JPC .CCP

Onchocerclasis Control Programme

in

Wcst Africa

pnograrure de Lutte contle l'Onchocercose en Afrique ^{de l'Ouest}

JOINT PROGRAI\{ME ^COMMITTEE

Office

of

the Chairztan

JPC .CCP

^{COIVIIIE CONJOINT DU} PROGRAIVIME Burcau du ^Pr6sident

JPC11.8(c)

ORIGINAL: ENGLISH

Septenber

1990 JOINT PROGRAUT{E COHUITTEE

Eleventh session

Cona

3-6

^{December 1990}

Provisonal agenda item

⁹

DEVOLTTTON PLAI{

-

^{CONTROL OF} ONCHOCERCTASTS, YAWS, LEPROSY AT{D GUIIIEA I|OR}I

IN

GHANA

t,

I

i

_i

t

DEVOLUTION PLAN

CONTROL OF ONCHOCERCIASIS, YA}VS, LEPROSY AND

GUINEA

^}VORM

Prepared by

NATIONAL

ONCHOCERCIASIS COMMITTEE

NATIONAL

ONCHOCERCIASIS SECRETARIAT MINTSTRY

OF

FINANCE

&

ECONOMIC PLANNInNG

ACCRA

JUNE

^I99O

3

SUMMARY

The Onchocerciasis

Control

Programme (OCP) began

its

control operations

in

Ghana ⁱⁿ 1974,

in what is now

called

the Original

Programme area

in

northern Ghana, covering the present-day Upper East, Upper West and Northern Regions.

In

¹⁹⁸⁸ the control activities were

further

extended southward to cover the southern Extension

area. In

the Devolution exercise about

to

take

off,

however,

only

the

original

Programme area is involved.

Prior to OCP control

operations,

the

epidemiological

data

showed

that the

original Programme area was

highly

endemic

for

the savanna

blinding

type

of

onchocerciasis. About a

third of

the population was

afflicted

by the disease,

with

a

blinding

rate reaching up

to

l09ir

in

certain

communities. The

area cqntained some

of the

worse

affected

localities, such as

villages

in

the Sissili/Kutpawn area and along the Btack Volta, where prevalence rates ^reachecl 70%

or

more. Nakong,

on the Sissili River, for

instance, had

a

prevalence rate

of

^{1000/u in}

adults.

The disease created serious obstacles

to

the socio-economic advancement

of

much ol' the highly endemic area.

Following

intervention

efforts by

the OCP,

significant control of

onchocerciasis

in

the Programme area has been

achieved.

However, a number

of 'black

spot" areas have remained problematic. _Those include the Sissili/Kulpawn area and the Bui area on the Black Volta where residual transmission

still

occurs, due to a combination

of

factors such as the high

CMFL

and

high

ATP in

the past, occurrence

of

insecticide resistance and reinvasion

by

the flies.

In

the Devolution Plan

of

Ghana, the

chief

aims are to sustain the gain so

far

achieved, to prevent recrudescence

of

the ^disease and to overcome the problems ^posed by the "black spot"

areas. The devolution activities will

be closely integrated

into the PHC

programme, full1, involving community

participation.

Apart

from

surveillance and control

of

onchocerciasis, the Devolution Plan envisages the inclusion

of

the control

of

three other ^diseases

of public

health importance endemic

in

the proS,ramme area. These are leprosy, ^yaws (to be eradicated

by

¹⁹⁹⁵⁾

and Guinea worm

(to

be eradicated

by t993). Their

inclusion

in

the Devolution ^programme is

fully justified by

the

fact

that,

like

onchocerciasis, they ^present distinct skin manifestations

which lend

themselves

to

easy

differential disgnosis. They

also constitute problems

for

the socio-econom

ic

development.

In the

Devolution Plan,

three

Potyvalent Teams,

a Monitoring

Team and

an

Evaluation Team are

to

be set

up in order to

ensure the

effective

execution

of the plan. The

PTs rvill provide technical resources and backings to all stages

of

the devolution activities, including ^the large-scale survey

to

be carried

out

once every three years. The Monitoring Team

will

assess

and ensure the smooth implementation

of

all aspects

of

the institutional arrangements to be put

in ^place. Finally, the

Evaluation Team

will carry out, in the third and fifth

^year

of

the programme, epidemiological

and

parasitological surveys

to

evaluate

the

progress

and

the achievement

of

the Devolution Plan.

High

priorities in

the Devolution Plan are also accorded to the training

of

health personnel

of all

levels

to

cope

with _the

integrated

control

programme and the strengthening

of

^health

facilities within

the programme area.

For the successful implementation

of

the Devolution Plan, the estimated cost

for

the l'irst

five

years amounts to 936,000,000 cedis

or

US

$

2.t40.000.

TABLE

OF CONTENTS EXECUTIVE SUMMARY

1. INTRODUCTION

2.

EPIDEMIOLOGICAL

SITUATION

2.1. Epidemiological situation

of

onchocerciasis

2.2. Epidemiological situation

of

other diseases: yaws, leprosy, Guinea worm

3.

GENERAL

SITUATION IN THE

COUNTRY

3.1. General presentation

3.2. Demographic and Socio-Economic Indices

3.3. Organization Chart

of Ministry of

Health and Health Policl' 3.4. Personnel and facilities

3.5. Cost and Financing

of

Public Health Services

3.6. Function and Resources

for

Epidemiological Surveillance

4.

SURVEILLANCE AND TREATMENT

4.1. Objectives

for

onchocerciasis, yaws, leprosy and Guinea worm 4.2.

Activities for

onchocerciasis, yaws, leprosy and Guinea worm

5. ORGANIZATION

OF SURVEILLANCE AND TREATMENT

5.1. Human resources 5.2. Material resources

5.3. Cost

of

^programme

for five

^years

5.4. Ghana Government

contribution to

Devolution Plan implementation

6.

PROVISIONAL

TIMETABLE

ANNEXES

l.

^Phases

of the

implementation

of

the Programme

in

the

original

Programme ^area 2. Northern Ghana

within

the

Volta

Basin

3. Pre-control prevalence

of

onchocerciasis

4.

Prevalence

of

onchocerciasis

in

¹⁹⁸⁹

5.

List of diMstricts in

the Devolution area

6.

Estimated cost

of

the Devolution-Plan 7. Material allocations

Pages

3

8 9 10 13

r3 14

14 4

5 5 7

8

15 15

16 L7 20

2t

22

23

25 26 27 28 29 30 38

5

2.

