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MINISTRY OF HEALTH/GHANA HEALTH SERVICE

Plan for Inactivated Polio Vaccine Introduction into Routine Immunization in Ghana

September 2014

Table of Content

Table of Content........................................................................................................................2List of Tables.............................................................................................................................4List of Figures............................................................................................................................5List of Abbreviations................................................................................................................6Executive Summary..................................................................................................................71. Justification for introduction of IPV and national decision-making process...........91.1 National Decision Making Process..................................................................................91.2 Justification for Introduction............................................................................................91.3 Technical and Operational Feasibility...........................................................................112. Overview of Inactivated Polio Vaccine......................................................................132.1 Vaccine preference and availability...............................................................................132.2 Licensure status of IPV in Ghana..................................................................................132.3 Target population and vaccine supply...........................................................................143. Introduction and implementation considerations.....................................................163.1 Policy development........................................................................................................163.2 National coordination and monitoring introduction......................................................173.2.1 Planning and Resource Mobilization Sub-committee................................................173.2.2 Communication and Social mobilization Sub-committee..........................................173.2.3 Training and Service Delivery Sub-committee..........................................................183.2.4 Data Management, Monitoring and Evaluation Sub-committee................................183.2.5 Logistics and Waste Management Sub-committee....................................................183.2.6 Safety monitoring and AEFI Sub-committee.............................................................193.2.7 Timeline of Activities.................................................................................................193.3 Affordability and financial sustainability......................................................................193.3.1 Overview of Multi-Year Plan.....................................................................................213.4 Overview of cold chain capacity at central, regional and district levels.......................213.4.1 Cold Chain Capacity at National Level......................................................................213.4.2 Cold Chain Capacity at Regional Level.....................................................................233.4.3 Cold Chain Capacity at District and Health Facility Levels......................................253.4.4 Plan to improve vaccine and cold chain management...............................................253.4.5 Vaccine and devices procurement and management..................................................263.4.6 Power supply and maintenance of cold chain equipment..........................................273.5 Waste management and Injection safety........................................................................273.6 Health worker training and supervision.........................................................................283.7 Risks and challenges......................................................................................................294. Situational analysis of the immunisation programme..............................................314.1 General context of Ghana..............................................................................................314.1.1 General Profile and Demography...............................................................................314.1.2 Health Status..............................................................................................................314.1.3 Health Priorities..........................................................................................................33

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4.1.4 Organogram of the National EPI Program.................................................................344.2 Geographic, economic, political, gender and social barriers to immunisation..............354.3 Findings from recent EPI Reviews, PIE and EVM........................................................364.3.1 Effective Vaccine Management Assessment.............................................................364.3.2 EPI Review.................................................................................................................374.3.3 Post-Introduction Evaluation......................................................................................404.4 Stock Management.........................................................................................................415. Monitoring and evaluation..........................................................................................435.1 Updating of monitoring tools.........................................................................................435.2 Adverse Event Following Immunisation (AEFI) monitoring and reporting.................436. Advocacy, communication and social mobilization..................................................457. Annex 1:Budget............................................................................................................488. Annex 2: Timeline........................................................................................................49

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List of Tables

Table 1: National Immunization and Vitamin A Supplementation Schedule...........................11Table 2: IPV vaccine preferences and estimated date of introduction......................................13Table 3: Target population for IPV for 2015 - 2019.................................................................14Table 4: Revised National Immunization and Vitamin A Supplementation Schedule.............16Table 5: Summarized budget for IPV introduction...................................................................20Table 6: Trends in Immunization Financing 2010 - 2013........................................................21Table 7: Cold chain capacity needs assessment for positive storage at the national level.......22Table 8: cold chain capacity need assessment for negative storage at the national level.........22Table 9: Cold chain capacity needs assessment for positive storage at the regional level.......24Table 10: Cold chain capacity needs assessment for negative storage at the regional level....24Table 11: Summary of EPI-related Health Indicators, 2003-2013...........................................33Table 12: Trends in national immunization coverage, EPI-GHS, 2012-2013..........................35Table 13: Quality and equity of immunization in Ghana.........................................................36Table 14: Key findings, recommendations and status of implementation................................37Table 15: Key findings from PIE for new vaccines introduction 2013....................................40

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List of Figures

Figure 1: Status of Incinerators in Ghana, 2014.......................................................................28Figure 2: Organogram of the EPI Programme..........................................................................34

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List of Abbreviations

AEFI Adverse Events Following ImmunisationBCG Bacille Calmette-GuerinCDC Center for Disease Control and PreventionCHPS Community Health Planning and ServicesCHR Child Health RecordsCWC Child Welfare ClinicDCD Disease Control and Prevention DepartmentDPT Diphtheria, Pertussis and Tetanus toxoid vaccineDSD Disease Surveillance DepartmentEPI Expanded Programme on ImmunisationGAVI Global Alliance for Vaccines and ImmunisationsGHS Ghana Health ServiceGIVS Global Immunisation Mission and StrategiesGoG Government of GhanaGPEI Global Polio Eradication InitiativeGVAP Global Vaccine Action PlanICC Inter-agency Coordination CommitteeIEC Information, education and communicationIPV Inactivated Polio VaccineMDG Millennium Development GoalMICS Multiple Indicator Cluster SurveyMoH Ministry of HealthMR Measles-RubellaMSD Measles Second DoseNGOs Non-Governmental OrganizationsNIDs National Immunisation DaysOPV Oral Polio VaccinePHC Primary Health CarePHD Public Health DivisionPPME Policy, Planning, Monitoring and EvaluationRED Reaching Every District SIA Supplemental Immunisation ActivitiesUNICEF United National Children FundUSAID U.S. Agency for International DevelopmentVPD Vaccine Preventable DiseasesWHO World Health Organization

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Executive Summary

In October 2007, Ghana’s documentation for polio-free certification was accepted by the African Regional Certification Committee (ARCC). Since then, Ghana has been vigorously pursuing interventions to ensure that the gains made in the country’s polio eradication efforts are maintained.

The World Health Assembly in May 2012 declared the completion of poliovirus eradication as a programmatic emergency for global public health. In response to this, the Global Polio Eradication Initiative (GPEI), in consultation with national health authorities, global health initiatives, scientific experts, donors and other stakeholders, developed the Polio Eradication and Endgame Strategic Plan 2013-2018. Under this plan, the use of OPV must eventually be stopped worldwide beginning with OPV type 2. The plan maintains that at least one dose of inactivated polio vaccine (IPV) must be introduced as a risk mitigation measure and to boost population immunity.

The Government of Ghana, with technical support from development partners, particularly, WHO and UNICEF took the lead in deciding on IPV introduction in Ghana. The decision was informed by available data including routine immunization and disease surveillance data, research papers, WHO recommendations and position papers, as well as expert advice including advice from the National Polio Expert Committee (NPEC).

The goal of IPV introduction is to maintain population immunity and consolidate the polio-free status of Ghana while supporting the global call to end polio. The introduction of IPV will lower the risk of re-emergence of vaccine derived type-2 poliovirus which is causing outbreaks in other countries. Structures that will be put in place before introduction will help strengthen the immunization programme and the overall health system in country.

The vaccine will be introduced nationwide. The target population for the vaccine is children less than on year. The vaccine will be administered at the same time with the OPV-3/PCV-3/Penta-3 visit and for that matter will not increase the number of visits by caregivers. When introduced, the EPI Programme will aim to reach at least 90% of the target population by the end of 2016. The programme will also aim to achieve 100% supply of vaccines at all levels during the planned period.

Prior to the introduction of the vaccine, the Ministry of Health/Ghana Health service will revise EPI policy documents, guidelines and data collection tools from January 2015. Official launching of IPV into routine immunization is scheduled for August 2015. Following the launching ceremony and subsequent introduction, supervisory and monitoring activities will commence. Post-introduction evaluation is planned to be conducted in August 2016.

In May 2012 the National Immunization Programme successfully introduced vaccines for pneumonia and rotavirus diarrhoea into routine immunization. In October 2013 measles-

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rubella vaccine was also introduced. The technical expertise developed and experience gained from the planning, development of guidelines, training, advocacy and social mobilization will be applied in IPV introduction. Adequate cold chain capacity is available at the national and regional levels for IPV introduction with the planned expansion in 2015

The expansion of the cold chain before the introduction of these vaccines greatly improved the cold chain capacity of the country. Walk-in-cold-rooms were installed for all regions and most districts were also provided with TCW 3000.

In order to achieve the above objectives, the following activities have been outlined;

High level advocacy and social mobilization for effective partnership, collaboration and public support

Revision of existing reporting forms (Child Health Records, tally books and monthly reporting forms etc.), reference materials and job aids

Training of staff on the new vaccines schedules, immunization safety and data management and reporting

Forecasting and maintaining availability of vaccines at all levels Improving cold chain capacity and the capacity of cold chain maintenance teams Strengthen surveillance and supportive supervision at all levels and achieve Acute

Flaccid Paralysis and other VPD surveillance indicators by 2015 and beyond

Despite the achievements, challenges beset the country’s EPI. These include financial sustainability to support programme implementation at all levels, therefore requiring every significant amount of partner support. Innovative and efficient use of resources including improved integration of the programme. The sector will also work with the Local Government structures through the District Health Administrations for support from the Metropolitan, Municipal and District Assemblies (MMDAs). Specific efforts will be made to support MMDA in advocacy.

A total of USD 1,000,416 is the estimated budget for introduction of IPV of which USD 646,000 (64.6%) is requested from GAVI as vaccine introduction grant (VIG). The rest will be provided through government, the GAVI HSS funding and partners.

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1. Justification for introduction of IPV and national decision-making process

1.1 National Decision Making Process

On 6 May 2014, the decision to introduce one dose of IPV into the routine immunization system was endorsed by the Inter Agency Coordination Committee (ICC) for immunizations. The presentation made at the meeting highlighted the rationale for IPV introduction, programmatic as well as budgetary considerations. Participants at the meeting included the Deputy Director General of the Ghana Health Service, Director for Public Health of the Ghana Health Service, the Head of Disease Control and Prevention, the Head of Disease Surveillance Department, the National Child Health Coordinator, the EPI Programme Manager and team, the Deputy Director for Planning and Budgeting of the Ghana Health Service. There were representatives from the World Health Organization and UNICEF, the Chairman of the Ghana National Polio-Plus Committee (GNPPC) of Rotary International, Ghana Coalition of NGOs in Health, Pediatrics Society of Ghana, and Ghana Registered Midwives Association as well as representatives from the Policy, Planning, Monitoring and Evaluation Division (PPMED) of the Ministry of Health.

