3,749 5,072 1,103Putu 21,172 847 3,599 4,870 1,059Cavalla 14,815 593 2,519 3,407 471Bhia 10,414 417 1,770 2,395 521TOTAL 134288 5372 22829 30886 6446

Due to the illicit mining a large proportion of the population is referred to as “floating population” making it difficult to invest in health facilities in those areas.. With the coming in of major investments in the mining and agro-industry there will be increase in the population of the county and shifts in the population. This will require increased investment in the health care delivery system.

1.3 Administrative structure

The county leadership is headed by a Superintendent appointed by the President of Liberia. He or she has oversight responsibility for the county and reports to the Minister of Internal Affairs. The Superintendent is assisted by the Assistant Superintendent for Development, who is also appointed by the president. He is responsible for the coordination of development activities in the county, including the formulation of county development agenda (see Figure 1). A Superintendent’s Cabinet made of heads of line ministries (including Health and Social Welfare) which serves as an advisory body to the county superintendent. All three statutory districts of the County have their respective District Development Committee (DDCs).

1.4 Description of current county health system:

The county health system consists of the County Health and Social Welfare team and partners. The operational arrangement of health delivery in the county is in line with National Health Policy, and the Essential Package of Health Services which calls for three levels of

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service delivery (community, primary health clinics) and the secondary level made up of the health centers and the county hospital).

Figure 1: The Grand Gedeh County Administrative Structure

1.5 Health Facilities

There are eighteen (18) functional health facilities in the county. Of the eighteen, fifteen (15) are clinics, two (2) are health centers and one (1) hospital. Martha Tubman Memorial Hospital, located in Zwedru, the County capital, is the county referral hospital. All of the facilities except one (Christ the King) are currently being jointly managed by County Health & Social Welfare Team, Merlin and Tiyatien Health. These facilities are supported primarily through the health sector Pool Fund Program under the Ministry of Health & Social Welfare. CKC is owned and operated by the Catholic Church. Most of the health facilities within Grand Gedeh County need rehabilitation or reconstruction. Some of the facilities were built with substandard materials and are therefore not durable.

1.6 County Health & Social Welfare Team

The County Health & Social Welfare Team is headed by the County Health & Social Welfare Officer. He is assisted by a corps of officers comprising; County Health Service Administrator (CHSA), Community Health Department Director (CHDD), County Hospital Medical Director, County Pharmacist, County Diagnostic Director, and County Monitoring and Evaluation Officer.

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Asst. Supt for development

Project Planner

Project Coordinato

rBudget &

Procurement

Agro-General

Supt./Council County Attorney

County Inspector

Relieving Commissioner

Administrative Consultant

Coordinator of Tribal native

District Commissioner

Township Commissioners

Paramount Chief

Clan Chief

General Town Chief

Asst. Superintendent Operation

Administrative Assistant

Special Assistant

Secretary

City Mayor

City Council Governor

District Statutory Superintendent

SUPERINTENDENT

The County Health & Social Welfare Board serves as an advisory body to the County Health & Social Welfare Team. The board is chaired by the Assistant Superintendent for Development with the County Health & Social Welfare Officer as secretary. Board membership includes various stakeholders within the county. The formation of a Hospital Management Board is in progress. The table below shows the current county health leadership.

Table 2: Composition of County Health Leadership

1.7 Human Resources

The county health and social welfare system presently has 527 persons working within the system. Of this number 125 are skilled (professional) workers while 403 are unskilled. This number of unskilled health workers includes 92 TTMs and 111 gCHVs.

1.8 Coordination and Partnership:

Merlin is the lead health partner in the county. It is currently involved in the delivery of the BPHS within the county. Merlin jointly manages 17 of the 18 health facilities in collaboration with the County Health & Social Welfare Team.

Tiyatien Health is also one of the partners in the county. Its areas of implementation include: HIV/TB Care and Treatment, Mental Health Care and Sexual Gender Base Violence. The implementation of these interventions is in all the facilities and at the community level.

The Catholic Church is a faith based health partner in the county that operates the Christ the King Clinic providing basic primary health care services.

Health Sector coordination meetings are regularly held on a monthly basis, where partners and CHSWT share idea, provide updates on planned activities, achievements and challenges within the county health delivery system.

The CHSWT serves as co-chair to the Ministry of Public Works in the WASH sector. Currently monthly meetings are held; these are usually held at the CHSWT offices.

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Position NameCounty Health & Social Welfare Officer Dr. Fred W. Amegashie

County Health Service Administrator Mrs. Eugenia T.Q. Huntington

Community Health Department Director Netus N. Nowine

County Hospital Medical Director (Currently Vacant)

County Pharmacist Ansumana V. Sherif

Acting County Diagnostic Director David P. Saywhean

County M&E Officer Zubah A. Blamah

Figure 2: Grand Gedeh County Health & Social Welfare Team Organogram

.

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County Health & Social Welfare Officer

Community Health Department Director

County Hospital Medical Director

County Health Services

Administrator

County Monitoring & Evaluation Officer

County Pharmacist County Laboratory Supervisor

Human Resource

Accountant

Logistic

Nursing Director

Hospital Administrator

Hospital Accountant

Clinical Supervisor

MCH Focal Person

Reproductive Health Focal Person

Environmental Health Supervisor

Surveillance Officer

Social Welfare Supervisor

Eye Care Supervisor

EPI Focal Person

Drug Deport Focal Person

District Health Officer

Health Facility OIC

Health Facility Staffs

Community Health

Members of CHSWT Senior

Staffs Health Promotion Focal Person

2.0 SUMMARY OF PREVIOUS COUNTY PLAN AND ITS IMPLEMENTATION

The previous county plan was developed on four strategic orientations which were consistent with the 2007 National Health Policy and Plan. They were: Basic Package of Health Services, Human Resources for Health, Infrastructure and Support Systems. The previous county plan considered these orientations and aligned its objectives with those of the 2007 National Health Policy and Plan which is further expressed below:

Objectives of the National Health Plan (February 2007)

2.1 Basic Package of Health Services

2.1.1 Service Package Improved child health Improved maternal health Increased equitable access to quality health care services Improved prevention, control and management of major diseases Improved nutrition status

2.1.2 Human Resources: Ensure a coordinated approach to human resource planning; Enhance health worker performance, productivity and retention; Increase the number of trained health workers and their equitable distribution; and Ensure gender equity in all aspects of employment in health.