EPIDEMIOLOGICAL SITUATION

2.1.

Epidemiologicel Situetion

of

Onchocerciasis

2.1.1. Situatiort before the beginning

of

^Vector Contol

The objective of the Onchocerciasis Control Programme (OCP) ^{is to} eliminate onchocerciasis as a disease

of ^public

health and socio-economic importance throughout the Programme ^area and to ensure that there is no recrudescence

of

the disease thereafter

(Anon,

1985). In ^pursuance

of this

the OCP

is

pre-occupied mainly

with

the savanna

or blinding form of

onchocerciasis

which, in the

Programme area,

is

endemic

mainly in the

savanna

regions. The forest

or

non-blinding form of

the disease is not covered

by

the Programme

(Anon,

1986).

Prior to

the launching

of

the OCP

in

1974

it

was estimated that onchocerciasis affected berween 1.0

and

1.5

million

inhabitants,

with blind

^people numbering

about

120,000

in

^the

Votta

River

basin

area.

This area covered an estimated 764,000 sq.

km in

the seven originalll' selected endemic countries

in

West

Africa ^(Anon,

^1973).

In

Ghana the area involved covered

all of

Northern Ghana circumscribed

by

the Black Volta

to

the West and south-west, the Oti

river to

the east and

with

the

Volta

lake as the southern

border. This

covered an estimated 98,000 sq.

km. with

a population

of

1.6

million

(1970-71 Census) ^(See Annex 2). Duke-Elder

(in Crisp,

1956) stated that about 30,000

of

them were blind, i.e., about 25%of

all

blind ^persons

in

the

original

OCP

area. In

some villages,

a

tenth

of the

people were

blind

^and

in

others, where the struggle had been won

by

the

fly,

the people had abandoned

their

homes carrying

wirh

them rhe menace

of

the disease to areas

further south.

Thus there were high population densities

in the

area between

the

valleys

of the

White

and Red

^Voltas,

the

Sissili

and

^the

Kulpawn rivers, while the

valleys themselves were sparsely populated

or

even uninhabited

(Crisp,

1956).

Relatively densely populated areas were encountered

in

the Bawku

district in

the extrenre north-east and around Tamale in the centre, and in the Wa and Lawra districts in the north-west.

Generally, the northern portion

of

Ghana has low population density while the southern portion is rather densely populated.

Annex 3,

shows

the

prevalence

of

onchocerciasis

in the

Programme

area. This

area, particularly

in

the Upper Regions

of

Ghana, ^was among the worst onchocerciasis endemic ^areas

in

the

Volta

basin.

The area drained

by the

Red and White Voltas, the Sissili and

the Kulpawn

rivers, and along the Black Volta supported prevalence ^rates

of

over 70%. And as stated above, the whole population was

affected in

some

localities.

Since the southern extension

of the

Programme.

the high prevalence endemic areas of Asukawkaw in the Volta Region and Pru in the Brong-Ahafo Region have now also been covered.

Crisp (1956) reported the

following

infection rates

in

the

different

age-groups

in

the ^Red Volta area: 30%

(under l0

^years);

9l%

^(10-20 years); 100% (31-40 years); 100% (41-50 years):

100%

(50-60 years). In the

village

of

^Nakong

^on

the Sissili

river

^100% prevalence rate u'as

recorded.

He also recorded 60J%

at

Widenaba,

?l%

at Sapeliga. ^77.E%

at Zongoiri

and ^89(),r ar

Tilli.

It

has been noted

in

the endemic areas

in

Ghana that blindness rates

of

over 590 were in villages

of

200 inhabitants or fewer whereas they were exceptional in villages

with

500

or

nlore.

Furthernrore

there

was

no

population

growth in the

communities where

the

blindness ratc'

equalled

or

exceeded 5%

(Rnon,

l9E5).

2. 1.2. Tlrc prcscttt sinrutiotr

a

I.

INTRODUCTION

Ghana is situated

in

the middle

of

the coastline

of

West

Africa. It

extends some 850 knt between

latitude 4o4'N and latitude llol2'N

and stretches some 480

km

between longitude

tol2'E

and

3ol5'W. It is

bordered on the east by Togo, on the west

by

COte

d'lvoire,

on the north

by

Burkina Faso and on the south

by

the

Atlantic

Ocean, the

Gulf of

Guinea.

Ghana

lies

squarely

within the

endemic onchocerciasis

belt of

West

Africa. There

is

blinding onchocerciasis in the Volta basin which includes all

of

the Northern and Upper Regions and portions

of

the Brong Ahafo and Volta Regions. Forest onchocerciasis is also endemic in many parts

of

the forested southern ^areas

of

the country.

In the past some

efforts

were made to study and control onchocerciasis by the Government

of

Ghana

with

assistance

from

various organisations such as the

British

Empire Society

for

the Blind and the

UNDP.

^These

^efforts

provided documentary information on the severity ol' the disease,

its

socio-economic importance,

the

^vector

blackfly

and

its

ecology and distribution.

They assisted

in

rhe use

of

^various insecticides

(including DDT) in larval

Simulium ^(vector)

control.

Chemotherapy invotved the ^use of such existing drugs as Banocide (Diethylcarbamazine)

in

the treatmenr

of all

forms

of

onchocerciaisis, savanna and forest

types.

These

efforts

did

not yietd

the desired

results.

The Government

of

Ghana therefore associated

itself with

the decision thar the chances

of

obtaining successful and lasting effects would be ^greatest

if

^the

control were carried our

in

a

sufficiently

large ecological zone to protect against reinvasion b1'

the fly after controt. It

has consequently been associated

with the

Onchocerciasis Control Programme (OCP) since

its

inception.

The OCP ^was launched

in

¹⁹⁷⁴ by the WHO, UNDP, the World Bank and

FAO. It

originalll"

covered

the Northern and Upper

Regions

of

Ghana (See

Annex l). In

1986

the

southern extension was included

in

the controt area to cover existing endemic areas

in

the Brong Ahafo and the

Volta

Regions

in

order

to

^prevent reinvasion

of

the

fly from

breeding sites south

of

the

original

area.

The idea of

"devotution"

in the

OCP has undergone much

evolution in

meaning and

implication. lt

is defined as progressive national participation

in

onchocerciasis control and ^a simultaneous

effort to

strengthen

the

preventive branch

of the

national

public

health systenr (JPC

9,9A,

1988).