Subsequently, the decision for IPV introduction was again endorsed at by the Health Sector Coordination Committee (HSCC). This committee is constituted by the Ministry of Health and all agencies of the Ministry of Health including the Ghana Health Service; representatives from the Ministry of Finance and Development Partners (DPs).

The Ministry of Health initiated the process by constituting the task team for IPV introduction. The committee was made up of representatives from the Ministry of Health, the Ghana Health Service, WHO, UNICEF, training institutions and Civil Society. Key data was provided by EPI technical staff and partner organizations, notably WHO and UNICEF for discussions before arriving at the final decision. Information provided included service data (routine immunization, surveillance, clinical, campaigns etc.), survey data, research papers, WHO recommendations and position papers, as well as expert advice including advice from the National Polio Expert Committee (NPEC) etc.

Recommendations from the HSCC were presented to the Minister of Health before the final decision to introduce IPV into routine immunization was made.

1.2 Justification for Introduction

The World Health Assembly in May 2012 declared that the completion of poliovirus eradication is a programmatic emergency for global public health. The Global Polio Eradication Initiative (GPEI) developed the Polio Eradication and Endgame Strategic Plan

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2013-20181. The plan outlines a comprehensive approach for completing eradication including the elimination of all polio disease by 20182.

As one of its four major objectives, the plan calls on countries to introduce at least 1 dose of Inactivated Polio Vaccine (IPV) into routine immunization schedules, strengthen routine immunization and withdraw Oral Polio Vaccine (OPV) in a phased manner, starting with type 2-containing OPV to hasten the interruption of all poliovirus transmission. The endgame plan calls for the introduction of IPV in all OPV-only using countries by the end of 2015. More specifically, IPV needs to be introduced for the following reasons:

To reduce risks; Once OPV type 2 is withdrawn globally, IPV will help fill the immunity gap by priming population against type 2 polio virus should it be reintroduced. A population immunized with IPV would have a lower risk of re-emergence or reintroduction of wild or vaccine-derived type 2 polio virus.

To interrupt transmission in the case of outbreaks; Should monovalent OPV type 2 (mOPV type 2) be needed to control an outbreak, those primed with IPV would be expected to have a better immune response, thus facilitating outbreak control and interruption of polio transmission.

To hasten eradication; IPV will boost immunity against poliovirus types 1 and 3 in children who have previously received OPV, which could further hasten the eradication of these two wild viruses

Ghana remained polio free since 2008 however there are still wild polio viruses circulating in the West Africa sub-region. Ghana intends to introduce one dose of IPV into the routine immunization by 2015 and replace trivalent oral polio vaccine (tOPV) with bivalent oral polio vaccine (bOPV) in 2016 in response to this objective. When introduced IPV will play a major role in;

Risk reduction due to planned OPV type 2 withdrawal,

Interruption of transmission if type 2 outbreaks occur, and

Boosting immunity against all types of poliovirus

1.3 Technical and Operational Feasibility

The Ghana EPI Programme follows the 6, 10 and 14 weeks immunization schedule beginning with a ‘zero’ dose of oral polio vaccine (OPV-0) and Bacille Calmette Guerin (BCG) at birth

1 GAVI Alliance. Supplementary Guidelines for Inactivated Polio Vaccine Applications in 20142 Global Polio Eradication Initiative. Polio Eradication and Endgame Strategic Plan 2013–2018 - See more at: http://www.polioeradication.org/resourcelibrary/strategyandwork.aspx#strategyandwork.aspx?s=2&_suid=1382372983385049930892531473775

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and ending with measles-rubella and yellow fever at 9 months for infant vaccinations. Measles second dose (MSD) is administered at 18 months. The dose per vaccine and the route and site of administration is shown in the table below:

Table 1: National Immunization and Vitamin A Supplementation Schedule

Vaccines Doses Route and Site of Injection

At birthBCGOPV0

0.05ml2 drops

Intra-dermal, right upper armOral

6 weeks

DPT-HepB-Hib1OPV1Pneumo 1Rota 1

0.5ml2drops0.5 ml1.5 ml vial

Intra-muscular, lateral aspect of left thighOralIntra-muscular, lateral aspect of right thighOral

10 weeks




14 weeksDPT-HepB-Hib3OPV3Pneumo 3

0.5ml2drops0.5 ml

Intra-muscular, lateral aspect of left thighOralIntra-muscular, lateral aspect of right thigh

6 months Vitamin A 100,000 IU Oral

9 monthsMeasles-RubellaYellow Fever

0.5ml0.5ml

Subcutaneous, left upper armSubcutaneous, right upper arm


18 monthsMeaslesVitamin A

0.5ml200,000 IU

Subcutaneous, left upper armOral

After 18 months Vitamin A is given every 6 months till child is 5 years old18 months – Give Long lasting Insecticide Treated Nets (LLINs) to the child

The goal of the EPI Programme is to protect all children and pregnant women living in Ghana against vaccine preventable diseases. The program works within the context of global interdependency and as such programme targets are based on the framework of the Global Vaccine Action Plan (GVAP). The ultimate goal of the programme is to contribute to the reduction of U5MR in order for the country to achieve the MDG-4.

In May 2012, the National Immunization Programme successfully introduced vaccines for pneumonia and rotavirus diarrhoea simultaneously into routine immunization. In October 2013 measles-rubella vaccine was also introduced. The technical expertise developed and experience gained from planning, developing guidelines, training, advocacy and social mobilization will be useful in IPV introduction.

Prior to the introduction of these vaccines, the programme undertook a series of preparatory activities including revision of the c-MYP, EPI Field guide, data collection and reporting tools, child health records booklet etc. An extensive training was organized for primary health

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care providers and EPI managers at all levels. Based on Knowledge, attitude, behavioural and practices (KABP) study which was conducted to assess caregiver perception about the new vaccines, social mobilization messages were formulated. A system for identifying and reporting adverse events following immunization (AEFI) was implemented. Monitoring of adverse events following immunization (AEFI) was highlighted at all training session and in addition, sentinel sites were established to provide quality data on all AEFIs.

A year after the introduction, Ghana recorded national coverage of 93% for the first dose of pneumococcal vaccine and 89% for the third dose. The coverage for rotavirus diarrhoea vaccine, was 92% for the first dose and 87% for the second dose. (See JRF 2013).

In August 2010 the Government of Ghana with the support of WHO and UNICEF conducted ‘Effective Vaccine Management Assessment (EVMA) in all regions. The study showed insufficient cold storage capacity at the regional and district levels. Since then steps have been taken to address the gaps. Walk-in cold rooms (WICR) have been installed in all the ten regions. There is now adequate cold chain capacity at regional levels. With regard to districts and health facilities, TCW 2000 and TCW 3000 refrigerators were procured and distributed to improve cold chain capacity at the operational level. Cold chain expansion at the operational level is still ongoing as new facilities are constantly being created.

The commitment of the Government of Ghana and the continuous support from GAVI and other development partners will facilitate the smooth introduction of any new vaccine(s) in the routine immunization programme in future.

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2. Overview of Inactivated Polio Vaccine

2

2.1 Vaccine preference and availability

The 10-dose vial is preferred. This decision was based on the fact that vaccinators are already used to a 10-dose pentavalent formulation in the system. This choice will also maximize the use of cold chain space as much as possible in anticipation of future vaccine introductions.

Table 2: IPV vaccine preferences and estimated date of introduction

Preferred IPV vaccine

Month and year of first vaccination

Preferred second presentation

Preferred third presentation

10-dose vial September 2015 5-dose vial 1-dose vial

Ghana understands that there is enough production capacity for current IPV standalone products to meet the needs for all OPV-using countries to introduce one dose of IPV into their routine immunization programme3. The month and year of introduction will be communicated early enough to UNICEF to assure vaccine supply.

2.2 Licensure status of IPV in Ghana

Licensure will be needed for IPV. The Food and Drugs Authority (FDA) is the national regulatory authority mandated by the Public Health Act, 2012(Act 851) of the Republic of Ghana to regulate drugs and medical devices including vaccines. The FDA is an Agency under the Ministry of Health.

The preferred formulation – 10-dose vial – is currently not a registered product in Ghana, though it is WHO-prequalified. Being a WHO-prequalified vaccine, the procedure for national registration would be expedited. The procedure involves submission of a sample of the vaccine and the dossier by the manufacturer to the regulatory body for consideration.

The licensure process will begin after the planned WHO orientation for NRAs for licensing of IPV scheduled for October 2014. The duration for licensure will take between 3 – 6 weeks after this meeting. The Government of Ghana will register the three IPV formulations (10mls, 5mls, and 1ml) indicated in this plan. This is because in the event that the preferred formulation is not available at the time of introduction, other formulations could be used. The registration should be completed by the end of the year (2014).

There are adequate arrangements at the national level for clearing and receiving vaccines from customs at arrival. Overall the vaccine arrival procedures are functioning efficiently and a

3 Joint GPEI-GAVI Statement on the Availability and Price of Inactivated Polio Vaccine | Press centre

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disciplined modus operandi is in place between the Ministry of Health and Customs. Delivery of vaccines is normally completed within 4 hours of arrival. UNICEF standard vaccine arrival report form (VAR) is used for all shipments and feedback sent within required deadline (see EVMA report).

All EPI vaccine shipments are consigned directly to the Procurement and Stores Division (PSD) of the Ministry of Health, which is responsible to clear the shipments using their appointed clearing agent. The shipping documents are sent by the UNICEF Global Freight Forwarders to the UNICEF country office as notified party. UNICEF then forwards the shipping documents to the Customs Authority with copies to PSD. UNICEF processes shipping documents to the authorizing clearing agent of PSD on behalf of the Government for clearance of the shipment at least 5 working days before the arrival of shipment.

The shipping documents are directly addressed to customs to expedite the processing time as the vaccines must be cleared within a few hours of arrival. The Local Customs Authority assesses the duties and taxes (CD/VAT) based on the value of the vaccine shipment. The consignee arranges payment on a provisional basis of duties and taxes to the Customs Authority. If there are any delays, UNICEF immediately takes action and asks all concerned authorities and concerned parties to take immediate action to ensure the safe storage of vaccines. Adequate cold storage capacity at the port of arrival to store vaccines should there be any unexpected delays.

Since vaccines are procured from WHO pre-qualified suppliers, a special requirement for pre-delivery inspection is not required.