2.1.3 Infrastructure:

Increasing access to PHC is a key objective of the National Health Plan. Since health clinics and health centers make up more than 90% of the health facilities, they are the key to increasing access to PHC. The infrastructure plan prioritizes restoring and reforming the capacity of health clinics and health centers to provide the BPHS and increase access to PHC. However, county and referral hospitals will also not be forgotten

2.1.4 Support Systems:

The priority and primary objective of the support systems component will be to develop the capacity of CHSWT to take charge of the planning process and resource coordination of development partners to shift from the humanitarian to development model before the end of 2008. To this end, the support systems capacity-building process will begin with Planning & Budgeting, Health Management Information System, Supervision, Drugs & Medical Supplies and Stakeholder Coordination.

2.2 Evaluation of Basic Package of Health Services

The County Health & Social Welfare Plan was formulated in consonance with the overall National Health Plan which provides the strategy for implementing the Basic Package of Health Services (BPHS). According to the 2010 BPHS Accreditation results, Grand Gedeh County scored 91% making her the second highest in the implementation of the BPHS. Seven (7) of her seventeen (17) facilities made two stars while eight (8) made one star. This is an enormous achievement which clearly shows the level of BPHS implementation that was accomplished in the county during the previous plan. The 2011 Accreditation Final Result Report (AFRR) saw the county dropping to the sixth position with only one facility attaining

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one-star and eight reaching two-star accreditation levels. This demonstrates the need for support system strengthening to sustain development in the health and social welfare sector.

2.2.1 Human Resource

For HR, the previous plan advocated for appropriate placement based on the standard in the BPHS. The county was able to fill almost its entire staffing gap identified in 2007. The county was able to succeed and in some instances surpass its staffing target in the following cadres: Doctors, Physician Assistants, Registered Nurses, Certified Midwives, Social Workers, and Environmental Technicians. However, despite this achievement the county still fell short of reaching its target with Pharmacists, and Laboratory Technicians.

It is worth mentioning that in 2007, the county had eight Certified Midwives to serve eighteen Health Facilities. Presently there are 21 midwives staffing almost all the health facilities.. This is primarily due to the establishment of the Southeastern Regional Midwifery Training School.

Low incentive was the major factor why the county was unable to recruit the target number of pharmacists and Laboratory Technicians during the period. The county lacks adequate environmental health technicians due to minimal recognition of their importance.

2.2.2 Infrastructure

During the period of the previous plan the county projected to rehabilitate ten (10) facilities of which eight were major and two were minor. Out of the eight major rehabilitations that were planned, five of them were done. Additionally, the County was also able to conduct minor rehabilitation on two (2) facilities. The county was unable to rehabilitate the balance three (3) due to funding constraints.

2.2.3 Training

In the previous county health plan, in-service trainings were planned to be conducted for staff in the BPHS clinics and hospitals based on the following targets:

Integrated management of childhood illnesses (IMCI) (75) HIV/AIDS (65) Prevention of mother to child transmission (PMTCT) of HIV/AIDS (30) Rational use of drugs (75) Syndromic Management (75) Malaria case management (100) Health Management Information System (HMIS) (5) Voluntary counseling and testing (VCT) (15) CHWs in-service training (120 CHWs)

Training was administered for all topics listed above, but not all targets were met. Reasons for unmet targets include delays from MOHSW at the central level, funding constraints, conflicting training schedules at national and local level, and human resource turnover.

2.3 BPHS Proposed Strategies

Most of the strategies that were agreed upon for achieving the County Health & Social Welfare Plan were accomplished during the implementing period. Achievements include the major upgrade, renovation, relocation and establishment of CHT facilities; incentive packages such as scholarships, accommodations and salaries to attract and retain qualified staff; developing job descriptions for all positions at all levels; procurement of x-ray

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machines; creation of the County Health & Social Welfare Board (CHSWB) to facilitate the mobilization of additional resources; engagement of key stakeholders in the mobilization of additional resources towards the successful implementation of the County Health Plan; and continuous monitoring of progress towards the County Health Plan’s agreed targets and implementation schedule as per the monitoring and evaluation activities outlined in the Plan.

Strategies that have yet to be successfully implemented include the convincing of other line Ministries (particularly Ministry of Public Works and Utilities / Ministry of Internal Affairs) to aid in the successful delivery of health services to improve access to health services (through roads rehabilitation and community education) and coordination with the central Ministry to ensure the timely disbursement of incentives and necessary materials for the successful implementation of the Plan.

3.0 EXPANDED PACKAGE OF HEALTH SERVICES

3.1 Mission and Vision

The mission of the Grand Gedeh County Health & Social Welfare Team is “to provide an equitable, accessible and sustainable health system to deliver quality health care to all citizens and others within the territorial boundary of Grand Gedeh County”.

The vision of Grand Gedeh County Health & Social Welfare System is to have “a healthy population with social protection for all persons within the county”.