It

^is

to

be concerned

with

the maintenance

of

the gains made so

far by

the OCP

in

the

original

OCP area through surveillance and monitoring

to

^provide

earll'

^warnittg

and prevent any recrudescence

of

onchocerciasis

in

the Onchocerciasis Freed Zone (OFZ)- Ghana ^has planned accordingly

to

incorporate and integrate the programme

of

devolution

into

her Primary Health Care programme which

will

include the treatment and control

of

^yarvs

(Framboesia),

and

leprosy

which like

onchocerciasis have

skin

manifestations and

could

be

diagnosed

simultaneously. In addition it ^woutd

^cover

Guinea worm for ^which a

^national

eradication ^programme is already

in

place and which is also endemic

in

the OFZ-

This document has set out the operational strategy

for

devolution in the context

of

Ghana's health care

delivery programme. It

covers

the

methodology, required

logistic

support ^and estimates covering the cost

of

implementing the devolution

plan.

The

original

OCP area ^no\\' covers a population

of

2,l3E,4OO in 24 districts

in

the Northern and Upper Regions. ^Emphasis is ptaced on strengthening the health care delivery system in those areas to enable thenr nraintain the gains

of

the OCP.

It

is hoped that this report would provide the ^necessary information to encourage bilateral and multilateral assistance and support ro enable Ghana execute the plan and thus help intprove and maintain

the

heatth

of the

^people

in the OFZ

and thereby also support socio-economic development

of

the area.

a

7

The achievement

of

these objectives entails extensive travel

by

health services ^personnel to towns and villages

in

the

country. Full

advantage

will

be taken

of

these visits to carry out

a

number

of

disease control

activities.

These activities essentially involve simple ^procedures requiring no complicated technology and are not time-consuming.

The decision

to

combine the eradication

of

^yaws and Guinea

worm,

and the control

of

leprosy

with the

onchocerciasis devolution programme was

thus

based

on

considerations

of compatibility

and cost-effectiveness.

Besides the health worker

will

_be trained to carry out simple examination

of

the

skin

for signs

of

onchocerciasis, yaws, leprosy and Guinea worm

all of

which are endemic

in

the OCP area.

The

Ministry of

Health in collaboration with _Global 2000

-

^(Bank for Credit and Comnterce lnternational, BICC) plan

to

eradicate Guinea worm disease

by the year 1993. ln

addition.

yaws is targeted

for

eradication

by

1995. However,

in

the case

of

leprosy, the objective is to improve control

of

the disease by expanding the facilities

for

adnrinistering anti-leprosy drugs.

2.2. Situation

of

otlrer diseases yaws

The logistic support

for

yaws eradication is very similar to that

for

onchocerciasis control using ivermectin.

At

present the disease is prevelent in

all

the regions

of

the country

with

more ^cases being reported

in

the forest areas

of

the

south.

ln

1974

51,432, cases were reported

l9g4 9,160 i

^r

19889,628rii l9E9E,824i"i

The disease has affected mainly the under

l5

year

old

males and is confined

to

the rural areas.

The control programme is

currently

being restructured.

I

enrosy

This is mainly a rural

disease

widely

endemic

in Ghana. ^The

logistic support requireci using anti-leprosy drugs is

similar to

that

for

onchocerciasis

control,

using ivermectin.

The incidence

of

leprosy

in

Ghana

for

^1984-1988 is as follows:

1984 I per 100,000

^people

1985 t.7 n i

t986 0.8 0

ⁿ

t9E7 0.9 i i

1988 2.3 r i

This

rise

in

incidence merits urgent attention.

Guinea worm

I

Annex I

shows the phasing

of

^the prog,ramme

in

the

original

OCP.area and how Ghana was covered. Phase

I

commenced

in

¹⁹⁷⁴ and covered the Black Volta and the extreme ^western area. Phase 2 which started

in

1975 covered the central area involving the Kulpawn, the Sissili, the White and Red Voltas and the Daka

river.

^Phase 3 commenced

in

¹⁹⁷⁶ and covered the

Oti river in.the east.

The southern extension treatment started

in

February 1989 and covered the rivers Asukawkaw and Pru.

Since the epidemiological ^and entomological evaluation

of

the programme began the ^general success achieved

in

the original OCP area also applied to Ghana. Thus

in

the

different

^Progress Reports

it

was recorded

that the

large number

of

evaluations done

in

northern Ghana had indicated that the epidemiological situation ^was very satisfactory

in

most

of

the areas. However

in

the

Kulpawn river

basin and

in

the villages

of

Nakong

in

the Sissili and Goreba Somun in

the Kulda river

basin the regression

of

Community

Microfilarial

^Load

^(CMFL)

^was

^not

^verv marked.

lt

was noted also that in the neighbouring Sissili river area onchocerciasis was generalll' no longer

a

^problem

of ^public

health importance though one

child

^born

after

the start

of

the

control

programme was

found to

be

infected.

But satisfactory control could

not

be clainred

for

the village

of

Goreba-Somun on an

affluent of

the White Volta south

of

the Kulpawn where

three infected children

^were

found. Since l98l no

decrease

in the CMFL

^{was observed.}

Furthermore there were indications that

significant

transmission had taken place

during

^the

period.

_Relapsed transmission had also been demonstrated

in

the southern

part of the

Black Volta near

Bui.

This was not really surprising because vector control had always ^been

difficult

in that area which contained the largest breeding site in the OCP and where Annual Transmission Potentials

(ATPs)

have exceeded values

of 500 for

several

years. However the ATP

^at

Bui-Akanyakron in

^{1989 was}

only

^128.

Thus although there has been significant control of onchocerciasis in the general programme area

in

Ghana there are some "black spot" areas. These include

the

Kulpawn/Sissili area, the Bui area on the Black Volta, Asubende on the Pru and the Asukawkaw area due to high CMFL and

ATP,

insecticide resistance and re-invasion respectively.

It is

encouraging

to

note

that the

Programme has taken note

of

these problem areas in Ghana and

is

attending

to

them through chemotherapy using ivermectin, and vector control

with

larvicides.

2.1.3.

Nsk ol

rccrudescence

ol

trunnnission ond itemrcctin treal,ncnt.

It is

noted that

control

has not stopped as

at now.

But should

it

be stopped now then it must be stated that the possibility

of

recrudescence would be

real.

Reinvasion

will

recur and

with

the high

CMFL

and

ATP,

transmission

will flare up.in

most places.

