Initial Health Assessment of the Ahafo and Akyem Project Areas

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SUMMARY REPORT
INITIAL HEALTH ASSESSMENT OF THE AHAFO AND
AKYEM PROJECT AREAS — GHANA

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Eric Simoes MD
Jessica Plumpton MD
Marci Balge
Kathy Kennedy Dr.PH
Blair Gifford PhD
Calvin Wilson MD
July 22, 2005

EXECUTIVE SUMMARY INITIAL HEALTH ASSESSMENT OF THE AHAFO PROJECT COMMUNITIES — GHANA

Background
The University of Colorado School of Medicine was requested by Newmont Mining Corporation in early 2005 to conduct community health assessments in their concession areas of Ghana and Peru where Newmont mining activities are currently under development, with the objective of identifying specific areas of intervention that would result in improved community health. The University Ghana team was on-site from April 30 until May 14, 2005, spending the majority of its time in the communities around the developing Ahafo site, which is primarily in the Asutifi District of the central tropical forest area of Ghana. A short visit was also made to the Akyem project area in the Eastern Region.

Methodology and Scope of Work
The University team consisted of 6 members with experience or specialization in the following areas: Public Health, Nursing, Pediatrics, Health Administration, Family Medicine, and Community Medicine. The team conducted interviews with community members in the five communities surrounding the Ahafo project area (estimated population 16,000), together with visits to most health centers and referral hospitals in the area, and interviews with local tribal and government authorities, regional and national health authorities, and representatives of active non-governmental organizations. A rapid assessment method was used with a comprehensive questionnaire addressing the health situation and infrastructure, perceived health priorities, and community attitudes. In addition, visits were made to the Kumasi National University of Science and Technology and the University of Ghana in Accra.