3.2. Service Provision

The Essential Package for Health Services (EPHS) which replaced the Basic Package for Health Services (BPHS) remains the cornerstone for the National Health Policy. The EPHS like the BPHS describes the service provision that will be available at every level of health care. This county health plan is being developed to roll out the EPHS at the county level taking into consideration national targets that have been set. The EPHS maintains and strengthens existing services that were implemented in the BPHS. It also adds new services which were not covered in the BPHS, thus expanding its scope compared to the BPHS. The EPHS will be implemented in a phase wide approach as the county capacity improves.

3.2.1. Existing services that were expanded in the EPHS include:

MATERNAL AND NEWBORN HEALTHI. Family Planning

II. Malaria in Pregnancy (MIP) III. Prevention of Mother to Child Transmission (PMTCT)IV. Maternal and Newborn Nutrition

CHILD HEALTHI. Growth Monitoring

II. Micronutrient supplementation

The scope of communicable diseases, mental health, emergency health and reproductive health remains largely unchanged.

3.2.2 New services included in the EPHS are: Environmental and Occupational Health Neglected Tropical Diseases (NTFs) Non-Communicable Diseases (NCD) Social Welfare School Health Package

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3.3 Brief Analysis of the Situation

Access to health services in Grand Gedeh County during the BPHS implementation was high in communities close to existing facilities. However, giving the vast land mass of the county, communities that are far away from the facilities could not easily access the health services needed. Utilization of certain health services was therefore low for some areas in the county while some services have high coverage.

Many hard to reach communities were never served because there were no strategies put in place to ensure services therein. This situation affected the overall health outcome of the county thereby making it difficult to achieve some of the targets.

The Consultation/Head for the county is measured at 0.9% which can be translated as the number of curative consultation divided by the county population. At 0.9 consultation/head, there is an indication that facility utilization and efficiency is low. Strategies will therefore be developed to enhance utilization and efficiency.

Maternal and Newborn Health

Maternal and newborn service utilization, as well as Reproductive health services, was shown to be very low. This was probably due to cultural practices as well as inadequate distribution of skilled birth attendants.

However, some progress was made in the area of maternal and newborn health because all health facilities have skill birth attendants including mid-wives that are found in sixteen (16) of the eighteen (18) health facilities. Ninety one percent (91%) of pregnant women in the health facility are followed-up to the 4th ANC visit. Only 34% of these pregnant women gave birth in the health facilities.

For ANC consultation, the county has a coverage of seventy-four percent (74%) which is two percent (2%) lower than the national annual target of seventy-six percent (76%). This clearly shows that ANC attendance is relatively high while institutional delivery is low.

The overall institutional delivery coverage of thirty-seven percent (37%) falls far below the national targets. This is primarily due to the uneven institutional delivery coverage by facilities and districts. For example, in Tchien District where the county hospital is situated and access to health services is high, institutional delivery coverage is at eighty-five percent (85%), making it five percent (5%) higher than the national target. To the contrary, Konobo District were there is only one health facility and both access and utilization are very low, institutional delivery is placed at 8%.

Child Health

All eighteen (18) health facilities providing routine immunization services in the county, but the coverage is low. For Penta 3 target, the county has the total coverage of 51% which is far below the national target of 90%. Penta 3 coverage in the county is totally imbalance with Tchien reporting the highest coverage of eight-six percent (86%) while Konobo and B’Hai Districts reported coverage are the lowest with twenty-three percent (23%) and thirty-two percent (32%) respectively. Penta 3 coverage is low in the two districts because of limited health facilities. Strategies will be developed to increase service delivery, thus improving Penta 3 coverage during the period of this plan.

Reproductive and Adolescent Health

Access to family planning services was as high due to the availability of family planning commodities and trained health workers in all health facilities.

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Communicable Disease Control

Much progress has been made in HIV care and treatment. Active ART sitesa have been established at MTMH along with 4 VCT and 11PMTCT sites at health centers and primary health clinics. Tiyatien Health is one partner who is working in the county to strengthen the HIV program. As a result of this partnership with the CHSWT, the lost to follow-up of HIV and TB patients is minimal. All health facilities in the county are DOT centers.

Mental Health

Even though national mental health program is not yet fully developed, there is a program in county for the treatment of epilepsy and depression. All health workers have been trained to identify and manage mental cases. Some gCHVs were trained to identify and refer epilepsy and depression cases to the health facilities.

Emergency Care

Since 2009 ambulance service have been operating in the county providing services to the general population. The deplorable road condition is causing a serious challenge to service provision in the county as the vehicles are frequently broken down. The emergency unit at the MTMH is being expended to be able to host the county dispatch center. The ambulance service has been decentralized with one ambulance stationed at Gbarzon Health Center.

3.4 Strategies for implementation of the EPHS

In an effort to achieve the set national targets based on the national indicators, it is necessary to develop the appropriate strategies that will enhance the require achievements. The following shall be employed or used during the ten years period.

MATERNAL HEALTH

Objective: Delivery of evidence based EPHS supported by innovative financing to improve health service delivery

Low level of institutional deliveries in the county

Coverage of institutional deliveries in county low, at 31%, mainly in Konobo District where only 8% were achieved (compared to Tchien District at 85%). Konobo has a population of over 33,000 most of whom are in scattered communities, far from the single health facility in that district. A large proportion of the population lives in temporary mining communities where there are no health facilities.

The target is to achieve 80% of coverage of institutional deliveries (by skilled birth attendants) by 2021. The strategies to achieve it are:

Expansion of the network of clinics with the construction of new clinics. Seven out of 16 proposed clinics are to be located in Konobo District.