It

has been accepted

that ivermectin

as

a microfilaricide

can

at

best

only

reduce

ocular morbidity but

ma1' nol

effectively interrupt

transmission. Measures should therefore be adopted

lo

sustain the control

currently

achieved as

well

as solving

the

problems posed

by

the "black spot" areas indicated above. The community must be involved in the imptementation of these measures as appropriate.

2.1.4. Predictiort

of cpidcntiolo$cal

tatds

As stated above some controt

work by

OCP continues

in

the Programme area particularl)'

in

the

'btack

spol" areas.

If

the ^problems

in

these areas are

ultimately

resolved then blinding onchocerciasis woutd have been

effectively

controlled

in Ghana. lf

the

infection

reservoir ^can be reduced

to a level which

does

not

support transmission.

it is

postulated

that

er'en

on

tht' return

of

the

fly,

transmission may

nol

recur.

On the other hand

if

OCP should cease control activities

in

the area before the ^problents

of the'btack

spot" areas are resolved then the gains made would be reversed sooner than

llter.

I

The highest

rainfall

occurs

in

the south-west forest zone

with

over 200 cm per

annum.

It diminishes progressively towards

the north with

an average

of

100-130

cm in the

northern

region.

The Coastal

belt

has the lowest precipitation

of

about 76 cm

annually.

There is one

rainy

season

in the north,

lasting

roughly from May to

October

with a

^peak

in August

ro

September. In the

southern

part

there

are two rainy

seasons

with

peaks

in

May/June and October

respectively.

Between December

and

February,

during the major dry

season, the north-east trade winds

from

the Sahara bring along the Harmattan, characterised

by

severely

dry

^weather.

3.2.

Demographic and socio-economic indices Demographic

Ghana has a population

of

about

l4 million with

under

l4

constituting approximately 459(r

of

the total (Census

1984). About

79%

of

the population

live in rural areas. In

recent ^years there has been a noticeable and steady

drift of

the rural population into the urban areas, thereby over-burdening the already

fragile

and inadequate

facilities

and infrastructures

in the

urban areas.

The population of Ghana has a relatively high annual growth rate

of

^2.6%

^with

crude birth and death rates

of

50 and 20

per

1000 respectively.

Life

expectancy

at birth

^is 52 ^years.

Socio-economic

Ghana is basically an agricultural

country.

^70%

of

its population are engaged

in

primarl, agricultural activities.

Cocoa is the most important foreign exchange earner, accounting

for

70%

of

the total ^value

of exports.

Gold comes second, accounting

for

l9%, followed by timber, mang,anese, diamond and

bauxite. Apart

from cocoa, other cash crops include coffee, kola, sheanus and pineapples.

Salt is also produccd and exported.

Petroleum and petroleum products account

for

35%

of

the total value

of

imports followed

by

machineryt transportation equipment and other manufactured ^goods.

Ghana produces also

a wide variety of

food crops and vegetables such as cassava, ^yanr, cocoyam, plantain, _bananas, palm nuts, coconuts, tomatoes, pepper, onions and beans. ^These are

mainly for

domestic consumption.

The per capita income

in

¹⁹⁸⁷ was 050,624.00 (Quarterly _Digest, June 1989,

VII

No 2) Culture and education

The people

of

Ghana have a rich and varied culture and historical heritage with diversified ethnic

groupings. A

number

of

languages and dialects are spoken

in

the

countr),but

Englislr has been adopted as the

official

language.

Side by side

with

modern administration, traditional chiefs apart

from

being the custodians of the countryis culture and customs still exercise considerable power and influence in maintaining social order and

stability within their

areas

of

authority.

The country's

educational system

is

undergoing

reform which

aims

at making it

^morc'

relevant

to the

needs and

reality of

the

society.

Education is on

a three-tier

basis: prinrarl'.

secondary and

tertiary.

Primary education is compulsory.

This

has been an endemic disease throughout the

country; it is particularly

prevalent in the

dry

savanna areas

which

include onchocerciasis endemic areas

in the north.

The disease tends

to

be seasonal

with

increase

in

the

dry

season when sources

of

water

dry up. ^It

affects

all

^ages but is more prevalent

in

young and active

adults. In

l9E9

with

intensive search a total

of

^{170 353 cases} have been recorded. The Guinea worm eradication programme would benefit

from

the logistic support

of

the onchocerciasis devolution prog,ramme.

Forest onchocerciasis

This

is prevalent

in

the forest parts

of

the country

but

has

not

been covered

by

the OCP control activities.

High

prevalence rates have been reported

from the Tano,

Pra,

Birim and

Densu river basins. Ivermectin (Mectizan) has been recommended

for

^use as a

microfilaricide

against forest onchocerciasis. Meanwhile there is no active control prog,ramme

in

Ghana.

3.

GENERAL

SITUATION

OF

THE

COUNTRY 3.1. Generel presentation

Political

Once known as the Gold Coast, Ghana achieved independance

in

1957, from British Colonial rule and became a Republic

within

the

British

Commonwealth

in

^1960.

The

country

is governed

by

the Provisional National Defence Council (PNDC).

Administratively,

the

country

is

divided into l0

Regions

and

^I

l0 Districts.

The district is the basic unit

of

the decentralised administration

with

its own assembly through which people

at

the g,rass-root level are expected and encouraged to exercise

their political

^power.

Geographical

As

stated

earlier,

Ghana

lies in the

West

African

Sub-region

within the

onchocerciasis endemic

area. It

^has an area

of

23E,538 sq.km (92,100 sq miles)

with

a coast

line of

537 knt.

Topographically, the coastal

belt

and

the Volta

basin have elevations

of

500 feet

or

less

above sea

level.

The rest

of

the country consists

of

plateaus and plains

of

varying elevations, above 500

feet, with

mountains above 2000

feet running

north-south along Ghana's eastern border

with

Togo.

There are many

rivers in

Ghana some

of ^which

are seasonal.

In

1964, when

the

Volta

River

was dammed

at

Akosombo,

the

biggest man-made

lake

was

formed

behind

the

dant, occupying ^{an area}

of

8,500 sq. km representing approximately ^4%

of

the

territory of

the countr)'.

Roughly the country can be

divided into

three vegetational zones. They are,

from

South

to North,

the coastal

plain of

shrubs and grassland,

the high rain

forest and semi-deciduous forest occupying the south-western part

of

the country and the Guinea Savanna covering the northern

half of

the country, characterised by ^grass and scattered trees.

