Ghana

Malaria Facts

Malaria is endemic and transmission is perennial in Ghana; there are pronounced seasonal variations in the northern part of the country. There are two distinct rainy seasons in the southern and middle parts of the country, from April to June and September to November. The northern part however has one rainfall season that begins in May, peaks in August, and lasts until September. There is a six-to-seven-month transmission period in a larger part of the northern part of the country and a shorter three-to-four-month transmission season in the upper part of the north. Peak vector abundance in the north is typically from June through October, but this tends to be limited to August and September in those areas where IRS is implemented. The highest number of malaria cases also occur between July and November.

Although Ghana’s entire population is at risk of being infected with malaria, children aged five and under five years of age and pregnant women are at higher risk of severe malaria because they have lower levels of immunity.

There are two distinct rainy seasons in the southern and middle parts of the country, from April to June and September to November. The North, however, is characterized by one rainfall season that begins in May, peaks in August, and lasts until September. There is a six to seven month transmission season in a larger part of the north of the country and a shorter three to four month transmission season in the upper part of the north, with the highest number of cases occurring between July and November.

In the southern part of Ghana, the transmission season is nine months or more, with a small peak from May to June and a larger peak from October to November. Although Ghana’s entire population is at risk of malaria infection, children under five years of age and pregnant women are at higher risk of severe illness due to lowered immunity.[1]

With 2.2% of global malaria cases and deaths, and 2% of global malaria deaths, Ghana is among the 15 highest burden malaria countries in the world. It accounts for 4% of malaria cases in West Africa. Between 2020–2021, however, Ghana made significant progress in malaria control – cases remained stable at 165 cases per 1000 of the population at risk – although deaths fell slightly by 1.7% (from 0.39 to 0.38 per 1000 of the population at risk over the same period). [2] To reduce the burden of malaria in the country, the high burden, high impact approach was introduced in Ghana in November 2019.[1]

Malaria Prevention 

In Ghana, ITNs are distributed via mass campaigns every three years and through school-based distribution. Continuous distribution channels include pregnant women during ANC visits and children receiving a second dose of measles/rubella vaccination at CWC visits. IRS districts and some urban centers are however not excluded from mass campaigns and school-based.

Access to insecticide-treated nets (ITNs) increased steadily from 30% in 2008 to 67% in 2019. ITN use has not increased as rapidly, however, from 21% in 2008 to 43% in 2019. The ratio of ITN use: access is between 0.4 and 0.6 in most of the country, with lower values in urban/peri-urban areas. Per the 2019 Malaria Indicator Survey (MIS), ITN use: access ratio is 0.47 in urban areas and 0.77 in rural areas. During the 2018 mass campaign, many individuals in urban settings either refused to register or did not redeem their nets after registration. The commonly cited reasons were that they are not able to hang rectangular nets in their rooms and they prefer other methods of mosquito control (e.g., use of mosquito sprays). This informed the National Malaria Control Programme’s (NMCP’s) decision to reduce the ITNs needed for urban settings for the 2021 mass campaign.[1]

ITN use among children under five years of age and pregnant women has followed the same trend as that of the general population in Ghana. ITN use among children under five has increased from 22 percent in 2006 to 54 percent in 2019 while use among pregnant women increased from 20 percent in 2008 to 49 percent in 2019. [1]

Acceptance and use of malaria prevention methods such as indoor residual spraying (IRS) and insecticide-treated nets (ITNs) continue to be a challenge to malaria control efforts. For communities benefiting from IRS, the seasonal movement of rural dwellers to urban cities as well as increased urbanization of rural communities make households unable to properly prepare houses for spraying.

Ghana’s strategy for drug-based prevention includes both nationwide intermittent preventive treatment in pregnancy (IPTp) for the prevention of malaria during pregnancy and Seasonal Malaria Chemoprevention (SMC) targeting treatment of children under five years of age with SPAQ.

Climate change, including changing patterns in rainfall, temperature fluctuations, humidity, deforestation, and other examples of environmental degradation have been observed in Ghana. These could lead to a change in malaria epidemiology and could impact how malaria prevention and control interventions are implemented.

In the most recent National Malaria Strategic Plan 2021–2025, Ghana seeks to protect at least 80 percent of the population with effective malaria prevention interventions.

An. gambiae s.l. tends to bite both indoors and outdoors, with humans being the preferred host.

Malaria in Pregnancy 

Ghana’s objectives for MIP are aligned with the national strategy, which includes providing ITNs during the first ANC visit, at least three doses of IPTp in malaria endemic areas starting at 16 weeks of pregnancy, and effective case management of malaria as per WHO guidelines as well as WHO’s 2016 recommendation of at least eight contacts. One contact is recommended in the first trimester; three in the second trimester (instead of the recommended two contacts, thus providing for early access to IPTp at 16 weeks); and a minimum of four contacts in the third trimester. These have all been articulated in the revised Ghana National Safe Motherhood Service Protocol. The guidelines have, however, been adapted to provide for other services such as IPTp.