Recommendations and Rationale Based on the observations and findings of the assessment, the University team has proposed fifteen recommendations for both short and long-term activities that should improve the health status of the target communities over time. Some items will require further study to determine the specifics of implementation, and may need to be modified to adapt to changing economic or political realities. These recommendations and their rationale include the following:
	1.	Strengthen regional health system capacity, and integrate all health activities with the regional level. This would involve coordinating all health-related activities with the Regional and District Directors of Health, and discussing proposed activities in sufficient time to allow for strategic planning. Graduated support of the computerization process, with progressive integration of the Health Centers, would greatly assist with the collection and analysis of health data. Some assistance will also be required in developing analysis tools of the data, such as expenditure and cost information systems, and mapping tools. Justification.
			In the Brong-Ahafo region, the central point for integration is the Regional Health Directorate in Sunyani. Discussions with the Regional Health Director and the District Health Directors in Asutifi and Tano Districts revealed many strengths in the health system, such as dedicated Directors of Health with an effective management team, knowledge of current health interventions, transparency in the management of funds and good administrative accountability, and relative autonomy of decision-making.
	2.	Implementation of a monitoring and surveillance system (DSS), together with the necessary infrastructure. This would be a long-term process in which a system utilizing community health volunteers would be developed to survey all households in the community for recent births and deaths (prior to scheduled National Immunization Days), identify and map each household with a unique number and GIS position, and enter this data into a central database. Repetition of these community surveys every 6 months would allow for tracking of birth and mortality trends, and could be expanded to include surveillance of specific diseases. In addition, this could be linked with a card containing the household identification, which would facilitate services at the Health Centers and regional hospitals. Justification
			The epidemiologic data for each district depends primarily on patients seen at the Health Centers, which does not reflect the true situation in a community. Since a survey of children under 5 years of age done by community health volunteers regularly results in numbers that are 25-30% higher than projected numbers from the census, it can be assumed that immunization rates, mortality rates, etc. are lower than estimated in the district and regional health reports.
			The purpose of implementing a monitoring and surveillance system would be to document the burden of disease for priority setting and to quantify changes that measure the impact of various interventions. This data would be important as a basis for the annual and biennial planning cycles of the GHS. A surveillance system that is shown to function effectively in a district health system would contribute greatly to the development and implementation of a national surveillance system.
	3.	Strengthen the Community-Based Health Planning and Services (CHPS) program. This could be done by assisting in the training of new Community Health Officers (CHO) designated for service in the Asutifi District each year, by supporting the housing for the CHO in the designated community, and providing necessary equipment for effective work. The Tonoso Nursing College should also be upgraded and expanded to accommodate larger numbers of students, and training equipment provided. Justification
			The CHPS program was designed to provide a trained health care worker for areas poorly served by the current system, such as those distant from the Health Center. It has been successful in the regions in which it was piloted in reducing the incidence of some common problems, such as the morbidity from respiratory disease, diarrhea, and malaria. Currently, there is only one functioning Community Health Officer (CHO) with the CHPS program in the Asutifi district out of 17 designated CHPS zones.
	4.	Upgrade health facilities — Health Centers and district hospitals. This should begin with a significant upgrade of the Kenyasi Health Center to a polyclinic, with new facilities for radiology, ultrasound, minor surgery, emergency treatment, and some observation beds. The Gyedu, Acherensua, and Dadiesoaba Health Centers all require renovation and/or expansion, and equipment necessary for effective service, including telephone service and computers. The district hospitals each have specific needs that could be provided over a period of time in collaboration with the Ghana Health Service. Justification
			Most of the health centers visited showed evidence of disrepair, and many lacked basic necessities such as a functioning water system for hand washing or adequate latrines. In addition, much of the basic medical equipment necessary for adequate primary health care (such as adult and infant scales, otoscope, blood pressure apparatus) was lacking or non-functional. Telephone communication is non-existent between the health centers and referral hospitals or Regional Directorate, and most of the computers were either old or non-functional.
			The Kenyasi Health Center has documented a 14% increase in visits in the past year, related to the project-induced population increase in the area, suggesting that there will be progressively increased pressure for services on this Health Center in the coming years.
	5.	Facilitate incentives for health workers. In collaboration with the Regional Health Directorate, this could be done by providing continuing education opportunities, by expanding the employee recognition program, and but upgrading the living conditions of the healthcare workers. Justification
			A low level of morale among health workers was a regular finding at many of the health centers. Their complaints focused on shortages of medical equipment, a need for more health personnel, limited training opportunities, low salaries, and dilapidated building infrastructure.