Ghana ^has a tropical climate

with

average annual temperatures ranging

from

26oC to -iO"C

with

the northern part

of

the country being relatively hotter and

drier

than the south.

I

10

ln

1984, the population

of

school going age

(6-t4

years)

for

the whole country was about 3.1

m. Out of this total

0.3 m. was recorded

for

the Northern

Region,0.l m for

the Upper West Region and 0.18

m for

the Upper East

Region.

The above figures indicate

that

l99o ol' the total population

of

school going age

in

1984 came

from

the 3 northern regions

with

a total population

of

0.59 million.

In

l9E5/E6, enrolment

in first-cycle

schools reached

2 million,

that

of

secondary schools 168,000 and that

of tertiary

institutes

of

higher learning about 9000 students.

The

country

has three universities,

offering a wide

range

of

^subjects

for

graduate and post-graduate study.

Despite efforts made in education since independence illiteracy rate remains high at 65-70%.

3.3. Organization

chart of Ministry of Health (MOH)

and

Heatth

policy

The

Ministry of

Health (MOH) is the

official,

^as well as the major agency

for

the provision

of

Health

Services. lt is

organised hierarchicalty

into

national, regional and

disrricr

healrh services. The

Ministry

is headed by the PNDC Secretary

(Minister) for Health.

He is assisted by the Deputy Secretary. The technical operation is directed by rhe Director

of

Medical Services (DMS) and assisted

by

three Deputy Directors (DDMS) and two Heads

of divisions.

There are

i. DDMS

Medicat Care

ii. DDMS

Manpower and Training

iii. DDMS

^pubtic Health

iv. DNS

Director

of

Nursing Services

v. DPS

Director

of

Pharmaceutical Services

The PNDC Secretary is also assisted by a

Chief

Director

of

Rdminisrration and Finance.

The Regional Director

of

Health manages the health activities

in

his Region.

At

rhe districr level, there is

a District

Medical

Officer of

Health, assisted b1'

a Districr

Heatth Management Team.

(DHMT)

In

order to achieve the goal

of

health

for all,

Ghana has adopted the Primary Health Care (PHC)

Strategy. This

is organised into a

3-tier

system

with

Level

A at

the communirl, level.

level B at the Health Centre/Post (HC/P) level and level C ar the

district level.

In rhis srructure.

the

district

is the basic operational unit responsible

for

planning and implemenring

of

the healrh

policies and programmes within is catchment area with an average population of

I00,000- 150,000.

The goal

of

the National Health services is to maximise the toral heatthy

life of

the Ghanaian

people. It

^has

two

objectives which are:

i.

To achieve basic and primary health care

for

atl the ^people

of Ghana by

the year 2000

ii.

To

effectively

attack the healtlr prob'lems that contribute 80%

of

the unnecessary deatEs and disabilities

affliciing

Ghahaiani-by the ^year 2000.

The

principal

means

for

achieving the

twin

objectives is the Primary Health Care Strategl'.

The

overall

philosophy

of

^this strateg,y

is to

reduce the rates

of mortality

and

morbidity

due to conditions

for which

prevention, easy treatment and control exist.

I o o z a { o

z

(n -.t

n

C o t C

rn

o

'T'l

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{ u

o

'T1

- m

1'(n

<0 o;- -y

>!- 1ln I

m

Ep o0

>;

6ln z

\,

C

P9 -P _mz

7'v, {

I

3p zo

m- n(

>ln r

o n

m

o

{ o 3 a c

!

\,

r

mU'

!m

a

U,

z o z

m

r

'Tl

z.

z o

rn

{ n

z a

!

o

D

i

m

a -l

{

m

n o

m

o

{ o

,

o o 3<_

Eg _oZ

U,

1 o z

\,

C

tr n

m

!-

o -

m

o0

=o{ -m

o

I

zV o Fm io

a1 =o

on o

'r, 0

3q

ffi8 IO

<.Tl

n2 OO

!O qo {rn

UC

'o z

0 o a

rn

o D

rn

-.1 :D

3 m0

9b o<

\:

m

Fp _-3

J- =b

e#

il3 1<-

9F

m=;fl

Ym aO m{ I'O m oo

^'Tt

U'

=

^!

<o

;P r.3 1? u a 2 utI

fl {>

aZ

ia

=

c)I

-tl

!

!C

Po H!, >3

it,

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z

C

{

f,

= o

z

m

z

*= to -z _{3

-m {

m

3

.o I

FACILITIES

t')

ORGANISATION OF HEALTH SERVICES IN THE REGIONS

MANAGERS ADMIN. LEVELS

REGIONAL HOSPITAL

DTSTRICT HOSPITAL

HEALTH CENTRE

&

HEALTH POST

COMMUNITY

cLrNtc

REGIONAL LEVEL

c

LEVEL

LEVEL

A LEVEL

REGIONAL OIRECTOR

&

REGIONAL HEALTH MANAGEMENT TEAM

DISTRICT MEDICAL OFFICER AND DISTRICT HEALTH MANAGEMENT TEAM

MEDICAL ASSISTANT

AND HEALTH POST STAFF

COMMUNITY WORKERS EG. V.H.W. & T.B.A.

)

tB

Health care

delivery is an integral part of ^the

^total socio-economic development

effort

based on intersectoral co-operation and the active involvement

of

the people at the community level in the spirit of self-reliance. The fundamental resource for all health work is the community

itself,

and

full

community involvement is the ^basis

for

expansion

of

the health care ^system.

Health care

manag,ement

is

decentralised

to the district which is the unit for

health

administration.

Health districts are co-terminus

with

administrative

districts.

^The

district

^is

managed by a Health Management Team, headed by a

District

Medical

Officer of Health.

The team is responsible

for

the

total

health care

of

the

district. It

has its own budget.

Each

district

^has a hospital usually located at the district headquarters. The district hospital is the highest referral

facility in

the

d.istrict.

In addition there are a number

of

level B centres situated

in different

^parts

of

the

district.

The level B

staff

supervise and

work

closely with the communities at level A.

Cost Recovery Policy

It

is the government's desire to extend health services to all Ghanaians. However

in

^view

of the rising

cost

of

health care

the

government has instituted

a

cost recovery

policy

which calls upon Ghanaians to contribute toward

their

health care which is heavily subsidised by the government.

Drrrg poliey

i.

