Empowering Mothers for Health Behaviour, Accra, Ghana A proposal from CARE International UK to The

CARE International is a global humanitarian organisation and works in over 70 countries around the world, tackling poverty, injustice and human suffering wherever the need is greater.

Almost a third of Ghanas population lives in extreme poverty. With few resources, most people cannot access quality healthcare. Only 22 percent of children under five sleep under treated mosquito nets and only 50 percent of births are attended by a skilled health care worker (professional or volunteer). Lack of access to health care has deadly consequences in this western African country where 7.3 percent of children die before their first birthday and for every 100,000 live births, 560 women loose their lives. To address these and other health issues, CARE is implementing Empowering Mothers for Health Behaviour in the capital, Accra, and the central and western regions of Ghana.

CARE International UK September 2009

10 13 Rushworth Street, London, SE1 0RB, Telephone: 020 7934 9334, Fax: 020 7934 9335

Email: info@careinternational.org www.careinternational.org.uk Registered charity number: 292506

Empowering Mothers for Health Behaviour, Accra, A Ghana

Background to Ghana
Please include context of poverty in Ghana

Poverty in Ghana Ghana has witnessed a general decline in poverty levels by a large margin in the last two decades. The incidence of poverty is relatively lower in female headed households than in male headed household. It is endemic among rural folks than among urban dwellers. Whilst all the administrative regions saw a declining trend in poverty in the first half of the period, Greater Accra and Upper West regions witnessed a reversal trend (an increase) in poverty in the second half. Despite the general positive outlook of poverty trends, the incidence of poverty is still considerably high and relatively higher among Ghanaians in the informal and agriculture sectors of the economy, particularly among food crop farmers who live in the rural areas. Majority of the people living in rural areas fit into the World Bank classification of extreme poverty, getting by on an income less than $1 a day. Households cannot meet basic needs for survival. Poverty among rural folks is said to be driven largely by environmental factors including irregular rainfall patterns and poor soil fertility, whilst that among urban dwellers is more by shifts in macro-economic conditions characterized by changes in consumption and availability of cash employment (Ashong & Smith, 2001). It is also argued that because of low level of education, rural folks are unable to diversify into more productive livelihood activities. Additionally the social network systems are not well developed to enable them gain access to finance and work opportunities, making them more vulnerable to poverty (ibid). Individuals and societies that are poor tend to remain so if they are not empowered to participate in the decisions that shape their lives. This calls for a more coordinated effort in addressing the remaining deficits in the human development outcomes with emphasis on health improvements and macroeconomic management amongst others. Intervention in healthcare, human capital development, microcredit provision, a strong savings promotion, capacity-building training programmes for micro-enterprises and a general focus on women will be able to make a difference.

Empowering Mothers for Health Behaviour, Accra, A Ghana

Stats on population and demographics

Greater Accra had a population of 2,905,726 in the 2000 National population census and a growth rate of 4.4% which gives an estimated mid year population for 2006 of 3,762,336. The total fertility rate in the region of 2.9 from the 2003 Ghana demographic and health survey is the lowest in the country. The high population growth rate in the region is thus a mixture of natural increase and rapid migration into the urban parts of the region from all over the country. Observation suggests that a fair number of the migrants are unskilled rural migrants moving into the city to look for non-existent jobs and ending up in the pool of urban poor. Its population density from the 2000 census was 1,019 persons per square kilometre. It is the only region in the country where the rural urban ratio is reversed. Eighty eight percent (88%) of its population lives in localities defined as urban (population five thousand or more) and only 12 percent live in small rural communities. Many of its urban localities are very large with population running into tens of thousands. The region therefore currently has six administrative districts Accra Metropolis, Tema Municipality, Ga West, Ga East, Dangme East and Dangme West. Please include information about the area where the project is operating and context of poverty.