Improving of the existing HF(Konobo Health Center) into a Basic EMOC center Monitoring the work schedule to ensure the facility opens 24 hours daily Empower gCHVs to conduct aggressive BCC activities on the appropriate health

seeking behavior in communities Institute regular integrated outreach via the county incorporating the REP approach Provide special incentives for TTMs who refer for intuitional delivery (Incentivize

TTMs and gCHVs to increase referrals for delivery including hard-to-reach areas) Establish a basic EMOC in each district

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Establish balance 9 new n all other district ensure 80% of population are within 5 km of service delivery points and assign skilled health workers (especially midwives) in all health facilities

Provide attractive salaries, incentives and suitable accommodations for medical staff, given the geographic location of the county

Engage other line Ministries, particularly Ministry of Public Work, Internal Affairs and Utilities, among others, to aid the successful delivery of health services to communities where access is difficult ( e.g., reconditioning bad road, creating new road, providing communication etc)

Low level of IPT 2+ administered in health facilities

The coverage of IPT 2+ in the county is very low at 22%. This ranges from 0% in Konobo to 12% in Gbarzon, 22% in Bhia and 48% in Cavalla. Drug stock outs, shortage of trained personnel and inadequate service delivery points are the main cause of low performance.

Target: 80 percent of pregnant women provided with 2nd dose of IPT for malaria. Strategies to meet the target are to:

Establish balance 9 new n all other district ensure 80% of population are within 5 km of service delivery points and assign skilled health workers (especially midwives) in all health facilities

Institute regular integrated outreach via the county incorporating the REP approach Empower gCHVs to conduct aggressive BCC activities on the appropriate health seeking behavior in communities

CHILD HEALTH

Low EPI coverage in the county using Penta 3 as proxy

Coverage of Penta 3 in the county as a whole is low at 51% where as the national target is 80%. It is worse in Konobo (23%), B’hia (32%) and Putu (41%) with the highest being 75% in Cavalla. Facilities are not strictly adhering to fill the monitoring chart nor keeping to outreach schedules. County level supervision of EPI is poor.

The goal is to achieve 90% of coverage of PENTA 3 by 2021 The strategies to achieve it are: Expansion of the network of clinics with the construction of 16 new clinics and

establish several integrated outreach sites in the county (using RED approach); training of all professional staff at primary level in EPI management including

conducting detailed micro-planning; Regular refresher training on EPI as there is a rapid turnover of skilled staffs; Monthly analysis of all HF against HF specific target and give written feedback; ensure adequate stock level of bundle vaccines including data tools at all times at

county level; Monthly supportive supervision from county to districts and health facilities; and Integrated IEC/BCC materials capturing RI, SIAs, & Surveillance.

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FAMILY PLANNING

The contraceptive prevalence rate (CPR) is low through out the county.

Target: 30% women of reproductive age (15-49) are currently using (or whose partner is currently using) a modern method of contraception

Strategies: Pilot community distribution using TTMs, gCHVs and Community health focus

persons from health facilities Ensure adequate stocks in county Integrated IEC/BCC materials capturing the benefits of planned parenthood

EXPANSION OF EPHS TO CATCHMENT COMMUNITIES

Community Health

Very irregular or no CHDC meetings held

Communities are not playing meaningful roles in managing their health. CCHDC meetings are never or irregularly held.

Target: 1 (one) CHDC meetings held per facility per quarter

Strategies to meet the target Ensure the formation of a CHDC in each clinic catchment area Provide regular refresher training for gCHVs to become effective in creating

awareness for functioning of CHDC Regular training and mentoring of CHC Central level supervisors to attend initial CHDC meetings to ensure quality

Very irregular CHC meetings

CHC meetings are very irregular in almost all catchment areas. Clinics staff and community leaders do not appreciate the importance of CHC

Target: 1 (one) CHC meetings held per facility per month

Strategies Ensure the formation of a CHC in each clinic catchment area through the

encouragement of facility staffs Provide regular refresher training for gCHVs to become effective in creating

awareness for functioning of CHC Central level supervisors to attend initial CHDC meetings to ensure quality

The gCHV network is not effective

No system for gCHV reporting is in place at county level..

Target: 80 % of gCHVs who received at least 1 supervision visit from county supervisors in last quarter. Strategies will include:

Training for reporting initiated at county level Obtain/ produce adequate reporting tools for gCHV Work with partners fto strategize and provide motivational incentives for gCHV Provision of regular feed back to gCHV

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COMMUNICABLE DISEASE

Objective: Delivery of evidence based EPHS supported by innovative financing to improve health service delivery

HIV services in the county need strengthening

Currently HCT is available only in MTMH, VCT in 8 facilities and PMTCT in 11 facilities. Large proportion is without HIV services including catchment communities of 7 health facilities. Now only 74% of people who received HIV counseling and testing and received their test results (HCT and PMTCT) current 26%

Target: 95% in county (National target o be Decided by NACP). Strategies will include: Establish HIV services in the remaining health facilities Suport gCHV to intensify IEC/BCC activities in all communities Ensure regular supply of HIV testing materials to the health facilities Regular monitoring and mentoring activities planned and conducted by CHSWT and

partners

SUPPORT SYSTEM

Objective: Upgrading the capacity (material and technical) of the county

Timely HMIS reports are submitted to the MOHSW but facility reports are largely done by county level personnel. Statistical analyses are currently not done and Individual feedbacks are not provided to HF. The target is 90% of timely accurate and complete HIS reports submitted to the MOH during every quarter. Strategies will include:

Refresher training for health facilities staff Regular supply of reporting tools to the health facilities Institute effective vehicle management and maintenance system to ensure timely

report collection and validation

The management systems at county level are weak

Management protocols are not in place at the county level. Because of this, effective supervision is not done. Supervision is not regular and it is of poor quality. The goal is 80% of facilities received at least one joint supportive supervision visit in each quarter

Strategies Training for supervisory team on scheduling and the use of supervisory tools Put into operation the supervisory manual and the national policies and procedures

produced at central MOHSW Institute effective vehicle management and maintenance system to ensure timely

report collection and validation

3.5 Priorities of The Essential Package for Health Services (EPHS)

The Essential Package of Health Services has added five (5) new services. It has also strengthened some of the existing services from the BPHS. The EPHS would be implemented immediately in a phase wide approach in accordance with EPHS (primary and hospital components) over the ten years period.