	6.	Support and expand interventions to reduce malaria. This should be done by partnering with the Ghana Health Service in the "Roll Back Malaria" program and promoting the distribution of insecticide treated bednets at subsidized prices to those adults and older children not covered in the program, and continuing support after USAID funding terminates (in 2006). Additionally, support could be provided to expand the community education campaign, and train teachers, birth attendants, caretakers and families in the home treatment of malaria. Justification
			Malaria is unquestionably the most important health problem in Ghana. It accounts for 30-40% of all outpatient visits, 8-11% of inpatient admissions, and 10% of in-hospital deaths. Childhood mortality due to malaria is even higher, accounting for nearly 25% of deaths between ages 0-15 years. In adults, it is also the leading cause of workdays lost due to illness.
	7.	Support the Regional Health Directorate in surveillance and treatment of HIV/AIDS. Expansion of the program for surveillance testing of high risk groups should be considered. It is also recommended that periodic anonymous surveys of HIV prevalence be done, particularly on blood specimens drawn for other diagnostic reasons. The program to establish testing and counseling centers, and expand the number of HIV treatment centers, could be accelerated. Justification
			The incidence of HIV/AIDS has increased by a full percentage point just in the past year (3% to 4%) in the Asutifi district. This suggests that the social changes brought by mining activity may be a significant factor, and that further increases are anticipated. The rate is higher in females of reproductive age than males, which presents the added but preventable risk of neonatal HIV infection. Currently, there are only enough HIV test kits available through the Ghana Health Service for screening of blood donors, and no testing is being done on pregnant women or high-risk groups.
	8.	Strengthen training and implementation of IMCI. This could be done by sponsoring the continuation of IMCI training courses for all Health Center clinicians and the Community Health Officers of the CHPS program, with periodic updates to maintain competency. This training has already been done to a limited extent in the Brong-Ahafo region, but requires some additional work to extend it to the entire region. Justification
			The Integrated Management of Childhood Diseases (IMCI) is a WHO strategy of child health that is a key strategy for reducing infant and under 5 mortality. Since IMCI is a key strategy of the government, it can be anticipated that the government will provide support for supplies and the CHPS program, ensuring successful implementation of the strategy once health workers are trained.
			USAID also is critically involved in IMCI training implementation and will utilize IMCI and CHPS as a major strategy for reducing neonatal and infant mortality.
	9.	Improve and expand maternal audits for the prevention of maternal mortality. This could be done by developing a strategy for conducting thorough audits and implementing the results, through a joint team of University of Colorado specialists and Regional Health Directorate personnel. After a comprehensive auditing program is in effective use, local clinical updates will be needed in order to implement the needed prevention activities. Justification
			Maternal mortality is nearly entirely preventable, and the rate of reported maternal deaths in the Asutifi District is unacceptably high. Only half of the maternal deaths in the region were audited in 2004, severe maternal morbidity is not measured and near-miss audits are not conducted. Early detection or prevention activities can only be implemented by understanding the exact circumstances around the problems of delivery and maternal deaths.
	10.	Increase accessibility to clean water in target communities. This should focus on working with the local Water and Sanitation committees (WATSAN) and partners such as World Vision to provide pump maintenance training and accountability, and expanding rainwater collection units in households and communities. Consideration should be given to supporting the development of new wells or boreholes in communities where there is an excessive wait at peak times for water. Justification
			Local water systems in communities surrounding the project area have become overburdened with the influx of personnel who have moved into the communities while working at the project. Increased demand has over-taxed the capacity of the small water system (Kenyasi) causing pump failures and has created wait times for access to pumps at other communities. Long wait times frustrate residents who then turn to unsafe water sources to avoid the wait.
	11.	Provide support for home latrines development and maintenance, and for improved garbage collection and landfill sites. This could be accomplished by facilitating the cleaning and emptying of community latrines through local WATSAN committees and youth organizations, or by subsidizing the pumping of full latrines. In addition, the work begun through the WATSAN committees on appropriate waste and landfill management should be continued, and a medical waste disposal system should be developed in collaboration with the Regional Directorate of Health. Justification
			The perception of the local communities is that the influx of construction workers within the communities surrounding the Ahafo project area has overburdened existing community latrines. Visual inspection of community latrines surrounding the project confirms that many are close to capacity and not sanitarily maintained.
			Overall, household waste is poorly managed. Trash disposal is irregularly collected in the village areas, and only the most rudimentary landfill is employed.
			Within many of the health centers, medical waste is not effectively managed, which can have a direct impact on the transmission of HIV and hepatitis.
	12.	Enlarge and/or renovate selected schools, and provide housing for teachers. This will require a needs assessment to determine the classroom needs in the communities of interest, followed by partnership with the District Assembly and Ministry of Education to renovate and/or expand selected schools as required. Assistance in development of housing for teachers would contribute significantly toward the retention of qualified, dedicated teachers. Justification