The project will be implemented in 25 communities in 2 districts in the Greater Accra Region Dangbe East and Ga East. Dangbe East District The Dangme East like the Dangme West district is completely rural and typical of rural districts elsewhere in Southern Ghana. Dangme East had a population of 93,112 in the 2000 census. Poverty is widespread. Most of the population are subsistence farmers using non-mechanized rain fed agriculture; and along the coast, fishermen. Dangme East district has 2 functional CHPS compounds, 5 health centres and a hospital that was completed and started operation in 2003. There are four sub-districts namely Ada-Foah, Kasseh, Sege and Pediatorkope. Ga East District The Ga East district used to be almost entirely rural but has been caught up in the urban spread of the Accra metropolis and Tema municipality and is rapidly urbanizing especially in the areas bordering Accra - Tema. Its estimated 2005 midyear population is 258,478. There is one functional CHPS compound, 3 health centres, one small MCH clinic and no government hospitals or polyclinics. The lack of health infrastructure is because urban growth has rapidly outstripped the infrastructure that used to be adequate for a sparsely populated rural district. There are numerous small private

Empowering Mothers for Health Behaviour, Accra, A Ghana

clinics in the urbanized parts and one small CHAG hospital run by the church of Pentecost.

History of CARE working in Ghana and what its priority focus areas are

CARE has successfully implemented HIV & AIDS projects in Ghana since 1996. CARE GoG has had the capacity and experience to build the capacity of partners to carry out effective (a) Health and Nutritional Support and (b) HIV & AIDS programming. CAREs HIV/AIDS and Health programs in Ghana since 1996 have included projects like SAPIMA and Wassa West Reproductive Health (WWRH) in Wassa West District in June 2003. WWRH was an integrated STI/HIV/AIDS and family planning project targeting mine workers and their partners, CSWs and the general communities in mining towns in two districts. a) ARCH in Adansi West District, b) The Western and Ashanti STI/HIV & AIDS (WASH) project in eight districts and submetros in Western and Ashanti Regions - funded by United States Department of Agriculture. WASH was implemented from 2002 to 2005 and it strengthened the capacity of local institutions to implement STI/HIV & AIDS programs. It was implemented through 10 partner organizations (local NGOs, CBOs, FBOs) in the Western and Ashanti regions of Ghana. The youth project through HACI in the Wassa West District. As part of the WASH project, CARE received funds from Hope for African Children Initiative (HACI) for a project to target orphans and other vulnerable children (OVC). PREVENT (August 2008 December 2010) The CARE consortium comprising CARE Denmark and Gulf of Guinea is implementing PREVENT Traditional Institutions and Positive People Preventing HIV/ AIDS and Stigma. Ahensan Water and Sanitation (AWSAN), 2007 -2008 The Ahensan Water and Sanitation (AWSAN) project provided: Clean water supply, sanitation facilities and hygiene education to selected schools. Pay-for-use toilet blocks in the community; and Improved hygienic conditions at the Kumasi Abattoir through provision of water reservoirs to augment the water available at the Abattoir for cleaning meat and the Abattoir premises

The Water and Sanitation for Urban Poor (WASUP) 2010-2013 is currently being implemented in the city of Kumasi, which is the fastest growing city in Ghana with a growing concern about environmental degradation due to poor sanitary conditions and pollution of waterways.

Empowering Mothers for Health Behaviour, Accra, A Ghana

The project will deliver clean water, improved sanitation facilities, and environmental and personal hygiene education to the urban poor dweller in five communities within the Kumasi Metropolis. The target communities have a total population of approximately 108,500. About 71% of the target population does not have access to hygienic toilet facilities. Women and children spend long hours to fetch water Trans-boundary Area (TBA) Water Project (2007 2008) This a Water management and development alliance between the he Coca Cola Company and the USAID focused on Community Water Management in Transboundary Watersheds (western Ghana and Eastern Ivory Coast). GHANA SUSTAINABLE CHANGE PROJECT (GSCP) JUNE 2004 TO MAY 2009 In June 2004, USAID awarded the Ghana Sustainable Change Project (GSCP) to the Academy for Educational Development and its partners, CARE, the Manoff Group and EXP Momentum. This five-year Program had the mandate to support the Ghana Health Service and other private and civil society groups to increase the health status of Ghanaians through communication interventions which can be sustained over time. The Project, with its partners and counterparts, ensured evidence-based communication interventions that increasingly impacted on reproductive and child health, and HIV/AIDS, and that took into consideration all aspects of a supportive environment including capacity building, advocacy and social marketing. The GSCP provided technical assistance to strengthen training and the implementation of communication programs for health, along with limited commodity support to the health sector under the four Project goals (Communication, Capacity Building, Social Marketing and Advocacy.