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Phase 1 (Year 1-3) Strengthen and expand reproductive health services, emergency health and

communicable disease management and control; Introduce mental health, school health and environmental health services; Assess and plan services for Neglected Tropical Diseases (NTD) and Non-

communicable diseases (NCD); Strengthen essential support services.

Phase 2 (Years 4-10) Initiate and Roll out NCDs and NTDs; Strengthen and expand mental health, school health and environmental health; Continue other services.

Targets for Neglected Tropical Diseases (NTDs) and Non-Communicable Diseases (NCD) will be set in year four (4) after the assessment exercise. For Mental, School and Environmental Health, the county will adopt/adhere to national targets.

The county shall implement the EPHS through the operational levels defined by the EPHS: (Community, District, County, and National).

New Services

In order to make the service package more comprehensive, other services will be better organized for inclusion in the EPHS as follow:

ENVIRONMENTAL AND OCCUPATIONAL HEALTH

Environmental health activities have regularly been conducted throughout the county. Health inspectors has worked to ensure and monitor water quality through chlorination and water quality testing. They are also involved with the monitoring of sanitation facilities (latrines) and food preparation sites. The CHSWT environmental health technicians participate in hygiene promotion where there are gaps left by our NGO partners. Our environmental health co-chairs the regular WASH sub-sector coordination meetings. Very little has been done in county relative to occupational health. The CHSWT will strengthen the ongoing services especially utilizing the community structures. Occupational health will be rolled our as per direction from the MOHSW policies.

NEGLECTED TROPICAL DISEASES (NTDs)

Of the NTDs Ochocerciasis control program has existed in the county for the past six years. Mectizan distributions cover all communities in the county. From reports of the national program, the Grand Gedeh program is among the best nationally. The policy documents will guide us in the roll out of a NTD program in the county.

NON-COMMUNICABLE DISEASES (NCD)

There has been no organized non-communicable disease program in the county. The availability of medication for diabetes mellitus in the county is very erratic. The program will be designed based on the national policies regarding NCD

SOCIAL WELFARE

Throughout the period of the last 5-year Plan, the social welfare program has not been well defined even at the national level. The county social welfare supervisor has been involved in the follow-up with SGBV cases and also working within the Protection Task Force in the county. The Social welfare Policy and Plan will be rolled out when launched.

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SCHOOL HEALTH PACKAGE

Currently we have ongoing school eye care activities where eye screening has been carried out in various schools in Grand Gedeh County. Teachers are also trained to screen students and refer those with visual problems. Schools are empowered to care for visually impaired students in regular schools. Partnership with the educational sector will be strengthened to ensure the creation of a robust school health program.

3.6 The County Hospital and the Referral Pathway

The county hospital shall receive referral from the Health Centers /district hospitals and refer cases to the Regional Hospital where necessary. Health centers/District hospitals shall receive referral from the peripheral clinics and refer to the county Hospital when needed. Peripheral clinics including MCH level-one clinics shall receive referral from the communities and refer to the Health Center/District Hospital where necessary.

The ambulance referral system (including ambulances stationed in districts) is controlled by dispatches at the county hospital. Drawing from the experiences of other ambulance systems in country, new partners will be identified to increase the capacity of the current system.

4.0. SYSTEMIC COMPONENTS OF THE 10-YEAR CHSWP:

This plan looks at six systemic components that are essential for smooth implementation of health delivery in the county. The components are:

Human resources management and development; Drugs/medicines distribution and rational use; Financing: local revenues and use of transfers; Network of facilities and SDP: current condition and plans for expansion, upgrading

or renovation; Supervision; and Quality improvement.

4.1 Human resources management and development:

Over the years there has been high turnover of skilled health workers in Grand Gedeh County. This situation is due to low incentives and harsh working condition, e.g., hard to reach areas, and poor staffs housing. The county shall endeavor to provide the optimal number of health work force with the appropriate skills to deliver the EPHS. Currently, the county has 527 health workers of which 125 are skilled while 403 are unskilled. The current number of work force shall be augmented to effectively and efficiently deliver the EPHS. With the creation of new service delivery points across the county, the need for more skill work force cannot be over emphasized.

In order to improve efficiency, the county shall consider the following strategies:1. Distribute staff based on work load, staffing gaps and skill mix.2. Provide treatment protocols for all health facilities3. Conduct periodic refresher training for all professional staff4. Provide training opportunity for potential health workers5. Provide accommodation for professional staff6. Advocate for attractive salary and allowances for staff

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7. Create human resource information system to evaluate, support and manage the health work force.

8. Coordinate all (partners) recruitment and deployment of health staff in the county9. Advocate and provide insurance scheme for health staff

4.2. Drugs/Medicines distribution and rational use:

The BPHS accreditation results consistently demonstrated the performance in drug management at all levels of the county health system. The need to have and maintain optimal stock level in all health facilities can not be over looked. The county shall ensure that drugs and medical consumables are available and equitably distributed based on need and consumption. The county shall adopt the strategies enshrined in the national supply chain plan to carry out its drugs/medicine distribution and its rational use. The county shall work along with the drugs/ medicines regulatory authorities to ensure that regulatory policies and guidelines are adhered to throughout the county. Mechanism will be put in place to expand the capacity of the county drug warehouses.

