Author: Maes, E.; Zimicki, S.
The goals of the new Community-Based Surveillance (CBS) system were to detect and tally monthly cases of polio, cerebrospinal meningitis (CSM), guinea worm, measles, infant deaths, pregnancy-related deaths, all other deaths, new births, and unusual events. Training materials and reporting books (registers) were developed to assist the volunteers in collecting these data. After approximately 3,600 volunteers received training, the CBS system became operational in January 1998.
The CBS system was first reviewed in May 1998 to assess the status of early implementation and to make mid-course corrections, with technical assistance from UNICEF. Overall, the review concluded that the implementation of the system was progressing well, but recommended clarifying the roles of the zonal coordinators, Sub-district, and District staff, and made suggestions about increasing the completeness of reporting. It also recommended an external review after the CBS system was operational for a full year. This report documents the evaluation of the CBS system that was carried out in March 2000, funded by UNICEF.
Purpose / Objective
The main objective was to conduct an evaluation of the community-based surveillance program in Northern Region, Ghana and make recommendations to guide the establishment of community-based surveillance activities in other parts of Ghana. In the process of doing this, the team was expected to develop and field test a methodology for assessing the role and impact of community level surveillance that could be used in other locations.
The Northern Region is divided into 13 districts. Each district typically consists of four or five sub-districts, with between 50 and 100 villages in each sub-district. The limited amount of time available for field work, the access constraints imposed by the terrain and road conditions precluded obtaining a large, representative sample of different villages. To maximize the variation that could be observed, the team used a contrast sample, that is, chose areas that were considered to exemplify good and poor reporting.
Based on a review of reporting statistics from mid-1998 to mid-1999 and consultation with regional staff, four districts and the capitol district of Tamale were chosen. The four districts included two that represented areas with good reporting (East Gonja and Saboba/Chereponi) and two that represented those with the most difficulty in reporting (West Mamprusi and Nanumba). Within each district, two sub-districts were chosen following a similar strategy, that is, one with good reporting and one with less good reporting were selected. Similarly, at the village level, attempts were made to select villages exemplifying good and less good reporting.
Interviews of health staff, zonal coordinators, and village volunteers were conducted. All interviews of District and Subdistrict health staff were conducted in English, while most of the interviews with zonal coordinators and almost all of those with village volunteers were conducted in a local language. Interviews of villagers were conducted by external evaluators through interpreters, or by local team members. Interviews were conducted using questionnaires, consisting primarily of open-ended questions.
Key Findings and Conclusions
The Ghana Northern Region CBS system works well:
It builds on the strength and infrastructure developed by the GWEP. It provides good information. It complements facility-based reporting of AFP, has improved response to measles outbreaks, and has identified outbreaks of cholera and anthrax. It benefits both the communities and the health system. It has improved relations between the communities and the health system. It functions at a high level of sensitivity for reporting of the targeted diseases. It provides many opportunities for exchange among the levels of the health system (region, district, sub-district). It provides a vehicle for transmitting data routinely. It is an active, rather than a passive, surveillance system.
However, there is room for improvement:
Case definitions need reinforcing at all levels, but particularly zonal coordinators and volunteers. The key role of zonal coordinators should be recognized, and they should be provided with special supervisory training. Specific changes to the register book, the reporting process and analysis of results (listed below) should further improve reporting. Specific line item allocation of budgets to transport, training and repair of motorbikes and bicycles should be considered. A range of types of incentives for volunteers should be considered.
The success of CBS in the Northern Region may stem, in large part, from its growth out of the guinea worm eradication program (GWEP). GWEP gave the community a common, clearly visible target for action, easily identified by residents and health staff, as well as subject to effective interventions (community health education, medical management, and environmental risk reduction). Those developing CBS in other areas that are not endemic for guinea worm may need to identify other conditions with similar potential for recognition and relative ease of control (perhaps onchocerciasis or severe diarrhea). It should be noted that not all Districts or Subdistricts of the Northern Region had guinea worm immediately prior to the introduction of CBS. In the limited sample of Sub-districts visited, there did not appear to be a relation between the timeliness of CBS reports and the prevalence of guinea worm.