2.3 Target population and vaccine supply

Inactivated polio vaccine will be introduced as a single dose injection to children at the age of 14 weeks during the 3rd doses of Pentavalent (DTP-HepB-Hib) and OPV starting September 2015. The target age group will be children under 1 year nationwide with a population of about 1.1 million annually. The estimated target from the year of introduction through to 2019 is shown in the table below;

Table 3: Target population for IPV for 2015 - 2019

2015 2016 2017 2018 2019

Total Population 27,955,56

7 28,654,45

6 29,370,81

8 30,105,08

8 30,857,71

5Birth cohort 1,118,223 1,146,178 1,174,833 1,204,204 1,234,309

Surviving infants 1,062,312 1,088,869 1,116,091 1,143,993 1,172,593

Target for IPV 372,741 1,146,178 1,174,833 1,204,204 1,234,309

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Ghana’s inactivated polio vaccine (IPV) will be delivered through the Supply Division of UNICEF.

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3. Introduction and implementation considerations

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3.1 Policy development

The National Policy for Immunizations in Ghana is currently being revised to include IPV. The immunization schedule has been modified to include IPV. The introduction of IPV will not increase the number of contacts in the national schedule as shown below;

Table 4: Revised National Immunization and Vitamin A Supplementation Schedule

Vaccines Doses Route and Site of Injection

At birthBCGOPV0

0.05ml2 drops

Intra-dermal, right upper armOral

6 weeks




10 weeks




14 weeks

DPT-HepB-Hib3Pneumo 3OPV3IPV

0.5ml0.5 ml2 drops0.5ml

Intra-muscular, lateral aspect of left thighIntra-muscular, lateral aspect of right thighOralSubcutaneous, left Upper arm


9 monthsMeasles-RubellaYellow Fever

0.5ml0.5ml

Subcutaneous, left upper armSubcutaneous, right upper arm


18 monthsMeaslesVitamin A

0.5ml200,000 IU

Subcutaneous, left upper armOral

After 18 months Vitamin A is given every 6 months till child is 5 years old18 months – Give Long lasting Insecticide Treated Nets (LLINs) to the child

A single dose of IPV will be given subcutaneously in the left upper arm. It will be administered at the same time as the third dose of pentavalent which is administered in the left thigh and the third dose of pneumococcal vaccine which is administered in the right thigh.

During vaccination sessions, opportunity is taken to counsel mothers on exclusive breastfeeding, growth monitoring and treatment of minor ailments including ORS zinc for treatment of diarrhoea.

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3.2 National coordination and monitoring introduction

The Health Sector Coordination Committee (HSCC) has overall responsibility of coordinating health sector activities and mobilization of resources for the sector. The Interagency Coordinating Committee on Immunization (ICC) takes decisions on immunisation policy, programme, advisory and finance-related issues. The ICC also reviews and endorses the Annual Progress Report (APR) and proposals for new and underutilized vaccines. The committee is chaired by the Chief Director of the MOH /The Director General of the Ghana Health Service. The proposal for IPV introduction was endorsed by the ICC. There are a number of sub-committees which work on different aspects of new vaccine introduction. These include resource mobilisation, logistics management, waste management etc., the details provided in subsequent sections.

Other committees are the National Polio Expert Committee (NPEC), National Taskforce for Laboratory Containment (NTF) and National Certification Committee (NCC) on Polio Eradication.

Ghana has considerable experience in introducing new vaccines. The country draws experience from pentavalent vaccine introduction and the dual introduction of pneumococcal conjugate (PCV) and Rotavirus vaccines. Working Groups exist for introducing new vaccines. These groups worked for the successful introduction of PCV and rotavirus vaccines into routine immunization in May 2012. The various sub-committee/working groups are;

3.2.1 Planning and Resource Mobilization Sub-committeeThe Planning and Resource Mobilization Sub-committee will coordinate and guide activities of the various sub-committees. It will also mobilize internal and external resources necessary for the successful introduction of IPV into the routine immunization programme.

At national level, the ICC Sub Technical Committee (Ghana Health Service, WHO and UNICEF) will coordinate all activities. At the regional and district levels similar committees will coordinate the activities in their respective areas. The regional and district EPI Officers will coordinate activities at the various levels.

Sensitization and consensus building meetings will be held as well as briefing of key decision makers and stakeholders on the public health importance and to seek their support. These will include; policy makers (cabinet and parliamentarians), development partners, media practitioners, health managers, leaders of civil society and traditional leaders.

3.2.2 Communication and Social mobilization Sub-committeeThe task of the Communication Sub-committee is to plan and coordinate all social mobilization activities at the national, regional and district levels and also develop and

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distribute guidelines on social mobilization activities for regional and district levels. The sub-committee will draw a budget for social mobilization activities for national, regional and district levels, develop, pretest, print and distribute IEC materials for the introduction and acceptance of new vaccine into EPI (leaflets, posters etc), develop social announcement for print and electronic media on the introduction of new vaccines into EPI (for Regions/Districts).

They will also coordinate press briefing and launching at national and regional levels for the introduction of new vaccine (writing of speeches, tentative program, venue selection and main speaker) as well as coordinate radio and TV discussions at the national level- news commentary on radio Ghana.

3.2.3 Training and Service Delivery Sub-committeeThe task of the Training and Service Delivery Sub-committee is to plan and develop training programmes relevant to the various levels of the service, develop training guidelines and manuals for the introduction of IPV, review child health records to include the new vaccine, review the EPI Field Guide to include the new vaccine and monitor training activities at regional and district levels.

3.2.4 Data Management, Monitoring and Evaluation Sub-committeeThe task of the Data Management, Monitoring and Evaluation Sub-committee is to serve as the principal advisory group in all matters pertaining to data management, monitoring and evaluation activities/issues with regards to the new vaccine introduction. The sub-committee will review and revise the EPI tally sheet book, monthly reporting forms, child health record books and other templates for reporting. The sub-committee will also facilitate the formation and training of monitoring teams, monitor vaccination performance of the new vaccine and again liaise with the Research Sub-committee to conduct a post-introduction evaluation six (6) months after introduction

3.2.5 Logistics and Waste Management Sub-committeeThe task of the Logistics and Waste Management Sub-committee is to ensure the establishment of logistics and waste management committees at all levels. Specifically, the committee will also identify and train logistics focal persons at national and regional levels, facilitate the update of cold chain inventories at all level and ensure availability of adequate cold chain equipment and dry storage space, ensure functionality and maintenance of all cold chain equipment, ensure all logistics are available on time and in sufficient quantities for the introduction of IPV, prepare distribution list for all logistics for timely delivery to regions and districts as well as identify and train waste management focal person at all levels.

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The sub-committee will also ascertain status and availability of incinerators by health facilities/districts and support district/regional plans to repair non-functional incinerators, collaborate with other sub-committees to determine adequate quantities of logistics and distribute items/materials. They will also collaborate with Data Management, Communication and Training Sub-Committees to print documents developed in support of the introduction of new vaccines.

3.2.6 Safety monitoring and AEFI Sub-committeeThe task of the Safety Sub-committee is to monitor the quality of safe immunization practices, detect and respond to emergencies, develop AEFI reporting forms and guidelines for the new vaccine, reassure the public about the safety of the immunization programme, collaborate with the Training Sub-committee for inclusion of relevant information in the training manual, plan for training of AEFI Focal Persons at all levels as well as setup sentinel sites for AEFI monitoring.

The sub-committee will also ensure availability of emergency drugs, follow-up and support the management of serious AEFI cases, establish and maintain database for all AEFI cases and also collaborate with the Logistics Sub-committees to determine adequate quantities of emergency drugs and reporting forms for distribution.

3.2.7 Timeline of ActivitiesActivities related to IPV introduction started in June 2014 and will continue till the vaccine is introduced in September 2015. Effective vaccine management assessment will be conducted in October 2014 to assess the cold chain and human resource capacity for vaccine management after which steps will be taken to address gaps. Revision of policy documents, guidelines and data collection tools will start from January 2015. Official launching of IPV into routine immunization is scheduled for August 2015. Following the launching ceremony and subsequent introduction, supervisory and monitoring activities will commence. Post-introduction evaluation is planned to be conducted in August 2016. The detailed timeline of activities is attached as Annex-C (Timeline of Activities).

3.3 Affordability and financial sustainability

A total of USD 1,000,416 is the estimated budget for introduction of IPV of which USD 646,000 (64.6%) is requested from GAVI as vaccine introduction grant (VIG). The rest will be provided through government, the GAVI HSS funding and partners. The summary of the budget with sources of funding is shown below;

Table 5: Summarized budget for IPV introduction

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Government support

Existing GAVI HSS funding

Requested GAVI VIG

TOTAL COST Amount Amount AmountAmount

requestedUS$ US$ US$ US$ US$

1 Program management and coordination 21,580 - - - 21,580 2 Planning and preparations 287,512 - WHO 7,439 - 280,073 3 Social mobilization, IEC and advocacy 119,022 - WHO/UNICEF - - 119,022 4 Other training and meetings 88,312 - - - 88,312 5 Document production 60,092 10,000 Rotary 19,429 - 30,663 6 Human resources and incentives 11,952 - - 11,952 - 7 Cold chain equipment 83,000 - - 83,000 - 8 Transport for implementation and supervision 49,800 49,800 - - - 9 Immunisation session supplies 6,640 6,640 - - -

10 Waste management 90,636 - WHO/UNICEF - 90,636 - 11 Surveillance and monitoring 23,240 - WHO 23,240 - - 12 Evaluation 48,140 - - - 48,140 13 Technical assistance 13,280 13,280 WHO - - - 14 Data management 85,258 - - 39,000 46,258 15 Capacity building 11,952 - - - 11,952

Total 1,000,416 79,720 50,108 224,588 646,000

Partners' support*

Cost Category Name

The Financial guidelines of the Ministry of Health were used to calculate the unit cost of the line items and for preparing the budget. The method used for the development of the budget took cognizance of existing health system plans such as the GAVI HSS funding (2014-2019), the Health Sector Program of Work and the Draft Health Sector Medium Term Development Plan 2014-2017. The budgeting focused on resources and related activities that must be implemented to achieve successful introduction of the vaccine. The main sources of funding for the health sector are Government of Ghana (GoG), Household/out of pocket expenditure, Internally Generated Funds (IGF) and Development Partners Funds (Budget Supports {MDBS} and (Sector Budget Support) SBS earmarked funding from multilateral, bilateral, UN, and Global Health Initiatives). GoG is the main financier of the health sector. Government funding comes from tax revenues and covers all the three areas of public expenditure (Employee Compensation, Goods and Services and Assets). Almost all public health sector workers are government employees and are remunerated from public funds allocated to the health sector from the Ministry of Finance. Just like all other public sector workers, all public health workers involved in immunization and related activities are compensated with GoG funds. GoG budget for Goods and Services are allocated to decentralized cost centers to be implemented according to their approved plans. Outreach, supervision, training and monitoring constitutes some of the major activities of the district plans.