^The

Ministry

^has an essential drugs

list

and National Formulary

of

^Ghana

which

was launched

in

June, 1988.

ii. Under

the existing Pharmacy

Act,

drugs

to

be manufactured locally are listed, and those to be imported are brought in under specified procedures subject to

qualily

_control.

iii. Under thc

cost recovery programme, drugs

for the

treatment

of

certain conditions

of ^public

^health importance such as aids, cholera, ^pulmonarl' tuberculosis are free.

3.4.

Personnel end

facilities

The MOH is the

largest single provider

of

health services

in

the

country. Its

facilities include

2

teaching hospitals,

8

regional hospitals, ^I

I

special hospitals (Psychiatric, leprosaria and children's hospitals),36

district

hospitals,

l5

urban health centres, about 300

rural

health centres posts

and

175 community clinics.

The Government's facilities are augmented by 35 Mission hospitals. 40 Mission clrnics ^and

a

number

of ^private clinics run by industrial and institutional

establishments

and

private practitioners.

At

rhe beginning

of

^1989, the MOH had on

roll

E55 Doctors and Dentists. ¹⁰⁵ Pharmacists' ll,5OO Nurses and

about

^l7,7OO supporting

staff. ^In

addition, there ^were about 300 Doctors

in

private practice throughout the country, and 487 Pharmacists

in

the private sector'

The health services personnel are trained mainly

in

the two medical schools and 37 health

training

schools including 2E nurses

training

^schools.

3.5. Cost

rnd

financing

of

Public Health Services

The provision and maintenance of a country-wide cost-effective health delivery ^proS,ramme is one

of

the cardinat social objectives

of

the Government.

t

14

Since the commencement

of

the Economic Recovery Programme (ERP I )

in

^{1984' a number}

of

Regionat and

district

hospitals and health centres have had

their

most essential equipment and infrastructures rehabilitated.

The health sector

investment programme

for the

^1989-91

^period is oriented

towards

improving

tire effectiveness

of

health

delivery

services as

well

as increasing the coverage in both urban and

rural

^areas.

The

total

Government expenditure

for

the

MOH

recurrent and capital development ^are:

(a)

Recurrent 09.8

billion in

^{1988 and}

015.8

billion in

¹⁹⁸⁹

(b)

Capital Development 01.6

billion for

^{1988 and}

43.6

billion for

¹⁹⁸⁹

From the Sectoral

distribution of

percentage share

of

investment, the health sector takes about

3%.

^{See PIP} 1989/91.

3.6.

Function end resources

for

epidemiologicel surveillence

The functions

of

the epidemiological surveillance

in

the country ^are:

i. ^To

^study

^the

^behaviour

^of

^{specific diseases}

^with a view to their

early detection and the

institution of

control measures.

ii. To study the trcnd and pattern of the

disease

for proper planning for

their prevention and control.

The resources needed

for effective

surveillance ^are:

i.

^Skilled and trained manpower

ii. _Quick

and

effective

means

of

communication

from

one level

to

the other.

Depending on the urgency

of

the information, weekly or monthly reports are ^made upwards

from Level B

through

the

Regional Director

of

^{Medical Services}

to

the National Directorate in.Accra.--Appropriate-actions are taken at each level as necessary. Normally transmission

of

information

from

level

A

to Level C could be by

foot,

bicycle, motor cycle

or

nrotor

car.

Frotn Level

C

through regional

level to

Accra

is by

motor car

or by

means

of

^radio

or

telegraphic communication.

iii.

Transport

to

investigate reported disease outbreaks

iv.

Data processing machines, and stationery.

4. SURVEILLANCE

AND TREATT\TENT

tn the devolution plan, the control

of

onchocerciasis tog,ether

*'ith

other diseases

of

^public

health

importance

will be

integrated

into the Primary

Health Care Progranrnre.

The

other diseases are yawst leprosy and Guinea worm.

A

major component

of

the devolution process

will

be

staff training.

Under the devolution plan, health services personnel

will

be given

training in

the control

of

Onchocerciasis, leprosl' and

in

the eradication

of

yaws and Guinea worm.

ln

addition, the

Ministry of

Health has plans to provide laboratory facilities

for

all Service

Delivery

Points (SDP) starting,

with

the Onchocerciasis-freed

zone.

Furthermore, the systenr

of

routine data collection and

utilization for

^disease control

will

be streng,thened.

4.1. Objectives

4.1.L

Ottcltoccrciasis

i. ^To

^{prevent a} recrudescence

of

the disease

in

the OCP ^zone

ii.

To safeguard the achievement

of

the control programme.

4.1.2. Yows

i. ^To

update

information on che prevalence of ^yaws in che countEr.

ii.

To eradicate the ^disease

from

the country

by

the end

of

^1995.

4.1.3. Leprosy

i. To

update

informationon

Ehe

prevalence of leprosy in the country.

ii. To

reduce incidence

of

the disease.

4.1.4. Grtinea ^wonn

i. To

determine the extent

of

Guinea worm infestation

in

Ghana.

ii. To

eradicate Guinea worm

from

the country

by

the end

of

^1993.

4.2.

Activities

Devolution

activities for

onchocerciasis, yaws, _leprosy and Guinea

worm

disease are ^as

follows. Their

common features are

the training of

health personnel

and the

^provision

of

back-up laboratory services. There

will

be an independent evaluation

of

the programme

in

its

third

and

fifth

^years.

4.21.

Onchocerciasis

i. Information,

Education

and

Communication Campaigns

will

be

carried out

in

the Oncho-freed zone to explain the expectations ^and achievements

of

the prog,ramme.

ii.

Yearly parasirological ^surveys of

first-line

villages along the importattt river stretches in order to monitor the level

of

infection and to enable early detection

of

recrudescence

of infection.

The village network for surveillance witt be selected

jointly

by the Onchocerciasis Control Programme and the

Ministry of

Health and the number

of

villages selected

in

each

high risk

area

will

be

sufficient to allow

^yearll'

screening

of the

area and the screening

of a particular

village at

3-yearly

interval.

iii.

Epidemiolog,ical

mapping of the surrounding villages

^for decision-making

for

^possible intervention when the number

of

ne$

cases

in the first-line

villages

is

such as

to

constitute

the

start

o[

recrudescence.

Mass treatrnent

of

Communities

with

high prevalence rale.

Passive screening and treatment

of

Patients attending SDPs.

