Moving Implementation Forward: Addressing Determinants of IDSR Performance through CapacityBuilding

1
Moving Implementation Forward Addressing
Determinants of IDSR Performance through
Capacity-Building in Tanzania and Ghana

• Rebecca Fields, CHANGE Project
• Lynne Miller Franco, PHRplus Project
• WHO/Geneva - October 2003

2
USAID Support to IDSR in Tanzania and Ghana

• Building on accomplishments of WHO and CDC
• Tanzania Partners MOH, PHRplus, NIMR, CHANGE,
  CDC, WHO
• Ghana Partners MOH, PHRplus, CDC, WHO
• Focus on identifying and addressing
  implementation issues for IDSR at district and
  facility level

3
Building on Groundwork Laid by WHO/AFRO

• Structure already in place
• Surveillance system assessment
• 5 year plan of action
• National IDSR technical guidelines
• IDSR training modules
• ME indicators

• Issues to be addressed at district level (and
  below)
• Technical competence
• Motivation
• Organizational processes
• Resource availability
• Knowledge of standards and job responsibilities

4
Successful Implementation Depends on
5
Approach to Capacity Building in Surveillance
and Response

• Identify underlying issues
• Build competence -- knowledge, skill and
  attitudes
• Apply adult education principles
• Communicate clear expectations for performance
• Go beyond training
• Ensure coherence across levels
• Develop problem solving capacity

6
Identifying Underlying Issues

• Purpose inform the design of interventions (not
  assess performance)
• Tanzania rapid assessment in 2 districts (2002)
• Interviews with health workers, districts,
  regions
• Focus group discussions with communities
• Review of management surveillance data
• Ghana
• Questionnaires to heath workers during training,
  discussions during training

7
Selected Findings from Tanzania Health Worker
Perspectives

• Many described surveillance/response as treatment
  and health education
• Limited benefits or consequences to performing
  surveillance tasks limited feedback, docking of
  pay
• Better understanding for outbreak than
  non-outbreak situations
• Lack technical reference materials
• Surveillance viewed as lower priority compared
  with clinical care

8
Selected Findings from TanzaniaOperating
Constraints

• Most facilities are small, with 1-2 trained staff
• Most dispensary staff are 1-2 grades lower than
  government norms
• 50 of dispensaries lack access to
  telecommunications (phone, radio call)
• Radio calls used effectively in one district for
  positive reporting
• Supervision very uneven across districts (72
  facilities with lt1 visits in past year average
  of 6 or more visits per year)

9
Selected Findings in TanzaniaVoice of the
Community

• Many cases of common diseases go to facility late
  or not at all
• Use of traditional healers is common
• Bias toward underreporting of cases
• Communities want more information following
  outbreak investigations what does outcome mean
  for them?

10
Strategic Framework for Strengthening IDSR
Improved prevention and control of infectious
diseases

• Improved IDSR at district and facility level
• Quality of data
• Use of data

Improved competence of health personnel
Improved support for IDSR within and beyond the
health system
Improved district organizational capacity
Improved communications technology and laboratory
networking
11
Build Competence Knowledge, Skills and
Attitudes

• Address the KAP gap and its causes
• Perceived consequences (does it make any
  difference if I do this? Will I get in trouble or
  be rewarded?)
• Accountability (Am I required to do this?)
• Social norms (Is this what my co-workers do? Do
  friends, family think its good to do?)
• Self-efficacy (Do I really know how to perform
  this skill correctly?)

12
Apply Adult Education Principles

• Participants are not tabula rasa build on what
  they know, what they say they need, and views
  they hold
• Develop training materials with learning
  objectives that focus on key tasks and that
  address what, how, why!
• Use active, participatory learning approaches

13
Communicate Clear Expectations for Performance

• Need clear and shared understanding of specific
  roles and responsibilities who needs to do
  exactly what, when
• Engage health staff in mapping out IDSR tasks
  for district and facility level
• Use in building training and other capacity
  building materials
• Example Epidemic preparedness organizing who
  is doing or responsible for what

14
Go Beyond Training

• Repackage guidelines and standards for easy use
• Develop appropriate job aids and tools
• Develop opportunities for continued sharing of
  experiences
• Look for ways to help health personnel problem
  solve and address barriers

15
Ensure Coherence Across Levels

• Design facility and district training so they are
  complementary
• Ensure feedback loops
• Make sure feedback contains information that is
  meaningful to recipients
• Link with labs, regions, local administration,
  etc.

16
Developing Problem Solving Capacity

• Performance will only improve if motivation and
  barriers addressed
• Use training and other sessions with staff to
  problem solve on barriers
• Build capacity for ME of performance at district
  level to identify issues
• Epidemic preparedness -- how to address problems
  before they happen

17
These concepts are not new!

• WHO VB series on Making Surveillance Work

18
Work in Progress

• Facility level training materials developed and
  implemented in Ghana, planned shortly for
  Tanzania
• Complementary DHMT training materials under
  development
• Other capacity building materials developed
  e.g., outbreak management guides, facility staff
  IDSR handbook
• Approaches tailored to situations in Tanzania and
  Ghana

Not universal solutions still somewhat
experimental
19
Conclusion

• Focus on field level, at point of data generation
  and first level of data management and response
  (district)
• Process begins with identification of key
  obstacles
• Interventions address obstacles and enabling
  factors, building on established technical content

20
Contribution to National, Regional and Global
Surveillance

• Ultimately, lasting improvements in disease
  surveillance are likely to happen on a
  sustainable basis when health personnel at lower
  levels provide timely and quality data that is
  useful to themselves as well as to higher levels