CARE currently implements over twenty projects in 56 districts (7 regions) in Ghana. For CARE, partnerships with, and capacity building for, government institutions and civil society, including community based organizations, are central to its mission in Ghana. CAREs portfolio in Ghana includes a broad range of complementary livelihoods and social services provision and capacity building in agriculture & natural services, girls education, health and HIV&AIDS, water/sanitation and community micro-finance. CARE has a long term presence in the Western Region of Ghana, and it is recognized for its capacity building work at community, district and national levels, as well as its policy advocacy and gender expertise. CAREs experience in building local capacities includes technical and organizational development training and facilitation of district level service providers networks/forums in a dozen districts in Northern and Western Ghana. Currently CARE works with over 200 womens groups in Northern Ghana.

Empowering Mothers for Health Behaviour, Accra, A Ghana

Background to problem What is the problem relating to Health and Malaria in Ghana and more specifically where the project is operating?

In Ghana, malaria is a major public health problem and cause of morbidity and mortality and directly contributes to poverty, low productivity, and reduced school attendance. Malaria accounts for more than 61% of hospital admissions for children under age five, and 8% of pregnant women. Nearly 38% of outpatient visits are related to malaria, which is the leading cause of lost workdays due to illness. It is estimated that malaria kills 22% of children under age five (or 20,000 children every year) and is the main case of death among children in the postnatal period, and 9% of maternal deaths. Again in recent BCS advocacy meetings in the Ga East and Dangme East districts malaria emerged as the topmost issue in the districts of which women and children are the most vulnerable (these came up in the presentations made by the District Directors of Health Services). To address these and other health issues, CARE is implementing Empowering Mothers for Health Behaviour in the Greater Accra, central and western regions of Ghana. The first phase will be implemented in two districts in the Greater Accra region.

Background to 4 year Programme supported by USAID and also CAREs experience in working in Health and Malaria prevention The Behaviour Change Support (BCS), a 4-year Behaviour change Communication USAID funded project (August 2009 - September, 2013) The project focuses on fostering positive health practices in households and communities by creating and strengthening social norms around health thinking and health behaviour and sustaining these practices in three regions within Ghana (the Greater Accra, Central and Western Regions all communities 3,600). The BCS Project is designed to create broad, ongoing interventions that address multiple, integrated health topics over the life of the project to bring about improvement in health and works through four key elements - Behaviour Change Communication(BCC), Community Mobilization(CM), Community Based Distribution(CBD) and Capacity Building. These elements are well coordinated to form the framework of - Communication for Social Change Framework (CFSC). In the CFSC framework, BCC campaigns serve as the catalyst of change; community dialogue and action of CM accelerates and deepens that change; community-based distribution allows people to take action based on transformed community norms; and capacity building, sustains change. The integrated thematic health areas are: Family Planning, Maternal Neonatal Child Health, Malaria, Nutrition, Water and Sanitation.

Empowering Mothers for Health Behaviour, Accra, A Ghana

The project teams work with counterparts in GHS units to maximize the contribution of BCC towards building on the successes, reversing the negative trends and creating momentum to move the stagnant indicators in a positive direction; as well as with other USAID funded projects, the private sector and stakeholders at the various levels in the target areas to enable them to make input and have ownership of the process for sustainability. The Johns Hopkins Bloomberg School of Public Health Centre for Communication Programs (JHU/CCP), in partnership with CARE Gulf of Guinea and PLAN International, form the team of choice to manage the implementation of the Project. With over 15 years experience in Ghana, CARE has demonstrated extensive capacity in community mobilization. CAREs role in this partnership is to conduct and coordinate both rural and urban community mobilization in two regions of Ghana (Greater Accra and Western Region), and urban community mobilization in one region (Central Region). Our community mobilization approach will not only help people improve their health, but by its very nature will strengthen and enhance the ability of the community to work together for any goal that is important to its members. The end result will not only be a health issue addressed but also increased capacity to successfully address other community needs and desires (BCS Project Proposal, 2009). Goal The overall goal of the project is to increase demand for and use of malaria prevention services among women groups in the Greater Accra Region. Objectives o Adopt the VSLA strategy to attract and draw women to regular meetings to share messages on malaria prevention and discuss how to apply information to real life situation for sustainable behaviour change. Increase antenatal attendance and demand for SP by pregnant women. Improve the skills of women in the home management of malaria Increase the demand and nightly use of LLINs by individuals and families. Form VSLA groups in 10 communities in the Ga East and 5 communities in the Dangme East Districts with income generation as a driving force to attract other women for health promotion in malaria. Information on Programme, objectives, who is involved and the timeframe