Ghana has achieved the highest rate of two doses of IPTp(2) for pregnant women in sub-Saharan Africa – 78% in 2016 and 80.2% in 2019 [2,6]. The percentage of pregnant women receiving the third dose of IPTp (IPTp3) also increased from 39% to 60% between 2014 and 2016, and to 61% in 2019. [6]

Challenges related to pregnant women accessing malaria interventions include late visits to health facilities, limited or poor education regarding the IPTp schedule, and unsupportive attitudes of providers toward pregnant women and adolescent mothers to be, which make them reluctant to visit health facilities for ANC.

Seasonal Malaria Chemoprevention 

Under the current NMSP, Ghana intends to protect at least 80 percent of children aged 3 to 59 months living in zones where malaria transmission is highly seasonal with sulfadoxine-pyrimethamine and amodiaquine (SPAQ) in accordance with WHO recommendations from 2012. This method is known as seasonal malaria chemoprevention (SMC).

Ghana implements SMC yearly via door-to-door campaigns for a period of four months during the peak malaria transmission season (July–October) in seven Sahel regions (select districts in Bono East, North East, Northern, Savannah, Oti, Upper East, and Upper West).

Although data on Seasonal Malaria Chemoprevention barriers and facilitators are limited, one study found that SMC uptake was influenced by the level of trust in health personnel and observed benefits of SMC. Barriers included preference for herbal medicines, limited access routes to families, and fear of adverse drug reactions. A few children were listed as ineligible due to a prior adverse reaction to SPAQ. Community Health Officers and volunteers identify challenges with SMC uptake, including monitoring SMC-associated adverse reactions and using community-based SBC to promote SMC adherence.

Case Management 

NMSP 2021–2025 aims to provide appropriate diagnoses of all suspected malaria cases and prompt and effective treatment to 100 percent of confirmed cases. Ghana subscribes to the 3Ts (test, treat, and track) approach, which seeks to test every suspected malaria case, treat positive cases with the recommended quality-assured antimalarial medicine, and track the disease through timely and accurate reporting to guide policy and operational decisions.

Although care-seeking is improving in Ghana, progress in this area is impacted by negative experiences with health care workers, local beliefs, and costs associated with testing and treatment, compounded by lack of knowledge, attitudes surrounding fevers, and social norms. SBC investments are needed to improve early care-seeking and treatment for malaria at both the facility and community levels.

Facility-based Case Management 

The Guidelines for Case Management of Malaria in Ghana (March 2020) describe the overall approach to diagnosis and treatment of malaria in Ghana.[1]

There are four levels of the health system where malaria is diagnosed and managed: [1]

• Community level: households, licensed chemical sellers, community-based agents, and volunteers
• Primary health facility level: CHPS compounds, health centers, private clinics and pharmacies, polyclinics, and similar institutions
• Secondary health facility level: district hospitals
• Tertiary health facility level: regional hospitals and teaching hospitals

When severe malaria is identified, parenteral treatment – intravenous (IV) or intramuscular (IM) medication – or rectal artesunate should begin promptly, and severe malaria cases should be referred immediately to a hospital after instituting pre-referral management.[1]

The following are included as pre-referral management: IM artesunate, IM artemether, or IM quinine. Rectal artesunate can be given to children less than 6 years of age. In a hospital setting, the order of preference of treatment is: IV/IM artesunate, IM artemether, and IV/IM quinine.[1]

Data from the drug efficacy sites in 2019 indicates that the recommended first line antimalarials continue to be efficacious.[7]

Community Health Planning and Services (CHPS) and integrated Community Case Management (iCCM)  

The Community Health Planning and Services (CHPS) programme is funded by the Government of Ghana, with Global Fund support for artemisinin-based combination therapies (ACTs) and rapid diagnostic tests (RDTs).[7] The services offered include, home visits, integrated outreach services for growth promotion, immunisation, family planning, community-based disease surveillance and response system and community durbars. [7] The government planned to expand coverage from 4,400 functional CHPS zones to 6,548 by 2020 (DHIMS Analysis).[4]

A major component of the CHPS strategy is that traditional community leaders must accept the concept and commit to supporting it. Malaria treatment is included in the Community Health Planning Services. Services provided by accredited CHPS are free for those having an active national insurance card.[6]

Community Health Officers (CHOs), who are selected by the community [4], implement Ghana’s Integrated Community Case Management (iCCM) model through home visits for service delivery in their catchment area.[7]

Health Funding 

As of 2017, less than 25% of the country’s spending on health was from national resources.[5] In accordance with its vision of “Ghana Beyond Aid”, the government aims to procure all malaria commodities with local funding.[1] It also plans to procure all its ACTs without international funding (donor support), beginning in 2020.[1]

The government also made a commitment to universal health coverage when it passed the law to establish the National Health Insurance Scheme (NHIS) at the end of 2003.[5] As of 2017, the NHIS covered 45% of Ghana’s population. All necessary malaria services and medicines are covered at no cost to NHIS members.[1]