Major investment expenditure and procurement items such as vaccines, cold chain equipment are budgeted and procured centrally at the national levels. Plans and budgets are developed within the context of the Medium Term Expenditure Framework (MTEF).

A number of global health initiatives including the Global Fund for HIV/AIDS, TB and Malaria and the GAVI have been supporting health systems strengthening initiatives. There

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are other partners who are working increasingly towards the use of new vaccines and technologies to improve Vaccine preventable diseases (VPDs).

MOH will continue to explore the many opportunities within the international community to mobilize resources to sustain IPV introduction. There will be strong advocacy with evidence of the successes of the NIP to the Government of Ghana through the Ministry of Finance to increase funding to the health sector. The sector will also work with the Local Government structures through the District Health Administrations for support from the Metropolitan, Municipal and District Assemblies (MMDAs). Specific efforts will be made to support MMDA in advocacy.

Table 6: Trends in Immunization Financing 2010 - 2013

FUNDING/YEAR 2010 2011 2012 2013Country 8,474,222 5,273,334 4,788,851 4,192,006GAVI 8,421,391 5,094,995 46,240,775 43,575,000UNICEF 3,514,057 5,530,551 - 625,451WHO 8,418,072 5,361,563 1,943,977 2,477,524USAID 100,000 - - -ROTARY 41,784 161,239 18,000 20,000EXPENDITURE 28,969,526 21,421,682 52,991,603 50,889,981

3.3.1 Overview of Multi-Year PlanThe current comprehensive multi-year plan for immunization spans from 2010 – 2014. Although provisions were made for the introduction of new vaccines, IPV introduction was not catered for. As indicated above, the lifespan of the cMYP elapses by the end of 2014, a new cMYP spanning the period 2015 – 2019 has been developed. The introduction of IPV into routine immunization is a key activity in the new cMYP.

3.4 Overview of cold chain capacity at central, regional and district levels

3.4.1 Cold Chain Capacity at National LevelThe net cold chain capacity for positive storage at the national level currently stand at 56,250 litres. This capacity will not be adequate to accommodate the vaccine requirements for 2015 – 2019. There is therefore the need to upgrade the positive cold chain capacity at the national level to accommodate the increase. The Government of Ghana has already procured two (2) units 40,000 litres (totaling 80,000 litres gross capacity) for installation at the national level in 2015.

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With regards to the negative storage capacity, there is adequate space for 2015 – 2019. These are presented in the tables below:

Table 7: Cold chain capacity needs assessment for positive storage at the national level

Formula 2015 2016 2017 2018 2019

A

Annual positive volume requirement, including new vaccine (specify:__________) (litres)

Sum-product of total vaccine doses

multiplied by packed volume per

dose

114,086 litr 120,890 litr 125,275 litr 129,506 litr 132,978 litr

BExisting net positive cold chain capacity (litres)

# 56,250 litr 56,250 litr 56,250 litr 56,250 litr 56,250 litr

C

Estimated minimum number of shipments per year required for the actual cold chain capacity

A/B 2.03 2.15 2.23 2.30 2.36

DNumber of consignments / shipments per year

Based on national vaccine shipment

plan4 4 4 4 4

E Gap in litres ((A*(1/D+Buffer/12) - B) 793 litr 4,195 litr 6,388 litr 8,503 litr 10,239 litr

F Estimated additional cost of cold chain

US $ $123,472 $0 $0 $0 $0

Table 8: cold chain capacity need assessment for negative storage at the national level

Formula 2015 2016 2017 2018 2019

A

Annual negative volume requirement, including new vaccine (specify:_______) (litres)

Sum-product of total vaccine doses

multiplied by packed volume per

dose

4,993 litr 5,783 litr 5,928 litr 6,076 litr 0 litr

BExisting net negative cold chain capacity (litres)

# 6,250 litr 6,250 litr 6,250 litr 6,250 litr 6,250 litr

C

Estimated minimum number of shipments per year required for the actual cold chain capacity

A/B 0.80 0.93 0.95 0.97 0.00

DNumber of consignments / shipments per year

Based on national vaccine shipment

plan4 4 4 4 4

E Gap in litres ((A*(1/D+Buffer/12) - B) 3,754 litr- 3,358 litr- 3,286 litr- 3,212 litr- 6,250 litr-


US $ $0 $0 $0 $0 $0

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3.4.2 Cold Chain Capacity at Regional LevelThe country embarked on cold chain expansion at the regional level following the EVM assessment 2010. Walk-in cold rooms of 40m3 capacity have been installed in Ashanti, Brong-Ahafo and Central regions. With the exception of Greater Accra Region which has 80m3 capacity WICR, all other regions now have 30m3 WICR.

The introduction of IPV and the subsequent introduction of bOPV into routine immunization will make the cold chain capacity in Ashanti Region inadequate. The Government of Ghana with the support of partners will procure and install a 10m3 walk-in-cold-room in the region to make up for the gap. There is therefore adequate positive cold chain capacity in all other regions.

Walk-In Freezers (20m3) have also been installed in Greater Accra and Ashanti regions to help improve quality of storage of Oral Polio Vaccines. There is adequate negative capacity at all regions. The tables below summarizes positive and negative cold chain requirement and capacity at the regional level needed for the introduction for the new vaccine using the WHO Logistics Forecasting tool:

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Table 9: Cold chain capacity needs assessment for positive storage at the regional level

Formula Asha

nti

Bron

g Ah

afo

Cent

ral

East

ern

Gre

at A

ccra

Nor

ther

n

Upp

er E

ast

Upp

er W

est

Volta

Wes

tern

A

Annual positive volume requirement, including new vaccine (specify:__________) (litres)

Sum-product of total vaccine doses multiplied by packed volume per

dose

25,926 litr 11,932 litr 12,129 litr 13,951 litr 22,087 litr 13,553 litr 5,352 litr 3,692 litr 11,400 litr 12,540 litr

B Existing net positive cold chain capacity (litres)

# 12,500 litr 12,500 litr 12,500 litr 9,375 litr 25,000 litr 25,000 litr 9,375 litr 9,375 litr 9,375 litr 9,375 litr

CEstimated minimum number of shipments per year required for the actual cold chain capacity

A/B 2.07 0.95 0.97 1.49 0.88 0.54 0.57 0.39 1.22 1.34

D Number of consignments / shipments per year

Based on national vaccine distribution plan

4 4 4 4 4 4 4 4 4 4

E Gap in litres ((A*(1/D+Buffer/12) - B) 463.15507 6,534 litr- 6,435 litr- 2,400 litr- 13,956 litr- 18,223 litr- 6,699 litr- 7,529 litr- 3,675 litr- 3,105 litr-


US $ $39,584 $0 $0 $0 $0 $0 $0 $0 $0 $0

Table 10: Cold chain capacity needs assessment for negative storage at the regional level

Formula Asha

nti

Bron

g Ah

afo

Cent

ral

East

ern

Gre

at A

ccra

Nor

ther

n

Upp

er E

ast

Upp

er W

est

Volta

Wes

tern

A

Annual negative volume requirement, including new vaccine (specify:_______) (litres)

Sum-product of total vaccine doses multiplied by packed volume per

dose

0 litr 0 litr 0 litr 0 litr 0 litr 0 litr 0 litr 0 litr 0 litr 0 litr

B Existing net negative cold chain capacity (litres)

# 6,250 litr 216 litr 264 litr 641 litr 6,250 litr 6,250 litr 110 litr 63 litr 183 litr 264 litr

CEstimated minimum number of shipments per year required for the actual cold chain capacity

A/B 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

D Number of consignments / shipments per year

Based on national vaccine distribution plan

4 4 4 4 4 4 4 4 4 4

E Gap in litres ((A*(1/D+Buffer/12) - B) 6,250 litr- 216 litr- 264 litr- 641 litr- 6,250 litr- 6,250 litr- 110 litr- 63 litr- 183 litr- 264 litr-


US $ $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

3.4.3 Cold Chain Capacity at District and Health Facility LevelsAs with the national and the regional levels, the WHO Logistics Forecasting tool was used to assess the cold chain requirement, capacity and the needs at the district level. The analysis showed that 85 out of the 216 districts in the country do not have adequate positive cold chain capacity for the planned introduction of IPV. As per the policy of the government, all these 85 districts will be provided with TCW 3000 refrigerator.

Provision has been made in the GAVI HSS funding to procure hundred (100) TCW 3000 refrigerators in 2014/2015 to support vaccine storage. A total of fifty (50) TCW 2000 will also be procured for distribution to health facilities.

3.4.4 Plan to improve vaccine and cold chain management Ghana conducted Effective Vaccine Management Assessment (EVMA) in 2010 with the goal of updating the storage capacity and improving on the vaccine management system at all levels. Storage capacity has been increased in all regions in the country. Brong-Ahafo and Ashanti regions have 40 meter cubic walk-in cold rooms whiles Greater Accra has a 60 cubic meter walk-in cold room. All other regions were provided with 30 cubic meter walk-in cold rooms.

Cold chain and Vaccines are managed at the national level by a team comprising headed by the Deputy EPI Programme Manager (Logistician). The other team members include a National Logistician, Cold Chain Manager, Supply Chain Officer and biomedical engineers who are responsible for cold chain equipment maintenance.

There are also trained Cold Chain Managers at the regional level who monitor all regional cold chain equipment in the regions and update the national cold chain Team for prompt action.

The country’s cold chain inventory is updated every six (6) months using the WHO Cold Chain Equipment Inventory and Replacement tool. Currently, there is a deficit in the positive cold storage capacity at the national level as presented in section 3.4.1. There is no cold chain gap at the regional level with the exception of Ashanti Region which will need cold chain expansion in 2017. At the district level, cold chain gaps exit in 85 districts. Plans are underway for these gaps to be filled.

The last EVM was conducted in 2010, the country intended to conduct another assessment in August 2014. However, there was a challenge with an external technical assistance; hence, the assessment has been rescheduled for October 2014. Findings from the assessment will reveal status of indicators such as storage facility, temperature monitoring, vaccine management, and staff capacity etc. at all levels. Recommendations from the assessment will help to improve

staff training, storage facility expansion, equipment replacement, monitoring and supervision which will go a long way to improve vaccine and cold chain management in general.

The EPI Programme is mindful of the effectiveness of the supply chain; hence vaccines from the national level to the facility level follows a laid down structure, which has been consistent since the inception of the programme. Based on this structure, Vaccines are supplied quarterly from national level to the regional level. Regions also supply to districts on monthly basis and facilities also receive vaccines on monthly basis.