Lack of timely reporting appears to be related to one of two situations: delays due to water barriers (rain-associated flooding and routine difficulty in traversing wide rivers), or management problems (lack of effective supervision of zonal coordinators or lack of coordination among the Ministry of Health staff and the non-Ministry of Health personnel). In contrast, a common finding in areas with timely reporting was frequent field visits by staff from the District and Sub-district level. In particular, frequent field visits appeared to outweigh problems related to water barriers and led to effective CBS management.
Many of the CBS village volunteers interviewed by the evaluation team had previously served as guinea worm eradication volunteers. Nevertheless, previous experience in the guinea worm program did not seem to be related to reporting timeliness of village volunteers. Also, virtually all of the CBS volunteers had been serving since CBS began in January 1998. Together, these findings suggest that a volunteer-based system is sustainable and that CBS could be extended into regions without a history of guinea worm disease.
In summary, the reasons for success of the CBS system, which are replicable, include:
- a limited number of events are tracked
- some of the events tracked are common
- some of the events are actionable
- most case definitions err on the side of over-reporting
- the volunteers' workload is reasonable; weekly to monthly visits are feasible
- volunteers are not asked to handle money
- surveillance benefits both communities and the health system
Workload of the CBS volunteer:
Because the CBS volunteers are working effectively at the village level, there is a tendency to consider expanding their role -- for example, to train the volunteers to assist with growth monitoring activities, or with bednet treatment or other malaria control activities. However, the evaluation team concluded that one of the reasons for the effectiveness of the CBS system is that the volunteers are able to manage the work involved without compromising their other workload. Thus, the CBS team must 'protect' the time of the volunteer. On the other hand, they also need to consider the fact that additional tasks, such as helping with National Immunization Days or vitamin A distribution, have been a welcome source of incentives. The balance between providing opportunities for incentives and not overburdening the volunteers is critical. In particular, the ongoing supervision of volunteers should be sensitive to detect any potential negative impact of the volunteers' expanded responsibilities on the operation of the Guinea Worm Eradication Program.
Further integration of the CBS system and its output with District and Sub-district activities:
In almost all Districts and Sub-districts, the entire team is involved with the CBS system, in the sense that they participate in the formal and informal supervision of the volunteers. The evaluation team found that some Districts and Sub-districts use information obtained by the volunteers to plan outreach activities (e.g., Nanumba District uses birth information to plan BCG outreach itineraries) or to organize work in the villages. However, this was not true in all Districts visited. Also, the team found that the health system has not yet begun to use CBS information for strategic, rather than logistic, planning. For example, information about maternal and infant mortality does not appear to be used to plan preventive activities. The CBS team should promote routine utilization of CBS information by District and Sub-district staff. An additional consideration is whether the CBS system could be considered as a model for developing community-based IMCI.
Role of the zonal coordinators:
The key role of the zonal coordinator in the timely transmission of data, in assuring consistency in data collection, and other means of supporting and supervising the village volunteers merit special additional attention and training activities. Training in giving feedback and showing the value of the data could help ensure long-term participation of the volunteer, as well as draw the community more into the surveillance process. For example, giving the communities examples of how CBS data was used successfully to curtail an outbreak may strengthen their support of the volunteer and cooperation with CBS. Giving the coordinator more guidance on how to detect errors in reporting will improve the data as well as show him the importance of his role.
Potential role for women volunteers:
The team did not observe any women serving in the role of CBS volunteers. When we asked the volunteers how they were selected, all indicated that the village chief had chosen them to serve. We can only speculate that the chiefs selected men to serve because it was more socially or culturally acceptable. Perhaps, further discussion between health personnel and chiefs or village leaders could suggest that they also consider using women volunteers. Perhaps women volunteers might be considered in activities where children are closely affected, such as nutrition, and mobilization around maternal and child health issues.
Rising expectations of communities:
As reporting has improved, so has the expectation of communities that health workers will follow up reported events. However, regular follow-up requires transport, fuel and staff time -- all of which are severely constrained. The CBS system may want to begin considering now how they would like the link between the communities and the health system to develop.
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Health - Management