Appropriate

training for

health workers

to

enable thent

carry

out the devolution activities.

tv

vi

I6

vii. Training of

community members

to identify the

black

fly

and to

report any

increases

in its biting activities to staff of ^the

^nearest

SDPs.

viii.

Educating the community to ^be aware

of

the importance

of

reporting any new immigrant to the community to the SDPs

for

screening l'or onchocerciasis and possible management.

4.2.2. Yows

il.

lll.

iv'

4.2.3. Leprosy

4.2.4.

i. ^Active

and passive ^case

finding

ii.

Treatment

of

leprosy patients using anti-leprosy drugs

iii.

Health education of the population aimed at helping to

identify

leprosl' patients

for

treatment.

iv.

Rehabilitation and social integration

of

leprosy patients.

v.

Collection and processing

of

data on leprosy

vi.

Periodic review

of

leprosy patients.

Guinea ^wonn

i.

^Training

^of

healrh personnet on the aetiology and control

of

Guine:t worm

ii. Active

case

finding

iii.

^Public education and information about the ^causes, prevention and control

of

Guinea worm

iv. Distribution of

^water

filter

materials

and

education about their proper use.

v.

Social mobilization

for

sinking wells and boreholes.

vi.

Treatment

of

Guinea worm patients

vii.

Data collection and ^processing

viii. ldentification

and,

in

some cases, insecticidal treatment

of

^unsal'e

water sources.

5. ORGANIZATION

OF SURVEILLANCE AND TREATIUENT

ln line with the

PHC straregy the

district will

be the

unit for the

implementation

ol'

thc Devolution Programme.

Active

case detection

Mass treatment

in

high prevalence areas and treatment

of

individual

cases and

their

close contacts

in low

prevalence areas.

Data collection, compilation and ^processing Periodic reviews.

Within

the

district,

health care delivery is based on a three-tier structure.

(a) Level

A

(the community)

(b)

Level B (the health centre and health post) (c) Level C (the district)

Each

district

is managed by a

District

Health Management Team

(DHMT). lt

is headed by a

District

Medical

Officer

who is responsible

for

the overall co-ordination

of

activities

in

^the

district. The DHMT is

responsible

for training

and supervision

of

the

field staff

as

well

as

planning and monitoring

of

their programmes. There are

twenty-four

districts in the devolution area ^(see annex ^5).

The Level B which is the

most peripheral

of the formal

health care

delivery

structure operates

within

its "catchment

areas'of l0 km

radius

or more.

^{Health workers}

at level

B do

not only

manage patients

who

come

to

them

but will

also

be

responsible

for carrying

out devolution activities

in all

communities which

fall within their

"catchment areas"

5.1.

Humalr resources 5.1.1. Level A

The community level workers are:

i. Traditional Birth

Attendants (TBAs)

ii.

Community

Clinic

Attendants (CCAs)

These Community Health Workers are supported by Government and Non-Governnlental Organisations

including

revolutionary organs and women's organisations.

In the Devolution

Programme

the

community members

will

be

trained to identify

^and report

to

Level B:

(a) presence

of biting flies

and

their

breeding sites

(b)

presence

of

immigrants

to

the communities

for

examination

(c) any

^person

with clinicial

changes associated

with

onchocerciasis, ^yaws, leprosy and Guinea worm

for

examination and .treatment.

Reports

will first

be made

to

the village Health Worker who

will

then report

to

Level ^B

for

appropriate

follow-up

action.

ii.

The village Health Workers (VHWs)

will

mobilise the community ^members

to carry out control programme activities ^{such as} sinking of wells for provision

of

^good

drinking

water

to

reduce Guinea worm transmission.

5.1.2.

I*wl

^B

Level B personnel are:

(minimum

level)

I

^Medical Assistant (Team Leader) 2 Community Health Nurses

I Midwife

I

Assistant Environmental Health

Officer

I

Laboratory Technician

Their activities in

the Devolution ^Programme

will

include:

i.

Appropriate training

of

the communities/VHW to enable them

to

^identify devolution diseases, understand

their

CauSes,

their

prevention and control

a

I8

ii.

^The examination

of

patients attending clinics as well as organising survelrs

to

determine

the

^presence

of

onchocerciasis, yaws, leprosy

and

Guinea worm

iii.

Appropriate treatment

to

be given

after

laboratory confirmation.

iv.

Data on all devolution diseases

will

be collected

from

the catchment ^areas, and regular reports submitted

to

Level C.

v.

Level

B staff will

pay regular

visits to

the communities to supervise the

work of

the VHW.

vi. will

assist the village health workers

in

sensitizing the communities

at

the time

of

yearly epidemiological surveys

for

new case detection.

5.1.3.

Lcvcl

C

The District

Level ^{personnel are:}

I ^District

^Medical

^Officer

^(DMO)

I District

Public Health Nurse (DPHN)

I District

Communicable ^Diseases Control

Officer

^(DCDCO)

I District

Environmental Health

Officer

^(DEHO)

I District

Health Education

Officer

^(DHEO)

Their

activities

will

include:

i.

receiving and analysing data

on

the devolution diseases collected within the

district,

and using the

information to

^plan the control activities.

ii. training of

^'Level

B staff in the

operations

of the devolution

activities,

particularly in the clinical recognition, laboratory identification

^and appropriate treatment

of

the devolution diseases.

iii.

Procuring and supplying

of

the requisite inputs

to

Level B stations

iv.

Paying regular visits to Level ^B stations to supervise their work and provide technical support,

for

example investigating and taking immediate action

on

increasing

biting

activities

of

the Simulium

fly,

^and

v.

Organising ^mass health education campaigns,

in

particular sensitizing the villagers

for

^yearly epidemiological surveys

vi. Organising the

onchocerciasis surveillance

activities in ^{the fornr}

^ol'

parasitological surveys

in

selected villages 5.1.4.

Polyvsl.^t

^Teants

(PT)

(Regionol Lewl)

In

the devolution areas there

will

be three Polyvalent Teams set up

at the

regional level to provide technical support to the

districts.

These teams

will

be stationed at Tanrale, Bolgatangn and Wa

in th

Northern, Upper East and Upper West Regions respectively. The co-ordination

of

the PTs

is the

responsibility

of

the National Epidemiologist through

the

Regional Medical

Officers of

Health.

Each Regional PT

will

be made up

of

the following:

I

Epidemiologist

I

Entomologist

I

Parasitologist

I

Ophthalmologist

I

Statistician

I

Computer Specialist

2

Laboratory Technicians

2

Field Technicians

Their

activities

will

include

i.