There is planned preventive maintenance of cold chain facilities at all levels; a team of technicians from the Biomedical Engineering Unit of the Ministry of Health and Clinical Engineering Unit of the Ghana Health Service assist the regional equipment management teams to repair broken down cold chain facilities.

Temperature is monitored twice daily at all levels and data is plotted on temperature monitor charts. It is also reported monthly in the DVDMT by every district. The Programme has also procured fridge tags for continuous monitoring of vaccines at the regional and district levels. Continuous temperature data loggers were procured for national and regional walk-in-cold rooms. However the data loggers have been re-called by the manufacture due to technical challenges for rectification. We are waiting for the equipment to be installed as soon as they are repaired to enhance cold chain management.

Vaccine ledgers are used at all levels to monitor vaccine usage. Additionally, national and regional levels use the WHO Stock management tool. Maximum and minimum stock levels as well as the first-to-expire first-out (FEFO) principles are followed in the management of vaccine stock. Vaccine wastage is monitored at all levels through the routine monthly reporting format. Immunization tally books are also in use at the operational levels to record daily immunization. Additionally, immunization coverage for various antigens are monitored by the use of immunization monitor charts. The programme intends to incorporate IPV into all these tools prior to the introduction.

3.4.5 Vaccine and devices procurement and managementVaccines for the immunization programme are estimated based on WHO-UNICEF guidelines and are procured by UNICEF. The estimation and procurement of the new vaccines and any others will be done by similar principle. Vaccine distribution will be done according to the quarterly supply schedule from national level to regions. Re-distribution to districts and to sub-districts and facilities is done on monthly basis. Vaccine management and distribution for IPV will follow same principles as already practiced at all storage and service delivery points of the levels in the country.

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3.4.6 Power supply and maintenance of cold chain equipmentThe cost of providing energy for cold chain equipment is covered by the Government of Ghana through the Ministry of Health budgetary support. Over 80% of health facilities in Ghana are connected to the national grid (EmONC). The cost of providing gas for gas-powered refrigerators is supported by internally generated funds.

The Biomedical Engineering Unit of the Ministry of Health and the Clinical Engineering Unit of the Ghana Health Service conduct planned preventive maintenance of cold chain equipment in the country. These engineering units have cold chain maintenance teams at the national level with similar teams at all regions.

Funding for maintenance of cold chain equipment at the national and regional level are provided by GOG and complemented with funds for Immunization Services Support (ISS) provided by GAVI. At the service delivery level, funds provided by GOG and GAVI-ISS are complemented by internally generated funds.

The national cold chain inventory (updated June 2014) indicates that there are about 2121 (78.1%) functional cold chain facilities. About 432 (15.9%) are awaiting repairs and about 6% are unserviceable.

3.5 Waste management and Injection safety

According to the EPI Policy on Injection Safety, the "bundling" principle is being followed for the procurement and distribution of vaccines with auto-disable (AD) syringes and safety boxes for the collection of sharps.

The final disposal of used syringes and sharps is done by incineration where an incinerator is available. Where there is no incinerator, the used safety boxes are stored in a safe place and later transported to a nearby facility for incineration. In the very distant areas open pit burning method is use for disposal. There are currently 46 new districts without incinerators and also a number of incinerators that were constructed from 2000-2008 require rehabilitation.

Figure 1 shows distribution of incinerators nationwide. There are 85 districts with nil or non-functional incinerators. WHO and UNICEF are sponsoring 22 more incinerators (in 22 districts) in addition to 43 already completed with their support.

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Figure 1: Status of Incinerators in Ghana, 2014

In response to equipping all districts with at least one incinerator, provisions have been made within the current HSS support from GAVI to construct 50 new incinerators in newly created districts. Additionally, existing but non-functional ones in old districts will be rehabilitated with same support. The remaining 13 districts will be catered for with funds from the IPV

Vaccine Introduction Grant (VIG).

In the current arrangement, districts without incinerators cart injection waste to nearby districts which have functional incinerators for disposal. Until new incinerators are fully built and functional, this arrangement will continue and districts will be supported with disinfectants and clothing kits for waste managers including boots, heavy-duty (utility) gloves, coverall gown, goggles, etc using funds from GAVI-HSS.

Plans are afoot to update healthcare workers and waste managers on infection prevention and injection safety within

support from VIG. The major component of the training will focus on disaggregation of waste under the principle of “DO NO HARM” to self and others.

Regular inspection of disposal sites will continue in all districts to ensure effective management of the waste. Protective materials for the attendants will regularly be supplied and they will be oriented to use the materials at all times to avoid other health hazards.

3.6 Health worker training and supervision

Currently community health nurses and disease control officers provide immunization services. Whenever a new vaccine is introduced all managers, supervisors and vaccinators are trained on the new vaccine. The national EPI guideline will be revised to include IPV. Based

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on this revised guideline, training materials ( e.g. training manual, fact sheets, training pre-test and post-test forms) will be developed.

The Training and Service Delivery Sub-committee will plan and develop training programmes relevant to the various levels of the service, develop training manuals and guidelines for the introduction of IPV, review child health records, field guide and all reporting formats to include the new vaccine.

The training for IPV introduction will be cascaded. National level Trainer of Trainers (TOT) for National and Regional training will be conducted at the central level. Participants are from Deputy Directors Public Health, Deputy Directors Clinical Care, EPI Coordinators, Public Health Nurses, WHO/UNICEF EPI Focal points. The National Master trainers will in turn facilitate training in their respective regions and districts. After completion of the district TOT, training of the vaccinators & supervisors will be conducted.

The major topics that will be covered are: rationale for introduction of IPV, vaccination schedule, injection site and technique with special focus on multiple injections at the same immunization session, injection safety and waste management, AEFI surveillance, vaccine storage and management, cold chain maintenance, communication, supervision, record keeping and reporting.

The methodology used for the training will be presentations, plenary discussion, question & answer sessions, role play, group work, demonstration, practice sessions. Supervisors from national, regional, districts and sub-district will supervise and monitor the implementation of all activities at all levels using a checklist.

3.7 Risks and challenges

Despite the achievements, challenges beset the country’s EPI. These include financial sustainability to support programmes, therefore requiring every significant amount of partner support. Innovative and efficient use of resources including improved integration of the programme, as well as sustainable measures for resource mobilization such continuous negotiation for ring-fencing for vaccine purchase and allocation to peripheral levels will be employed to mitigate this effect.

The inadequacy of human resources and skills within the health system remain a major obstacle. Other major systemic bottlenecks to improving and sustaining high immunisation coverage are inadequate/poor access to services in hard to reach districts (especially, islands and lake communities), inadequate health staff to provide required services, inadequate cold chain capacity at lower levels (about 41% of fridges and freezers are over 10 years), weak community engagement and involvement in immunisation services, weak capacity for micro

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planning and logistics management at the sub-district and CHPS zone level, poor documentation of primary data which impacts on data quality and inadequate infrastructure among others (See Ghana Immunisation Service Review, 2012; Effective Vaccine Assessment Report 2010; the Policy on immunisation 2011; and the Assessment of the Health Sector Programme of Work 2012).

Plans are already afoot to address some of these bottlenecks including Government’s policy of getting community health nurses in every CHPS zone in the country which has resulted in acceleration of numbers trained over the past few years. Again, through partnership with major stakeholders including WHO, UNICEF, Rotary International and Coca Cola/Accenture, provision of Service Boats for hard-to-reach island communities as well as improvement in cold chain equipment stock across the country are being undertaken. Health worker knowledge will be improved through phased in-service training at all levels of the immunisation service delivery chain. Continuous implementation of the WHO strategy of Reaching Every Child (REC strategy) approach and improved partnership with CSOs as well as improved community engagement should help improve community participation in immunization service delivery.

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4. Situational analysis of the immunisation programme

4

4.1 General context of Ghana

4.1.1 General Profile and DemographyGhana is centrally located on the west coast of Africa, sharing borders with three French-speaking countries: Burkina Faso (548 km) to the north, Cote d’Ivoire (668 km) to the west and Togo (877 km) to the east. On the south are the Gulf of Guinea and the Atlantic Ocean, which form the coastline of Ghana. The country is stratified into 3 vegetative zones, coastal lands and deciduous forest from the south towards the middle belt to savannah regions in the north towards Burkina Faso. Ghana has a tropical climate throughout the year with two major seasons – a dry (Harmattan) season and a wet (rainy) season.

Administratively, the country is divided into 10 regions and 216 decentralized districts, covering an estimated population of 24,658,823 (GSS, 2010) with varied population density among the regions. The Ashanti and Greater Accra Regions are the most populated with 4,780, 280 and 4,010,054 of the country population, representing 19.4 percent and 16.3 percent, respectively. The Upper East and Upper West Regions to the north of Ghana are the least populated with 1,046,545 (4.2 percent) and 702,110 (2.8 percent), respectively.

The National population density is estimated to have increased from 79 per square kilometer (km2) in 2000 to 102 in 2010 and 114 in 2014. Ghana has a youthful population consisting of a large proportion of children under-15 years and a small proportion of elderly persons (65 years and older). Life expectancy is estimated at 56 years for men and 57 years for women, while the adult literacy rate (age 15 and above) is an estimated 65 percent. An estimated 97.6 percent of the population are Ghanaians while 2.4 percent are non-Ghanaians.

Each district is headed by a politically appointed District Chief Executive (DCE), who is also the head of the District Assembly, the highest political and administrative authority in the district.

4.1.2 Health Status Ghana’s health sector operates a decentralized system with established mechanisms that coordinate policy formulation, resource mobilization, policy implementation and monitoring and evaluation of activities. The health sector is split into a policy-making arm and a service delivery arm. The Ministry of Health (MoH) is the central decision-making body in health matters, and has the responsibility to recruit, train and manage staff postings as well as remunerate health workers on government payroll. The training of health professionals for the health sector is by both public and private health-training institutions that have been accredited. of 49

The Ghana Health Service is the largest service delivery agency and operates through the government-owned facilities, whilst the faith-based institutions and private sector provide about 40% of service delivery.

Health service delivery is organized at three levels – national, regional and district. The district level is further divided into a number of sub-districts and also incorporates a community-level health delivery system. Public health services are delivered through a hierarchy of hospitals, health centres, maternity homes and clinics including a Community-based Health Planning and Services (CHPS) strategy. CSOs also play a considerable role in delivering health services to communities. CSOs are effective medium for community mobilization for immunization service delivery.