o o o o

CAREs experience and expertise in this area Health and Malaria prevention

CARE has over 15 years experience in Ghana and has demonstrated extensive capacity in community mobilization in health. Currently CARE plays a similar role in the BCS partnership in conducting and coordinating both rural and urban community mobilization in two regions of Ghana (Greater Accra and Western Region), and urban community mobilization in one region (Central Region).

Empowering Mothers for Health Behaviour, Accra, A Ghana

Summary of Project A paragraph explaining project, the aim and how many women it will reach The Empowering Mothers for Health Behaviour project aims at deepening the existing activities being implemented by the GHS and NGOs with respect to the adoption of healthy behaviours in Malaria and other related issues to improve the health of the people in the selected communities and gradually expand while building on the initial experiences. This initial phase will be implemented in 15 communities in the greater Accra Region; 2 groups will be formed in each community. The idea is to use the VSLA approach to attract and draw women to regular meetings where malaria control messages will be consistently discussed using materials produced by ProMPT and also used by BCS. Through this initiative, the women will appreciate the relationship between health and economic wellbeing. When the women start managing income from VSLA they would want to be healthy always to continue to contribute to accumulate wealth. They will therefore be motivated to apply the health messages for the desired behaviour change to take place. The successes of the initial groups will lead to the formation of more groups and the number of health advocates in the communities will increase. Implementation starts from the Greater Accra Region because Hopeline Institute is currently implementing the VSLA in some communities in the Ga East District and we plan to expand the base and at the same time introduce Prolink to the VSLA strategy to be implemented in the Dangme East District. In this first phase Hopeline will manage a minimum of 20 groups and Prolink, 10 groups. We hope to extend to the Western and Central Regions in the next phase. Because children are also vulnerable, 5 basic schools will be reached with malaria prevention information; the emphasis will be on children at the kindergarten level (the under 5 vulnerable group).

Project goal, objectives, activities and expected outputs

Please provide: Project goal

The overall goal of the project is to support households to experience improved quality life through a combination of health and financial behaviour change approaches.

Objectives and specific activities

Objectives

Empowering Mothers for Health Behaviour, Accra, A Ghana

o Adopt the VSLA strategy to attract and draw women to regular meetings to share messages on malaria prevention/home management and discuss how to apply information to real life situation for sustainable behaviour change. The women will adopt healthy behaviours and become advocates in their communities. Increase antenatal attendance and demand for SP by pregnant women. Improve the skills of women in the home management of malaria Increase the demand and use of LLINs by individuals and families. Form VSLA groups in 10 communities in the Ga East and 5 communities in the Dangme East Districts with income generation as a driving force to attract other women for health promotion in malaria (form 2 VSLA groups in each community with between 15 to 25 members per group).

o o o o

Activities Facilitation of workshops for about 500 women (15 women groups in rural areas, peri-urban, communities and market/trading communities of the Greater Accra Region) to share knowledge, attitudes, and practices on malaria, using already developed materials. Training sessions to prepare the womens groups to appreciate the concept of VSLA. Capacity building workshops for the Prolink Organization, the NGO partner in the Dangme East District on VSLA to enable them supervise the groups in their district. Workshops with the communities to build commitment for specific actions, including support to the set up of group level malaria emergency funds within the village savings and loans group procedures; Support the implementation of a Malaria day in 5 basic schools, to raise awareness and commitment to actions amongst pupils and their families. Facilitate 30 women groups representatives to attend major health meetings/events at the Regional level, to share their efforts and stories and influence relevant decision makers with some key evidence from the communities. This project will improve the health of thousands of Ghanaians and improve their capacity to access and advocate for better health care in the future.