			The increase in the number of workers at the mine site has put pressure on the community infrastructure with regard to both primary and secondary schooling, and has raised local housing prices beyond the ability of most teachers to pay. The expansion of classroom space in the local schools, the construction of additional classrooms, and provision of adequate, affordable housing for teachers will provide a one-time contribution to the community with a sustainable impact on the viability of the schools.
	13.	Support community education regarding domestic violence prevention and management. Technical assistance in the creation of community violence prevention curricula and training in conflict resolution could be developed through a partnership of involved Ghanaian organizations and the Universities of Colorado and Kumasi. The nature of the prevention strategy should be determined with and by the traditional leadership, especially the queen mothers, and the Youth Development Association, both of whom are interested and involved in social and health issues. Justification
			Community interviews with various women's groups confirmed the relatively common practice of abuse of women by their husbands, and some families were identified as abusive to the children. By definition, domestic violence is a cause of injury to women (and children). Families and communities at peace are better able to contribute to the work force and economic viability.
	14.	Support and development of adult literacy programs, especially focusing on women. Ghanaian or West African organizations that work in adult literacy could be engaged to design and initiate women's literacy programs that would be socially acceptable and practical for working women, under the administration of the LEEP program. Existing teachers in the community may be available to provide instruction, especially if there is some compensation, and some of the literate women in the community could also be encouraged to help. Justification
			Around the world, women are the gate-keepers of family health, who decide for the family when to seek health care and from whom. Women's literacy is associated with better states of health for their children and families. Women who can read can comply with written medical instructions and understand written social marketing materials, and they are less intimidated by the health care environment. The sustainable impact of adult education is an impact on the health of the community as well as on the potential economic vitality of the people.
	15.	Promote improved transportation to hospital for emergencies. A program could be implemented through the collaboration of the District Health Directorate, local Health Centers, and community groups, in which taxis or other vehicles could be could be given a retainer fee to be available in the case of emergency. Some form of reliable communication between the health facilities and the drivers would need to be put into place, such as a subsidized mobile phone service, which could be part of the compensation. Justification
			During emergencies, such as in the case of serious injury, complications of malaria, complications of delivery, etc, rapid access to critical care can determine survival. In the communities of interest, good care is available (and will be improved further by implementing some of the recommendations here), but the most significant barrier to emergency medical attention is distance.
AKYEM PROJECT AREA Although the visit to the Akyem project area and Eastern Regional Directorate of Health was brief, several significant health issues were encountered:
		The rate of HIV/AIDS is 6.1%, which is almost twice the national average of Ghana. It is thought that contributing factors include the proximity to Accra, the high of truck traffic through the region, and previous mining activities.
		The incidence of maternal mortality is very high, and the percentage of deliveries supervised by qualified healthcare personnel is very low.
		Malaria remains the most common problem treated and major cause of deaths in all age groups, especially in children.
Recommendations for the Akyem Area No formal recommendations could be made after such a brief visit, but some suggestions are offered for further assessment:
	1.	Further evaluation of Holy Family Hospital would help determine its equipment and staffing needs.
	2.	Conversion of the Health Center in New Abirem to a Polyclinic (as suggested for the Kenyasi Health Center) rather than a district hospital (as currently planned by the Eastern Regional Directorate) would be both cost-effective and efficient, primarily because of the very close proximity of New Abirem to the Nkawkaw and Holy Family Hospitals.
	3.	The current high incidence of HIV/AIDS in the Eastern region will require a heightened and coordinated effort to bring this under control. Together with malaria control, this could be a significant priority for support and interventions, similar to the recommendations made for the Ahafo region.
	4.	The high rate of maternal mortality and of low rate of supervised deliveries should be addressed. This will require a concentrated effort in collaboration with the Regional Directorate.

STAKEHOLDERS AND POTENTIAL PARTNERS

The Regional Directorate and District Directors of Health of the Ghana Health Service are perhaps the most significant stakeholder in any health-related intervention, and will be an important partner in almost all of the recommended interventions. The directors of the local Health Centers can be an invaluable source of information in activities that require changes in health behavior, such as malaria interventions, family planning, and domestic violence. Both the Chief Executive of the District Assembly and the Traditional Chiefs of the target communities have expressed significant interest in the health-related activities of NGGL, and asked to be included in discussions related to community development activities, especially those related to health education and improved water facilities and sanitary practices.

Contacts with the Kumasi University of Science and Technology (KNUST) indicate that they could serve as an important consultative and research resource for the Ahafo project, as could the University of Ghana through their School of Public Health. Since NGGL has already established a relationship with Opportunities Industrialization Centers International (OICI), it is anticipated that their role could be expanded to include some of the additional recommended projects. Finally, the University of Colorado is well positioned to participate with and assist these local partners.