Giving technical support to level C in epidemiologicalactivities, in particular carrying out parasitological surveys

in

selected communities in oncho high risk areas at yearly intervals and taking remediat action in conjunction witlr the DHMT

ii.

Investigation

of

any reported recrudescence

iii.

Giving general support

for

health care in the region, in particular conducting epidemiological investigation into other endemic ^and communicalbe ^diseases as appropriate.

iv.

Carrying

out

specific research activities as found appropriate

v.

Providing the necessary data base on

all

endemic diseases

in

the regions and servicing the national network.

5.1.5.

Monitoing

Teom (MT)

A monitoring

team

would

be set

up jointly by the

National Onchocerciasis Secretariat (NOS) and the

Ministry of Health.

The team

will

consist

of four

^persons made up

of

two social scientists and

two public

health specialists.

The team

will visit

the districts, monitoring the prog,ramme through the assessment

of

^the

plans and mechanisms at

all

levels

of

the programme activities to ensure

that the

institutional arrangements that have been

put in

place are satisfactorily implemented.

Their

report should be available

by

the end

of April

every ^year.

20

5.1.6. Evaluatiott

An

independent evaluation and review

of

the Devolution Programme would be carried out

during the third ^and fifth

^years

of the

Programme

activities. The main objective of

the evaluation is to ^assess the ^progress and impact

of

the Devolution Programme. The ^evaluation ream formed by OCP/MOH would consist

of

5 specialists

in

related fields and its

work

would be co-ordinated

by the

National Onchocerciasis Secretariat. The evaluation team may ^spend up

to five

^weeks to complete

its

work. One week

at

the head

office,

three weeks

in

the

field,

and one week

to

finalise and

write

reports.

5.2. Material

^resources

For the

efficient

management of the Devolution Programme, requisite logistics and technical resources

will

be needed

for

the various operations.

As indicated

in

Annex

7,

material resources would be procured

for

use

by

the following:

i.

Programme Co-ordinator ^(PC)

ii.

Polyvalent Teams (PT)

iii.

Level

C

Personnel

(L-C)

iv.

^{Level B Personnel}

^(L-B)

v.

National Onchocerciasis Secretariat/Monitoring Teams (NOS/MT)

5.3. Cost

of

programme

for five

^yeers 5.3.1. Investments and Training

These Capital Costs are ^as follows:

(i)

Logistic Support

(ii)

Data Processing equipment

(iii)

Technical equipment

(iv)

Field equipment

(v)

Educational Materials

(ui) Training

and Retraining

(vii)

Evaluation

of

Programme

Sub total

5.i.2.

Reanmnt E4endirure

These costs include the following:

(i)

Vehicle Maintenance

(ii)

Vehicle running cost

(iii)

Other equipments maintenance

(iv)

Per diem allowances

(v)

Stationery, drugs and insecticides

Sub total

SUMMARY

OF COSTS

(i)

Capital Investment and training

(ii)

RecurrentExpenditure

Total

(iii)

Contingencies ^(10%)

Total cost

of

Devolution Plan rounded

off

to

cedis

400,980,000 24,500,000 73,692,000 2,769,000 2,964,000 47,092,500 2,800,000

554,797,500

cedis 73,450,000 49,634,000 49,430,000 45,600,000 78,000,000

296,114,000

554,797,500 296. t 14,000 850,91 1,500 85,091,1 50 936,002,650 936,000,000

us$

2,840,000

22

5.4. Ghena Governmctrt

conlribution to

Devolution Plen Implementalion

The government

of

Ghana is committed

to

the

total

and integrated development

of

the arens

of the country which

have been

freed from the

scourge

of

onchocerciasis.

Already,

the government has voted money

for

feasibility studies and drawinBs

for

the construction

of

bridges and roads so as

to

improve accessibility

to

some

agriculturally rich

areas

ol'the

oncho-freed zone.

Ghana's

contribution to

the devolution ^programme

is in two

main areas. The Governntent

of

Ghana

will

provide personnel whose totalemoluments over the five-year devolution ^period u'ill amount to approximately

six

hundred and eighty

million

cedis (C 680,000,000)

tn addition, the construction and rehabilitation

of

health infrastructure

-district

hospitals. health posts,

office

accommodation-

within

the OCP area

will

cost about

l'our

hundred and l'il'teerr million cedis (C 415.000.000). Other contributions

will

come in the forrn

of

laboratorl'ec;uiprttent and reagents as well as other medical supplies.

6.

PROVISIONAL

TIME

TABLE

Table

I

I

^indicates schedule

of activities under the five year Devolution

Progranlnle.

However mobilization towards the

take-off of

the Programme in Year One needs to be ^preceded

by informal training

and orientation courses

by

the OCP

for

the key progranrme personnel to ensure a smooth take-off.

l.

Establishment

of

PTs/MTs

2.

Procurement

of

Logistic Supplies &

Construction

of

Ofl'ices

3. Provision

of

technical,

field

and data processing equipment

for

operations:

-

^PTs

- ^District

^Health Management Teams

-

Health Centre/Post

4.

Long-term Training:

-

^PTs

5. Short-term Training:

-

Ophthalmic Nurses (48)

-

^Lab. technicians (24)

-

Entomological Tech. (24)

- Monitoring

Team (4)

6.

Retraining Seminars

7. Public Education (Campaigns)

8. Supply

of

ivermectin and other drugs 9. Screening and passive treatnrent

of

onchocerciasis

10. Simple epidemiological Survey

of

any new cases

I

l.

Simple epidemiological Surveys ⁱⁿ indicator villages

12. Inspection

of

Areas liable

to

high Annual Transm ission ⁽ tvlapping)

t3.

Detailed

examinltion

and

lrr'ltnlent ol

cases discovered

YEAR

I

YEAR II

ilt

YEAR IV

YEAR YEAR

---i

---'1

E---

E---

:.1

14. Vector control (entomblogical surveillance)

in

co-operation

with

^village communities 15. Collection and analysis

of

data

16. Monitoring

&

Supervision

of

local and Polyvalent teams (Monitoring

Teams-NOS/MOH)

17. PT

Monitoring of

index areas

18. First evaluation

of

Devolution Programme 19. Final evaluation

of

Devolution Programme

I

YEAR

ll

YEAR

lil

YEAR

IV

YEAR YEA ^R

I