Expected outputs Please provide timescale of project.

Expected Outputs

Empowering Mothers for Health Behaviour, Accra, A Ghana

Timescale of the project

Empowering Mothers for Health Behaviour Activity Month Output Responsibility

Advocacy meeting with the October, NGO partners 2010 Capacity building for the Prolink Organization, the NGO partner in the Dangme East District on VSLA to enable them supervise the groups in their district. Identify VSLA communities October, 2010

Hopeline Institute and Prolink CM Team/ VSLA Expert Organization CM staff (10) Prolink Staff trained, training CM Team/ VSLA Expert report produced

October, 2010. November, 2010 November, 2010 December, 2010.

About 15 communities

CARE/GHS/VSLA Expert/NGO Partners.

Community entry Advocacy meetings with stakeholders in the communities. Formation of the VSLA groups and introduction to VSLA Approach Training of the women groups

About covered

15

communities CARE/GHS.

About 30 formed

VSLA

groups CARE/GHS/VSLA Expert/NGO Partners.

About 600 women in 30 CMTeam/VSLA Expert/NGO groups trained to manage Partners. VSLA

Implementation of VSLA in Jan Sept, List of group members and CARE/NGOs/Mobilizers. the communities 2011 their shares documented; Terms of reference for each group in place. Meeting schedule developed. Communities workshops April, 2011 on building commitment for specific actions, e.g. malaria emergency funds within the VSLA group procedures. Support the implementation of a Malaria day in 5 basic schools, to raise awareness and commitment to actions amongst pupils and their families. FebMarch, 2011 Workshops held in 15 CMTeam/VSLA Expert/NGO communities; Malaria funds Partners/. VSLA Group set up for each community; members 15 workshop reports produced. Malaria day organized in 5 CMTeam/VSLA Expert/NGO schools and reports produced Partners/. VSLA Group members

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Empowering Mothers for Health Behaviour, Accra, A Ghana

Facilitate 30 women groups representatives to attend major health meetings/events Representatives of 30 CARE/NGOs/Mobilizers/GHS womens groups attended Health meetings/events

Monitor implementation of October, Monitoring checklists CARE CM/NGOs/Mobilizers/ community Action Plans 2010 developed for use. VSLA Expert. September, Monitoring visits conducted 2011 by Mobilizers, NGO partners, VSLA Expert and CM Team

Hold stakeholders meetings

review AugustWeekly meetings by group CARE CM/NGOs/Mobilizers/ September, members held. VSLA Expert/VSLA group 2011 members. Monthly review meetings with mobilizers. Quarterly review meetings with, NGO Partners and CM Team. Stakeholders meetings review

Location of project and a summary of the project beneficiaries

Monitoring and Evaluation Neighbour to neighbour information sharing pairs. No of VSLA women of women groups formed and the number of women who participate in meetings regularly. List of best practices identified, documented, shared and employed by other groups. No of schools reached, number of teachers and children, number of meetings held with each school and action taken by the schools in response. % of pregnant women 15-45 years who slept under ITN/LLIN the previous night. % of children under 5 who slept under ITN/LLIN the previous night. % of pregnant women who have received IPT two times and above

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Empowering Mothers for Health Behaviour, Accra, A Ghana

Can you describe how the project will be monitored (I assume that the larger project will monitor these activities?) - Development of workplans at all levels (VSLA groups, mobilizers, NGO Partners, CM Team) Weekly meetings by group members. A checklist will be developed to be completed by group leaders capturing data on the activities. Monthly review meetings VSLA Groups with mobilizers; NGOs with mobilizers; CM Team with NGO partners/mobilizers/VSLA group members. Quarterly review meetings with, NGO Partners/CM Team/ Community stakeholders Activity reports, minutes of meetings, quarterly reports and annual report.

CARE Ghana is requesting 25,000. In summary the funds will be used (in up to 1 yr, starting Oct, 08) see attached budget:

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