4.3. Financing: local revenues and use of transfers:

In line with the National Health financing policy, the county shall continue the free service for three years and shall gradually introduce user fee for certain services for those who can afford. Services to be paid for shall be determined by the central ministry.

Community-based insurance shall be piloted by the county as a means of helping the locals to pay for health services when user fees are introduced.

4.3.1. Local revenues and transfer:

The health services has been under funded with central level being able to provide the fraction of what is needed to run the County Health and Social Welfare System. The county health sector shall therefore advocate for at least 15% share of social development funds paid by concession companies in the county for support to the health system. User fees shall contribute to local revenue and shall be used to run the health system. Other sources of local revenue shall include (donations, programs support, revenue from rental fees, etc).

Local and transferred funds will be used for the running of the Health & Social Welfare System in the county to include payment of incentives, medicines and essential equipment and supplies, investment and other recurrent expenditures. All funds will be expended and liquidated based on the financial guidelines of the Ministries of Health & Social Welfare and Finance.

4.4. Network of facilities and Service Delivery Points (SDPs)

4.4.1 Network of facilities

The county health service currently has eighteen (18) functional health facilities. The eighteen (18) health facilities make up the current network of facilities which include clinics, health centers, and hospital.

The number of facilities is presently inadequate to cater to the growing population. Currently there are many people who cannot access health service because of distance away from facilities. Additionally, facilities distribution is not equitably done in the county. For

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example, Konobo District with has the second largest population (32,711) among the six (6) Health Districts has only one health facility, while Cavalla on the other hand which the population of 16,662 and is the second smallest health district by population have five (5) health facilities. This has made access and utilization to service low and has subsequently made the county unable to achieve its target. Some health facilities are currently too small to fully implement the EPHS. These facilities will need to be expanded or upgraded to be more efficient. Moreover, additional facilities will also be needed to enhance access and effectively implement the EPHS.

Facilities that need upgrading include: Zai Town Clinic (Cavalla District)…….To be upgraded to a health center Toe Town Clinic (B’hai District)………To be upgraded to a health center Pennoken Clinic (Putu District)………..To be upgraded to a health center

Facilities that would be rehabilitated shall include: Zai Town Clinic………………..Heavy rehabilitation and expansion Tuzon Clinic…………………….Light rehabilitation Janzon Clinic……………………Heavy rehabilitation and expansion of MCH wing Beh Town……………………… Light renovation Gbarzon Health Center…………Heavy rehabilitation and extension Polar Clinic……………………..Heavy rehabilitation Gbarzon Jarwodee………………Reconstruction Toffoi Town Clinic……………..Light rehabilitation Kumah Town……………………Reconstruction Gorbowogba Clinic……………..Reconstruction Christ the King Clinic………….Light rehabilitation Gboloken Clinic………………..Heavy rehabilitation Konobo Health Center…………Light rehabilitation Karworwleh Town Clinic………Reconstruction Pennoken Clinic……………….Heavy rehabilitation with expansion Putu Jarwodee Clinic…………..Heavy rehabilitation Toe Town Clinic……………….Heavy rehabilitation with expansion

4.4.2 New Service Delivery Points

New service delivery points shall be established to enhance access. There shall be different types and characteristics that shall be undertaken. They include the monthly integrated outreach services to communities greater than five (5) kilometer from an existing facility, the construction of mini-clinics (MCH level-one) to smaller communities with population ranging from one thousand (1000) to three thousand five hundred (3500), and the construction of Health Centers/District hospitals and hospital.

The county shall establish sixteen new service delivery points within ten years. The types, characteristics and location of new SDPs are reflected in the map and table below:

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Figure 3: Map of Proposed Service Delivery Points

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Table 3. : New SDPs to be establishedCity/Town DISTRICT SDP TYPE

1. Zwedru Tchien Hospital2. Bentley Tchien PHC Level One Clinic3. Ploe Podee B’Hai PHC Level Two Clinic4. Duogee Town B’Hai PHC Level Two Clinic5. B’Hai Tarway B’Hai PHC Level One Clinic6. Boe Geewon Gbao PHC Level Two Clinic7. Chayee Town Gbao PHC Level One Clinic8. Gbablor Town Cavalla PHC Level One Clinic9. Bartejan Cavalla PHC Level One Clinic10. Tarloken Konobo PHC Level Two Clinic11. Flahn Town Konobo PHC Level One Clinic12. Boundary Town Konobo PHC Level Two Clinic13. Glay Town Konobo PHC Level One Clinic14. Belleh Yallah Konobo PHC Level One Clinic15. Twarbo Sayou-wou Konobo PHC Level Two Clinic16. Konobo Sayou-wou Konobo PHC Level One Clinic

The current Martha Tubman Hospital shall be turned into a District Hospital while a new 100 bed hospital will be constructed as the new county referral hospital. The future establishment of the new county hospital is due to limited space at the present county hospital which inhibits expansion.

4.5. Supervision:

The role of supervision in health delivery system is key to ensuring effective and efficient delivery of services and improving performances. County wide integrated supportive supervision will be done by the County Health & Social Welfare Team and partners once a month using supervisory tools. However, district level supervisions will be conducted at least twice a month by the District Health Officer and Team using supervisory checklist. Additionally, vertical programs will carry out their individual program supervision per their schedule. On the other hand, the Monitoring and Evaluation (M&E) Team will carry out quarterly supervision using the M&E tools.

Feed back report on all supervision activities/visits will be required before the subsequent supervision.

4.6. Quality Improvement:

County/district wide surveys, assessments, meetings and operational research shall be conducted to improve the quality of services. Those to be conducted include:

Insecticide Treated Nets (ITNs) ownership and utilization survey Patient satisfaction survey Health facility utilization survey Family Planning commodities utilization EPI coverage survey Morbidity and mortality review EmOC assessment Training need assessment Quarterly review meeting Community Case management impact assessment

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4.7 Sector Issues.