Ghana is making progressive improvements in the health status of the population in spite of being confronted with the double burden of disease across all ages and sexes with non-communicable diseases becoming the major causes of morbidity and mortality alongside the existing and emerging communicable diseases.

Child health has significantly improved over the years, with the child survival rates increasing as a result of the high impact healthcare services and economic progress. Despite these efforts, one in eleven Ghanaian child die before their fifth birthday, largely from preventable childhood diseases. In 2000, Ghana recorded an under-five mortality rate of 167 per 1000 live births that reduced to 90 per 1000 live births in 2010, an estimated 46 percent decline. This decline notwithstanding indicates that Ghana, although making progress, still appears off-track in achieving the MDG target of 39.9 per 1000 live births by 2015 as the progress is painfully slow.

The national Infant Mortality Rate (IMR), like the under-five mortality, has also declined over the years. The IMR dropped from 90 deaths per 1000 live births in 2000 to 59 deaths per 1000 live births (2010 PHC). In the GDHS (2008) report, however IMR was 50 per 1000 live births over the survey period. Although there has been substantial progress towards achieving the MDG target of 26 per 1000 live births by 2015. There is still a lot of work to be done.

Immunization of children against vaccine-preventable diseases as outlined in the Child Health Policy of Ghana account for much of the progress made in reducing morbidity and mortality. The introduction of new vaccines such as the 2nd dose measles, pneumococcal and rotavirus vaccines is expected to result in further reduction in infant and U5MR.

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Table 11: Summary of EPI-related Health Indicators, 2003-2013

Indicator 2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Infant mortality rate/1000 LB 64 64 64 64 64 50 50 50 50 53 53Under five mortality rate/1000 LB 111 111 111 111 111 80 80 80 80 82 82

Maternal mortality ratio/100,000 LB 214 214 214 214 214 451 451 451 451 350 350

Penta3* vaccination coverage (%) 76 76 85 84 88 87 89 87 87 88 86

Measles vaccination coverage (%) 79 78 83 85 89 86 89 88 88 89 84

BCG vaccination coverage (%) 92 92 100 100 102 103 104 102 105 104 98

OPV 3 vaccination coverage (%) 76 76 85 84 88 86 89 87 87 87 86Yellow Fever vaccination coverage (%) 73 76 82 84 88 86 89 88 87 88 84

TT2+ vaccination coverage (%) 66 62 71 68 71 76 79 76 76 74 71

Non polio AFP rate (%) 1.4 1.5 1.8 1.7 1.7 2.4 2.5 1.8 2.2 1.6 2.7

*Penta3 is used as proxy for immunization performanceNB: All coverage rates calculated using birth cohort as the denominator

Achieving a desired maternal health indicators remains a major challenge despite several interventions to improve the situation. In the 2010 PHC, variations in the maternal mortality ratio (MMR) across age- groups, revealed disconcerting highest incidence of deaths occurring among 12 and 14 year olds, with a MMR of 5671 deaths per 100,000 LB, more than ten times higher than the national figure of 350/100,000 LB. There is also evidence that the risk of death increases for women who are above age 40 years. Women aged between ages 45-59 is the second age group with highest likelihood of dying from pregnancy-related complications.

To address the high maternal mortality rate, a number of interventions have been introduced within the framework of GPRS II and the GSGDAs. Specific to GSGDA, the policy measures include improving access to quality maternal and adolescent health services.

4.1.3 Health PrioritiesAmong the health priorities in the country are;

1. Strengthen the district and sub-district health systems as the bed-rock of the national primary health care strategy

2. Accelerate the implementation of the revised CHPS strategy especially in under-served areas

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3. Deepen stakeholder engagement and partnership (public, private and community) for health care delivery

4. Improve health information management systems including research in the health sector

5. Accelerate the implementation of the Millennium Acceleration Framework (MAF)6. Intensify and sustain Expanded Programme on Immunisation (EPI)7. Scale up the implementation of national malaria, TB, HIV/AIDs control strategic plans8. Implement the Non-Communicable Diseases (NCDs) control strategy9. Strengthen Integrated Disease Surveillance and Response (IDRS) at all levels and

implement fully the International Health Regulations (IHR)

4.1.4 Organogram of the National EPI ProgramThe Expanded Programme on Immunization (EPI) is responsible for immunization in Ghana. It is located within the Diseases Control Department (DCD) of the Public Health Division (PHD) of the Ghana Health Service. It is headed by a Public Health Specialist and assisted by trained personnel who are specialists in areas that include logistics management, data management, monitoring and evaluation, cold chain management, injection safety, social mobilization and communication. The figure below shows the organogram of the National Immunization Programme.

Figure 2: Organogram of the EPI Programme

The mission of the programme is to contribute to the overall poverty reduction goal of the government through the reduction in morbidity and mortality by controlling, eliminating or eradicating vaccine preventable diseases (VPDs) through immunization; as an essential component of Primary Health Care (PHC). Ghana has been at the forefront of showcasing immunization as the platform for health systems strengthening.

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Logistics, Waste & Cold Chain

Management

Cold Chain Maintenance

Dep. EPI Programme

Manager

SIAs, Research, Monitoring and

Evaluation

Advocacy and Social Mobilization

Support (Secretary, Accounts, stores)

EPI Programme Manager

Yellow fever vaccine was added to the immunization schedule in 1992. Ten years later, hepatitis B and the haemophilus influenza type b vaccines were introduced. These vaccines were combined with the already existing DPT into DPT-HepB+Hib (Pentavalent). In 2012, the Government of Ghana introduced vaccines for pneumonia and diarrhea and in 2013 Rubella-containing measles vaccine was added. The EPI Programme currently vaccinates against twelve (12) vaccine preventable diseases.

4.2 Geographic, economic, political, gender and social barriers to immunisation

A number of innovative strategies are used to deliver immunization services. Static immunization is the main service delivery strategy. Every health facility has a static clinic responsible for daily routine immunizations. The increasing availability of such clinics in the country has made access to routine immunization easier. Outreach immunization services are organized to reach children in communities where static clinics are not available. The outreach programme has contributed immensely towards bridging the gap between communities with health facilities and those who do not have. Thus, increasing access to EPI services to all eligible children and women.

However challenges remain in accessing the communities on the islands of the Volta Lake and also the riverine areas. Coverage in the urban slums also has been poor. Mop-ups are done in areas with low coverage and difficult to reach areas (areas not accessible during the rainy season) with the aim of reaching every child. Transit point vaccination including vaccinations done at Lorry parks, markets, churches, mosques etc. are also used. When necessary, mass vaccinations are conducted to reach out to specific groups.

Table 12: Trends in national immunization coverage, EPI-GHS, 2012-2013

Vaccine Vaccine Used Target population (2013)Coverage reported (JRF)

2013 2012BCG 20-dose vial 1,063,767 98% 104%OPV 3 20-dose vial 1,010,579 91% 92%DTP 1 / Penta 1 10-dose vial 1,010,579 94% 97%DTP 3 / Penta 3 10-dose vial 1,010,579 91% 92%PCV 1 10-dose vial 1,010,579 93% 81%PCV 3 10-dose vial 1,010,579 89% 64%Rota 1 1-dose vial 1,010,579 92% 75%Rota 2 1-dose vial 1,010,579 88% 65%Measles 1 10-dose vial 1,010,579 89% 93%Measles 2 10-dose vial 1,010,579 54% 58%Yellow Fever 10-dose vial 1,010,579 89% 92%

Table 13: Quality and equity of immunization in Ghana of 49

Components Indicators Achievement2010 2011 2012 2013

Immunization demand

Percentage drop-out DTP1 – DTP3 3.4 3.2 4.6 3.9Percentage drop-out BCG – Measles 14.1 16.4 15.0 14.2Percentage gap Measles-Yellow Fever 0.2 0.6 1.0 0.5

Immunization equity

Percentage gap in DTP3 between highest and lowest socioeconomic quintiles 5.3 1.4 1.4 1.4Percentage gap in fully vaccinated children between males and females 1.3M 2.5F 2.5F -Number and proportion of districts with DTP3 coverage >80% 78.8 78.8 80.0 75.0

F=Vaccinations favouring femalesm =Vaccinations favouring males

The table above shows the quality and demand of immunization services as well as indicators for equity. From the table, the drop-out rate between the first and the third doses of DTP containing vaccine has been maintained below 10%, signifying sustained quality in immunization service delivery. The gap between measles and yellow fever vaccines have been maintained at low levels. However, the BCG-measles drop-out rate is high. Steps will be taken to address this. Gap in coverage between the highest and the lowest quintiles as well as between males and females are low, signifying that, there is no significant difference in immunization with regards to sex and wealth.

4.3 Findings from recent EPI Reviews, PIE and EVM

4.3.1 Effective Vaccine Management AssessmentGhana conducted effective vaccine management assessment in 2010. The assessment was done in 43 facilities comprising national, regional, district and health centers using the WHO standard effective vaccine management (EVM) tool. Data was collected through interview using questionnaire with the 9 Global EVM criteria, site observation and review of relevant documents at all levels. The results revealed a fall below the standard score of 80% in key variables such as temperature monitoring, storage capacity, stock management and vaccine management at all the levels and require urgent attention for improvement. Below is a summary of the implementation of the EVM improvement plan:

Activity StatusBriefing of ICC and regions DoneConstruction of 9 cold rooms 100% completedProcure 50 TCW 3000 100% completedProcure 200 TCW 2000 100% completedProcure Freeze Tag 100% completedProcure vaccine carriers 100% completed

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Procure cold boxes 100% completedProcure 3 cold vans (11 procured) 100% completedConduct cold chain inventory every 6 months 100% completed (cycle; Ongoing)

4.3.2 EPI ReviewThe Ministry of Health/Ghana Health Service conducted review of immunization activities in Ghana with the support of WHO and UNICEF. The purpose was to document EPI performance and achievements over the past years, identify shortfalls and challenges and make recommendations in key areas for strategic advances in the future of the immunization programme. The review was conducted from 1-29 March 2012.