The Grand Gedeh County health sector currently consists of the CHSWT, NGOs, Faith-based Organization and UN agencies. Partnership plays an important role in the health delivery system of the county. The partners help in resources mobilization, provision of professional staff, payment of incentives, provision of drugs/medicines and medical supplies, capacity building, infrastructure development and other logistics. Partnership and Coordination will continue to be encouraged in the county at all levels (community, district and county).

The health and social welfare partners presently in county are: Merlin Tiyatien Health Catholic Church German Agro Action Action Aid Medical Mondale Red Cross WHO WFP UNHCR

Merlin is the lead health partner presently in the county. They provide support to the CHSWT and seventeen (17) of the eighteen (18) health facilities in the county. The support they provide include: payment of incentives to health workers, provision of drugs/medicines and other medical supplies, capacity building, infrastructure development, logistics, supervision, data collection and reporting.

Tiyatien Health is a local health partner involved in HIV/AIDS, TB and Mental Health (depression & epilepsy) awareness and treatment. They also engaged in Sexual & gender-based violence.

Catholic Church provides primary health care services at one health facility (CKC) located in Zwedru City.

GAA provides support to Water, Sanitation and Hygiene promotion (WASH) in the county.

Action Aid is involved with access to Justice for women and other social welfare issues.

Medical Mondale is involved in social welfare issue including access to Justice for women and children. They also provide training for health workers on clinical management of rape and other SGB issues.

Red Cross provides humanitarian support including WASH and training in First Aid.

WHO provide technical support to the CHSWT?

WFP provide nutritional support through the distribution of food for the inpatients, ANC clients, chronically ill patients (HIV/AIDS & TB) and malnourished children.

UNHCR gives support to health partners to provide services to refugees and host communities.

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4.7.1 Coordination Mechanisms:

Partners support to the county health plan is very essential for successful implementation of the plan. During the implementation of the previous plan, some partners’ activities were not fully aligned with the county health plan. For example, partners were expected to follow the plan as it relates to the infrastructure development, but this was however ignored by some partners. Additionally, some partners’ cooperation during campaigns was poor. However, when it comes to coordination meetings, partners’ participation was generally good. Poor coordination has led to overlapping health programs and unhealthy competition bringing about inefficient use of the already scarce resources.

During the implementation of the new plan, all partners will be expected to align their activities with the county health plan. In order to improve the partnership coordination mechanism, the following strategies are being advanced:

Full participation of all partners at Regular monthly Health &Social Welfare coordination meetings will be required;

Action points and decisions of all meetings are to be executed; Minutes of all meetings will be required and circulated to all concerned; All partners shall be required to form part of the planning and implementation of

every county-wide health campaign and events; Adequate information sharing between CHSWT and partners shall be required; and All health activities reporting shall be channeled through the CHSWT or copy shared

with the county team for creation of county health and social welfare data-bank.

5.0. EPHS IMPLEMENTATION

5.1 EPHS implementation

The county shall implement the EPHS through the operational levels described in the document. Service provision shall be provided in line with the EPHS.

The county shall implement the EPHS as per the table below.

Table 4: EPHS Schedule of ImplementationEPHS Components Implementation Time Frame (by year)

1 2 3 4 5 6 7 8 9 10MATERNAL & NEWBORN CAREAntenatal Care Labor & Delivery Care Post Partum Care Newborn Care Basic Emergency Obstetric Care(EmOC) Comprehensive Emergency Obstetric Care Maternal & Newborn Nutrition Family Planning Counseling & Services PMTCT Malaria in Pregnancy CHILD HEALTHExpended Program for Immunization Integrated Management of Neonatal & Childhood Illnesses

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EPHS Components Implementation Time Frame (by year) 1 2 3 4 5 6 7 8 9 10

Essential Nutrition Actions Nutrition Assessment & Growth Monitoring Micronutrient Supplementation Infant & Young Child Feeding Management of Acute Malnutrition (MAM) ADOLESCENT SEXUAL & REPRODUCTIVE HEALTHFamily Planning Adolescent Health Sexual Gender Base Violence Reproductive Cancer Screening COMUNICABLE DISEASE MANAGEMENT & CONTROLManagement & Control of STIs/HIV/AIDS Management & Control of Tuberculosis Management & Control of Malaria Management & Control of other Diseases with Epidemic Potential

MENTAL HEALTHMental Health Introduction Expand and Strengthen Mental health Services EMERGENCY HEALTHEmergency Care Services NON-COMUNICABLE DISEASESNon-communicable Disease Assessment & Service Plan Non-communicable service rollout NEGLECTED TROPICAL DISEASESNeglected Tropical Disease Assessment & Service Plan Neglect Tropical Disease Service Rollout ENVIRONMENTAL & OCCUPATIONAL HEALTHIntroduce Environmental & Occupational Health Services through out the county

Strengthen & Expand Environmental Health Services SCHOOL HEALTHIntroduce School Health Services Strengthen & Expand School Health Services XI. SOCIAL WELFAREIntroduce Social Welfare Services Strengthen & Expand Social Welfare Services

5.2 Implementation Schedule for the upgrading of PHC facilities to Health Centers

Table 5: Upgrading PHC Facilities to Health CentersFacility Name District Implementation Time Frame

1 2 3 4 5 6 7 8 9 10Zai Town Clinic Cavalla Toe Town Clinic B’Hai Pennoken Clinic Putu

5.3 Implementation Schedule for the Rehabilitation of existing facilities

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Table 6: Schedule for Rehabilitation of Existing FacilitiesFacility Name District Implementation Time Frame