The review identified that there is high political commitment by the Government of Ghana (GOG) demonstrated by financial, human and material resource allocations to immunization programme, strong legal framework backing immunization and visibility of the immunization programme in the GOG policy documents and strategic multi-year plans. Below are the key findings, recommendations and status of implementation of the recommendations;

Table 14: Key findings, recommendations and status of implementation

System Component Key Findings Recommendations Status of

ImplementationProgramme Management

Some health facilities did not have the updated EPI policy document

Distribute updated EPI Policy and Field guide to all districts and facilities

The EPI policy and field guide have been updated, printed and distributed to districts. However, they will be reviewed to include IPV introduction

Poor quality micro-plans at some sub-district levels for achieving target of reaching every child

All districts and HFs should develop and use micro plans to streamline their actions to reach all children and women in Ghana with special emphasis on hard to reach communities

Districts and Health facilities have been orientated through campaign trainings on Micro Plan development

Lack of systematic supportive supervision

The Ministry of Health/GHS should prioritize allocation of funds for integrated supportive supervision to improve the quality of implementation of services. Technical programmes to share resources for integrated

An integrated monitoring and evaluation checklist has been developed by PPME and is in use

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Implementationsupportive supervision. Careful selection of each programme priorities is essential for an effective integrated supervision package

Service Delivery

Potential of CHPS not fully utilized for integrated service delivery at community level to enhance EPI performance

Maximize integrated services using CHPS as entry points to enhance EPI

Currently, CHPS are being provided with cold chain facilities

Limited Services to hard-to-reach areas due to high cost

Ring fence funds for hard to reach areas

Funds for hard to reach areas have been earmarked in the GAVI HSS support

Routine vaccination not conducted daily in most facilities, leading to missed opportunities

Reorient staff on daily immunization

Adequate staff are now available at the peripheral level to conduct outreach services and daily static immunization services

Logistics and Cold Chain

Vaccine stocks are not properly monitored at some facilities

Provide vaccine ledger and reorient staff on its use

Updated vaccine ledgers have been printed and distributed. A survey on vaccine wastage is being done to establish baseline data on vaccine wastageThe EVM will be conducted soon

Surveillance Adverse events following immunization (AEFIs) not always documented nor investigated for routine immunization

Reorient staff on vaccine safety and AEFI reporting and provide job aides and other tools

Vaccine safety and AEFI monitoring training done for some staff during the MR campaignWhat about job aid?

There is weakness in surveillance data analysis and use for timely action at district and lower levels

Continuous training in data analysis of staff

Quarterly data analysis and reviews are conducted with districts

Poor timeliness of reporting from health facilities to district level and district to region level

Institute measures to improve timeliness of reporting at the peripheral level

Nationwide rollout of DHIMS has improved the timeliness of data reporting

Advocacy, Communication and Community Participation

Insufficient participation of international and national agency heads in ICC meetings.

Participation of the MoH in the ICC needs to be secured at the highest level so as to ensure formal linkage between the ICC

Efforts are being made to ensure representation of key partners to the ICC meeting. Concept paper for the creation of NITAG

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Implementationand other MoH partners’ fora. Key partners in immunization should be represented at the highest level in the ICC to enhance its decision making power. The creation of the National Immunization Technical Advisory Group (NITAG) in Ghana is another option that could be considered.

has been developed and submitted to the Minister of Health. The Programme is awaiting inauguration of NITAG.

Inadequate dissemination and implementation of EPI integrated communication plan.

Ensure the dissemination of EPI Communication plan

Communication plan has been updated to include new vaccines and disseminated to key partners for comments

NGOs and private sector involvement in NIDs and SIAs is not sustained for routine EPI.

Strengthen involvement of NGOs and private sector in routine EPI

Private Midwives have been trained to provide immunization services. There is sustained funding support through the GAVI HSS platform for NGOs(Coalition of NGOs in Health) to support immunization activities

Weak capacity of district staff in area of communication which hampers efforts to change people’s behavior.

Orient staff on behaviour change communication at the district level

District Staff are oriented on Communication for EPI

Teachers at training institutions lack training and reference material on current information on EPI

Orient staff at Health Training institutions on EPI and provide updated reference materials on EPI

There is strong collaboration between EPI and Health Training Institutions. The curriculum for health training institutions has been updated and teachers have been trained on MLM. Plans are underway for the curriculum of basic schools to be updated

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4.3.3 Post-Introduction EvaluationThe following are summary of strengths and challenges observed during the post introduction evaluation of the new vaccines introduced in 2012:

Table 15: Key findings from PIE for new vaccines introduction 2013

Strengths Challenges Efforts to address challenges

Planning For all antigens, early planning in 2011 provided time for bench marking before the introduction of the new vaccines into the routine immunization programme and permitted good involvement of stakeholders.For PCV and rotavirus, establishment of area specific working groups to provide guidance and monitoring.For MCV2, integration with other programmes like nutrition and malaria facilitated reaching eligible children.

Lack of clear policy on “catch up” dosing for children over 1 year who missed vaccines in their infant series.

As part of the review of the EPI Policy and Field guide to include IPV introduction, the policy on dosing children more than 1 year will be clarified.

Data management

Coverage data for all vaccines including the newly introduced vaccines were available for the year of introduction (2012).Updated recording and reporting forms were available for PCV and Rotavirus.

Most of the immunization monitoring charts available in the health facilities were not updated with the new vaccinesPoor availability of reporting documents including MCV2.

The immunization monitoring charts have been updated to include the new vaccines. The updated charts have been printed and distributed. All data collection and reporting tools have been reviewed to incorporate all new vaccines.

Vaccine and Cold chain management, transport and logistics

The cold chain was expanded in preparation for the anticipated increase for PCV and Rotavirus (cold rooms were built in every regional office)Cold chain equipment at health facilities was sufficient and supplied timely for the introduction of the new vaccines

Malfunctioning refrigerators were found in some health facilities.Baskets meant to separate the various antigens in the refrigerators were not being used in a number of TCW refrigerators in the majority of health facilities visited.

The country is constantly updating the cold chain inventory and maintenance protocols have been established to ensure non-functional but serviceable refrigeration equipment are repaired. There are still some non-serviceable equipment that are yet to be disposed.

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Strengths Challenges Efforts to address challenges

AEFI, injection safety, waste management

Adequate waste management practices have been adopted and implemented in most health facilities.22 of 24 (92%) of HCW used safe injection techniquesDespite lack of guidelines, HCW were able to describe the process of managing and reporting AEFI.

Over half (58%) of health facilities visited did not have written guidelines or protocols on AEFIs.

An AEFI section was part of the training manual that was developed for the new vaccines. The National Guidelines on AEFI monitoring has also been developed and shared (softcopy). The document is however yet to be printed.

Advocacy, communications, community acceptance

57% of care-givers interviewed knew of the new vaccines100% of caregivers accepted the new vaccines and trusted HCWs even when they did not know the diseases they prevent.

Care givers had very little knowledge about the diseases prevented by the new vaccines.

Health workers are constantly being oriented to strengthen interpersonal communication with caregivers

4.4 Stock Management

At the national level, both computer and manual based stock management systems are used. The computer-based system involves the use of the WHO-stock management tools (SMT) for managing vaccine stock. With regards to the manual system, vaccine ledgers are used to monitor stock levels. Stock levels of the country are reported to the Ministry of Health and the Ghana Health Service, UNICEF and to the WHO-IST through the WHO country office on monthly basis.

The principle of first-to-expire, first-out (FEFO) is adhered to. Vaccine arrival reports are filled any time vaccines are received in the country and issue vouchers are provided to receiving stores (regions). There is a clear laid down policy for disposing expired vaccines. Devices and other logistics are managed manually. Vaccine issues to lower levels are bundled to ensure matching quantities of vaccines and all other logistics.

The WHO-stock management tool (SMT) is also used at the regional level for managing vaccine stock. Vaccine ledgers and tally cards are also used at the regional level.

At the peripheral level, both electronic and manual stock management systems are used. The District Health Information Management System (DHIMS) and District Vaccination Data

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Management tool (DVDMT) are in use. In addition to this, vaccine ledgers and tally cards are also used.

To improve the management of vaccines at the peripheral level, freeze-tags have been procured and distributed to all level. Plans are underway for the programme to procure and install continuous temperature loggers in all walk-in-cold-rooms.

Challenges faced with the stock management system includes incomplete reporting from health facilities/districts and non-adherence to maximum and minimum stock levels in some health facilities.

At the national level, there are three (3) refrigerated vans for vaccine transportation. However, two (2) of these vans are overaged. The Ministry of Health has provided refrigerated vans to all regions to facilitate transportation of vaccines. At the periphery level, pick-ups are used to transport vaccines in cold boxes.

Although, the introduction of IPV will not increase the frequency of vaccine delivery, the volume of vaccines to be transported will increase. The workload for loading and offloading of vaccines will increase and it is envisaged that this can be handled with the current workforce and equipment in the country.

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5. Monitoring and evaluation

5

5.1 Updating of monitoring tools

All EPI guidelines, recording and reporting formats and stock management tools will be revised and produced incorporating IPV. The current record keeping and reporting forms will be revised to incorporate vaccine recording disaggregated by sex. This will be done with the PPME to conform to the reporting systems already established in country. EPI will reprint routine EPI coverage monitoring charts incorporating IPV for the monitoring of coverage, dropout and left out rates.

The current cMYP (2015-2019) has been developed to include IPV. All districts Ghana are using web-based DHIMS2 software and DVD-MT for reporting routine coverage on a monthly basis. This routine EPI databases will be updated with IPV.

5.2 Adverse Event Following Immunisation (AEFI) monitoring and reporting

There is a policy on Adverse Events Following Immunization as part of the National Policy on Immunizations. There is also a Guideline for Surveillance of Adverse Events Following Immunization in Ghana. This guideline will be adapted to IPV AEFI reporting.

There is an expert committee for AEFI monitoring. The AEFI committee is made up of experts from diverse medical and social disciplines which includes but not limited to general medical practice, clinical pharmacy, clinical pharmacology, toxicology, epidemiology, pathology, industrial pharmacy, dermatology and child health. There are also co-opted members as and when required. The capacity to conduct investigations into AEFI is available but needs reinforcement.

The routine system for reporting AEFI will be enhanced and expanded to cover IPV. Health-care providers who administer vaccines maintain permanent vaccination records and are required to report occurrences of certain adverse events to a central point. Reporting by parents or guardians of all adverse events after vaccine administration will be encouraged. There is also an existing system for addressing rumours. This however needs to be enhanced at all levels.

Adverse events following immunization with IPV will be reported by health-care providers to the Food and Drugs Authority through and existing structure of District, Region and National EPI-FDA focal persons. Reporting forms and information about reporting requirements or completion of the forms will be discussed as part of the pre-implementation training of Health care Providers. The existing Guidelines for Surveillance of Adverse Events Following Immunization in Ghana will be adapted to IPV AEFI reporting. A separate detailed AEFI of 49

Monitoring Plan will be developed for AEFI monitoring. Printed guidelines will be provided to all health facilities.The following activities are to be implemented to ensure effective surveillance measures at all levels

Sensitization of clinicians and other health staff on surveillance measures, particularly AEFI surveillance and the need for adequate reporting and documentation

Update AEFI recording and reporting forms, guidelines and investigation forms Strengthening routine surveillance and monitoring of AEFI Monitoring of monthly reports and feedback to districts and regions

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6. Advocacy, communication and social mobilization

In Ghana the EPI structure has an existing working group which takes care of Advocacy, Communication and Social Mobilization (ACSM) at the National, regional and district level. The group is made up of health promotion officers, disease control officers, media practitioners, development partners in health education and communication, as well as representatives from school health, information service, NGOs in Health, the Ghana Red Cross and other partners.