1 2 3 4 5 6 7 8 9 10Zai Town Clinic Cavalla Tuzon Clinic Cavalla Janzon Clinic Cavalla Beh Town Cavalla Gbarzon Health Center Gbao Polar Clinic Gbao Gbarzon Jarwodee Gbao Toffoi Town Clinic Tchien Kumah Town Tchien Gorbowogba Clinic Tchien Christ the King Clinic Tchien Gboloken Clinic Cavalla Konobo Health Center Konobo Karworwleh Town Clinic Putu Pennoken Clinic Putu Putu Jarwodee Clinic Putu Toe Town Clinic B’Hai

5.4 Implementation Schedule for New Service Delivery Points

Table 7: Schedule for New Service Delivery PointsFacility Name District Implementation Time Frame

1 2 3 4 5 6 7 8 9 10Zwedru County Hospital Tchien o o Bentley MCH Tchien Ploe Podee Clinic B’Hai Duogee Town Clinic B’Hai B’Hai Tarway MCH B’Hai Boe Geewon Clinic Gbao Chayee Town MCH Gbao Gbablor Town MCH Cavalla Bartejan MCH Cavalla Tarloken Clinic Konobo Flahn Town MCH Konobo Boundary Town Clinic Konobo Glay Town Clinic Konobo Belleh Yallah MCH Konobo Twarbo Sayou-wou Clinic Konobo Konobo Sayou-wou MCH Konobo

6.0 MONITORING & EVALUATION

Monitoring and Evaluation is an essential component of any planned activity. The county shall carry out regular monitoring exercises. Monitoring will be done using the monitoring framework as adopted by Central Ministry of Health & Social Welfare (see Annex 1). The plan shall be quarterly, biannually and annually monitored by the County Monitoring and Evaluation Officer who shall be required to submit a narrative report to the County Health Officer with copies to the County Health and Social Welfare Board and the Central Ministry.

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There shall be three evaluations of the plan. First evaluation exercise shall be conducted after the first three years of implementation. The second evaluation exercise shall be the mid-term review after five years of implementation. The last evaluation exercise shall be conducted at the end of the ten years implementation period.

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ANNEXES

Annex 1: EPHS Indicators (Grand Gedeh County)NHP

Component # Indicator Base-line Target Definition Source

of Data

Objective 1: Delivery of evidence-based BPHS, supported by innovative financing to improve health service delivery

Maternal & Newborn 1

[# and] % of deliveries that are facility-based with a skilled birth attendant  31% 80%

Numerator: Total deliveries in facility by skilled personnel, Denominator: expected deliveries

HMIS

2

[# and] % of pregnant women provided with 2nd dose of IPT for malaria  22% 80%

NMCP Target

Numerator: Total pregnant women provided with 2nd IPT, denominator: expected pregnancies; (also report with ANC1 as denominator, but not PBC)

HMIS

Child Health 3

[# and] % of children under 1 year who received DPT3/pentavalent-3 vaccination  51% 90%

Numerator: total children under 1 year who received DPT3/pentavalent-3 vaccination; Denominator: population of children under one

HMIS

4

Number and percentage of children under 5 receiving artemisinin-based combination treatment (ACT) for malaria

 26.3% 90%

Numerator: total children under 5 receiving ACT ; Denominator: malaria cases in U5 (clinical, RDT & microscopy)

HMIS

Family Planning 5

Couple year of contraceptive protection provided by facilities and CHVs (disaggregated by method)

 TBA ???

HMIS and distribution outlets

Communicable Disease 6

# and % of people who received HIV counseling and testing and received their test results (HCT and PMTCT)

 24% Ref. NACP

HMIS

7 Ref. NTLCP

Objective 2: Expansion of BPHS services to catchment communities

Community 8

Average number of CHDC meetings held per facility in the last quarter  0

At least 1 per

facility/quarter

CHDC records

9

Average number of CHC meetings held per facility in the last quarter

At least 1 per

facility/month

CHC records

10

[# and] % of gCHVs who received at least 1 supervision visit in last quarter  TBA 80%

gCHV records and EHT supervisory report

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NHPComponent # Indicator Base-

line Target Definition Sourceof Data

Objective 3: Strengthening the capacity (material and technical) of the County Health Team to manage a decentralized health system.

Support Systems 11

[# and] % of facilities reaching two-stars level in accreditation survey including clinical standard

 39% >90%

Numerator: number of facilities reaching one-star level in accreditation survey; Denominator: total number of facilities surveyed

Accredita-tion report

12

[# and] % of facilities with no stock-out of tracer drugs during the quarter (amoxicillin, cotrimoxazole, paracetamol, ORS, iron folate, ACT)

100% 100%

Numerator: number of facilities with no stockout of tracer drugs; Denominator: Total facilities supervised

Supervision report

13

[# and] % of timely, accurate and complete HIS reports submitted to the MOH during the quarter 99% 100%

Numerator: number of timely, accurate and complete HIS reports submitted; Denominator: Total HIS reports submitted for the quarter

Central HMIS Reporting Checklist

14

[# and] % of facilities that received at least 1joint supportive supervision visit in last quarter

 76.4% 80%

Numerator: number of facilities jointly supervised; Denominator: total functional facilities

Supervision report

15

[# and] % of facilities that received at least 3 supportive clinical supervision visits in last quarter

 TBD 80%

Numerator: number of facilities supervised; Denominator: total functional facilities

Supervision report

16

[# and] % of CHT/NGO submitting timely and complete quarterly report to MOHSW

 100% 100%

Report reaching MOH on or before reporting deadline (30th of month following end of quarter)

External Aid Reporting Checklist

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Annex 2

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