To promote the introduction of IPV, the entry point for this team will be to secure a high-level political commitment with key stakeholder consultations. Advocacy meetings at the national, regional and district levels will be held to sensitize the political and opinion leaders on IPV introduction, benefits to the population and contribution to the polio endgame strategy. The advocacy targets will include

Policy makers - Cabinet and Parliamentarians Interagency Coordinating Committee (ICC) for Immunization Media practitioners - Print and Electronic (including Telcos) Development Partners and Non-Governmental Organizations(NGOs) in Health Other Government Ministries and Agencies like, Local Government and Rural

Development, Ministry of Information, Red Cross Society, Department of Social Welfare etc.

Leaders of Religious and Traditional councils at both National and Regional levels

A Comprehensive advocacy, social mobilization and Behaviour Change Communication strategies targeting different audiences as well as service providers will be developed before the beginning of the IPV introduction. Emphasis will be given on ensuring a well-defined and executed advocacy and social mobilization strategy in order to:

create awareness and sustain demand for IPV among the participant groups address all rumours and misinformation that exist or may occur reach all children in the age bracket, especially in hard to reach or hard to access

areas detect and report on any potential AEFI

As part of the communication strategy some of the key stakeholders will also be selected for a training of trainers’ workshop on how to engage the participant groups to create both awareness and demand for IPV through mass media and interpersonal communication. Issues of potential AEFI detection and reporting and how to address the major concern of parents on the number of injections for children will also be addressed in this training. Formative research will be conducted prior to the training to guide the training plan and the comprehensive communication plan.

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The participants for the training will be drawn from the national and regional level as well as personnel from the Media, Traditional and Religious leaders groups and other Public Health Practitioners and Communicators. It is expected that the training will be cascaded.

Communication activities will be undertaken through print and electronic media. These channels will present messages through Jingles/Spots, “Live Presenter Mentions”, SMS, Panel discussions with phone-in segments in English as well as in 7 key local languages and Public Service Announcements.

As part of the communication strategy, demand for the vaccine will be created at the community level through community sensitization which will be enhanced three (3) months prior to the introduction.

The Interpersonal Communication (IPC) channels to be used under this strategy are Weekly OPD fora, in all health centers, religious fora, like Friday prayers, church services or meetings, organised group meetings such as mother support groups, Public criers and community durbars, Child Welfare and Antenatal Clinics House-to-house visitations, traditional festivals, Mobile Van announcements on market days at transport stations and major markets. Social mobilizers from both the health sector and partner volunteers like the Red Cross mother support members, and EPI volunteers will be the main means of awareness creation and interpersonal communication which will start at least six weeks before the introduction date and continued till IPV is fully integrated into the system – end of 2016.

Furthermore, ccommunication materials like posters, leaflets, fact sheets etc. will be developed and used for different target audiences to make them aware of and knowledgeable on the importance of IPV in the vaccination schedule and its importance in the polio eradication efforts. Issues of AEFI detection and reporting will also be addressed in these IEC materials.

A national launch of IPV will be organized one month before the introduction of the IPV implementation, and a high profile personality will inaugurate this event to disseminate the importance and need of IPV introduction and to create awareness among the people.

During the month interval for the introduction, mini launches will be organised at the lower levels of Regional and districts to also create awareness on the introduction and create the necessary demand for the service.

All the activities will be monitored by the ACSM team together with the M&E team under the EPI Structure and the team will also participate in the PIE which will be conducted between six to eight month after the introduction and any amendments and adjustment to the communication strategy will be addressed.

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Summary table of activitiesAdvocacy Social mobilization Behaviour Change

Communication (IPC)Sensitization meetings with Policy makers ICC for Immunization Media practitioners Development Partners

and NGOs in Health Other Government

Ministries and Agencies. Leaders of Religions and

Traditional councils

FM/ Community Radio Radio/TV Spots/

Jingles Radio/TV Discussions

– Phone in programs Public Service

Announcement Live Presenter

Mention

Health Centers Weekly OPD fora, Child Welfare and Antenatal

Clinics

Training of Trainers National and Regional level Media, Traditional/Religious

leaders groups. Mother support groups Public Health Nurses Health Promotion

Officers

Other Educational Programs Feature Articles in the

print media Press briefing Launching PSA

Community Religious fora, like Friday

prayers, church services or meetings,

Development and dissemination of Information, Education and Communication (IE&C) materials, fact sheets, banners leaflets, posters, calendars etc.

Public criers community durbars, traditional festivals, Mobile Van announcement CIC announcements

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7. Annex 1:BudgetCountry Ghana 0.332 810,711

Cost CategoryUnit Description (e.g.

name of training or item)Unit price

(local currency)

Multiplier (e.g. no. of days or

items)

Total(local currency)

Totalin US$

Government contribution

Partner(s) contribution

Existing GAVI HSS funding

Requested GAVI contribution

1 Program management and coordination: 65,000 21,580 - - - 21,580 Advocacy with Parliamentary Select Committee Advocacy 15,000 1 15,000 Ministry advocacy and monitoring Advocacy 10,000 3 30,000 Incidentals (Fuel, lunch, airfares etc.) Incidentals 20,000 1 20,000

2 Planning and preparations: 866,000 287,512 - 7,439 - 280,073 National Planning Committee Meeting 18,000 10 180,000 Effective vaccine management Assessment 182,000 1 182,000 Update cold chain inventory Assessment 25,000 1 25,000 Planning meetings with regions Planning 25,000 1 25,000 Planning meetings at districts with sub-districts Planning 2,000 227 454,000

3 Social mobilisation, IEC, advocacy: 358,500 119,022 - 119,022 Press brieing at national level Briefing 15,000 1 15,000 National launch Launch 40,000 1 40,000 Social mobilization at regional level Mobilization 5,000 10 50,000 Social mobilization at district level Mobilization 500 227 113,500 KAPB study 105,000 1 105,000 Quiz on Polio by Junior High Schools Quiz competition 25,000 1 25,000 Text messaging on IPV introduction Social mobilization 10,000 1 10,000

4 Other training & meetings: 266,000 88,312 - - - 88,312 Training of trainers at national level Training 30,000 1 30,000 Regional level training of regions Training 20,000 10 200,000 Orientation of immunizaton ambassadors Orientation 12,000 3 36,000

5 Document production: 181,000 60,092 10,000 19,429 - 30,663 Material development Workshop 22,500 2 45,000 Development and printing of leaflets and flyers Printing 23,000 1 23,000 Development and printing of T-shirts Printing 18,000 1 18,000 Printing of updated child health records Printing 20,000 1 20,000 Printing of immunization monitor charts Printing 25,000 1 25,000 Printing of updated vaccine ledger book Printing 25,000 1 25,000 Printing of updated tally book and reporting format Printing 25,000 1 25,000

6 Human resources and incentives: 36,000 11,952 - - 11,952 - Monitoring and supervision (technical) Perdiem 20,000 1 20,000 Financial monitoring Perdiem 10,000 1 10,000 Store management/Book keeping Perdiem 6,000 1 6,000

7 Cold chain equipment 250,000 83,000 - - 83,000 - Installation of cold room at national level Installation 180,000 1 180,000 Procurement of spareparts Spareparts 50,000 1 50,000 Funds for cold chain maintenance Maintenance 20,000 1 20,000

8 Transport for implementation and supervision: Supervision: 150,000 49,800 49,800 - - - Fuel for implementation Fuel 20,000 1 20,000 Vehicle maintenance Cash 20,000 1 20,000 Vehicle for monitoring IPV introduction Vehicle 110,000 1 110,000

9 Immunisation session supplies: Supplies: 20,000 6,640 6,640 - - - Procurement of cotton wool Procurement 20,000 1 20,000

10 Waste management: Management: 273,000 90,636 - - 90,636 - Construction of incinerators Construction 21,000 13 273,000

11 Surveillance and monitoring: Monitoring: 70,000 23,240 - 23,240 - - AEFI Surveillance System Monitoring: 50,000 1 50,000 Disease Surveillance Monitoring: 20,000 1 20,000

12 Evaluation: Evaluation: 145,000 48,140 - - - 48,140 Post introduction evaluation Assessment 70,000 1 70,000 Peer-evaluation/monitoring among regions Assessment 75,000 1 75,000

13 Technical assistance: Assistance: 40,000 13,280 13,280 - - - Planning Planning 20,000 1 20,000 Evaluation Evaluation: 20,000 1 20,000

14 Data management Management 256,800 85,258 - - 39,000 46,258 Training on Data Management at all levels Training 25,000 10 250,000 Procurement of ArcGIS Procurement 6,800 1 6,800

15 Capacity building Other: 36,000 11,952 - - - 11,952 Capacity building for staff Training 12,000 3 36,000

TOTAL Total 3,013,300 1,000,416 79,720 50,108 224,588 646,000

Current exchange rate to 1 USD: Target Population size:

8. Annex 2: Timeline

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul AugActivity 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8

1 Preparatory Activities

Development of proposal and supporting documentsBrief key stakeholders and bui ld concensusTAG meetings for IPV IntroductionBrief ICC and other relevant stakeholdersDraft implementation planConduct cold chain needs assessmentConduct stakeholder briefings at district levelSubmit application to GAVIReactivate new vaccine introduction committeesReactivate IPV Introduction teams at regional levelConduct Effective vaccine management assessmentOrder vaccines

2 Vaccine IntroductionImplement EVM improvement planAddress cold chain gapReview recording & reporting toolsAdapt communication plan and materialsDevelop training manual and update field guide & policyPrint training materialsConduct microplan at districtDevelop training plan and conduct training of trainersTrain healthcare workersIntensify communication in districtBrief press and conduct national launchDistribute vaccines and logisticsIntroduce IPV nationalwideMonitor and supervise introduction at al l levels

3 Post IntroductionReview performancePeer-Monitor IPV introduction among regionsDebrief ICC on IPV introduction & PerformancePost-Introduction ReviewSubmit financial report to GAVISubmit progress report to GAVI

Post-Introduction2016

Pre-award/approval Vaccine Introduction2014 2015

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