Background
IDSR implementation structure in Zambia
Methods
Study setting
Study design
Sampling procedure
Sampling of key informants
Data collection
Data analysis
Ethical considerations
Results
Main themes | Sub-themes |
---|---|
Structure | Legal and regulatory framework |
Core functions | Case detection |
Case confirmation | |
Case registration | |
Case reporting | |
Surveillance data analysis | |
Response and control | |
Feedback | |
Support functions | Training |
Logistical (financial, material and human resource) support | |
Monitoring and evaluation | |
Supervision | |
Quality attributes | Representativeness |
System stability |
Legal and regulatory framework
“… all issues of prevention, reporting of cases, events and conditions exist within the Public Health Act of 1995 specifically under the section for notifiable diseases and most of the notifiable diseases are the IDSR diseases, only that this time around decision (parameters) have been changed. When you look at the International Health Regulations of 1969 and the International Health Regulation of 2005, they are no longer mentioning that this disease or that disease, instead they are saying any case, condition or event that is unusual or is of international public health concern should be reported”. (Key Informant MoH Headquarters)“I do not think they are because you cannot just have one regulation or document that is a guiding principle for the entire implementation of the IDSR. If you look at the Technical Guidelines for the IDSR, you will see that actually, they is a lot that is involved and may be if we can have back up of some other laws, then it will be easier”. (Key informant LPHO)
Core functions
Case detection
Our findings also revealed that none of the four (4) health facilities that were visited in Chongwe and Lusaka districts had copies of the Zambian Technical guidelines on IDSR, although most of them had copies of the Standard Operating Procedures. The Technical guidelines on IDSR do provide stipulations on the procedures of handling suspected cases of a priority notifiable infectious disease at the facility level. Availability of these guidelines especially at the clinical level and their effective implementation at that level is the foundation of a strong disease surveillance system particularly in the early detection of priority notifiable infectious diseases and events of public health concern. However, what this study has found is that currently there is a challenge in ensuring that the simple procedures of that is, recording and investigating any rumour of a suspected disease or events of public health concern, promptly recording, reporting and obtaining laboratory confirmation of any suspected priority notifiable infectious disease, and optimal utilisation of the IDSR technical guidelines at all levels of IDSR implementation was inconsistently being done.“A log, we do not have, but we only have reports of rumours investigated, outbreaks investigated and so on. Any rumour that we hear we always investigate/follow ups”. (Key Informant – DHMT)
Case confirmation
“…not very good because at times you find that some of the things we ordered if they do not have they don’t supply. But for HIV test kits they are very consistent… At times, they could be one or two or three months when they could be challenges with the supply. Basically, what you report is what you get. The supply chain is report dependent. The supply of laboratory material is dependent on the report”. (Key Informant - Chongwe health facility)
Case registration
“This means that data is missing, and it is missing because the clinicians are overwhelmed [by the high patient demand] and they have no time to tally all the cases that they see. Equally, the clerks are also overwhelmed because of the huge number of patient books and other materials from which they are supposed to uplift data from and make a weekly and monthly report. So, at the end of the day, they just do what they feel they should do”. (Key Informant – DHMT)
Case reporting
Note that, the information that is contained within the notification reports is not the information that is entered in the Excel worksheets (treated as databases) at the DHMTs and PHOs. Only information that is contained in the weekly IDSR reports is entered in the Microsoft Excel work sheets. The other challenge we found was that (at the time of the study), the weekly IDSR reports had not yet been fully incorporated in the DHIS II for reporting to the next level. This is despite the fact that, the Ministry of Health rolled out the DHIS platform as far back as 2007 and around 2012, the Ministry upgraded the system to DHIS II. As a result, weekly reports are sent to the next level through phone calls, email and sometimes through the delivery of hard copies on a weekly basis:“Age, gender, place of residence, occupation, date of first attendance, phone numbers, next of kin, specimen that were taken, whether or not they were confirmed, the actual diagnosis among other things. It also contains the historical background for that particular patient and whether or not the patient had died and what was done after that, recommendations and conclusion are also provided.” (Key Informant – LPHO).
This study also found that there is a parallel and well-established reporting structure for the monthly notifiable infectious disease surveillance reports which are sent to the M&E unit (under the Directorate for Policy and Planning) through the use of the DHIS II. This system is available currently at the district level, however, it is not yet available at the health facility level. On a monthly basis, health facilities tally all information about suspected and admitted cases of all notifiable infectious diseases as well as their associated mortalities that they had seen during that month. This information has to be submitted to the DHMT by the 7th day of every month. Once the information has been validated at the district level, the DHIO now enters this information in the DHIS II which makes the information instantaneously available to anybody who has access to the system. This information should be entered in the system by the 21st of every month. Thus, there is a 14-day delay between the time DHMTs receive monthly surveillance counts from the respective health facilities and the time this information is entered in the DHIS II:“The [weekly] surveillance data is not sent through the DHIS II. The disease surveillance unit have their own database [Microsoft Excel Worksheets] – created by the surveillance unit. They compile a weekly report and submit it through email on a weekly basis. For those who are unable to email, they have hard copies that are blank which they fill in on a weekly basis. ” (Key Informant – LPHO).
“Before the data is even entered …, you check through the facility reports. If you find that there are issues you can even retain the report to the facilities for them to read through. Then it can be resent. But of course, the person who is sending the data may not be able to check through every indicator. So, certain indicators, you will find that they are okay while in others they may be some lapses…” (Key informant – DHMT)
Surveillance data analysis
Microsoft Excel is used to tally and analyse the received weekly IDSR reports while in most cases the statistical functions available in the DHIS II are normally used to analyse the monthly disease surveillance reports. Advanced statistical software such as Stata, SPSS and so on are used only in times when they need to do some further digging on the data.“…we do that, but on a quarterly basis but it’s not like every day or every week but from our data, we are able to see that Measles, for example, is coming down or it’s going up. Once we see that it is going up or down we notify the next level. ” (Key informant – LDHMT).
“We used to have what is called the health mapper, [for] GIS… what you should bear in mind is that we do not have a system now that is in a sharp we would have loved it too. But when we had EPI info system, mapping was provided, meaning that you can do (analyse) your data and show it. Even at this (national) level, we were able to analyse and show which district and in which province or which province has a particular disease. If we wanted to particularise to a district we would be able to paint the districts that are affected. If we wanted to show which health facilities within the particular district where the cases were coming from, we were able to show those health facilities.” (Key informant - MoH Headquarters)
Response and control
“…as a province, we have a Rapid Response Team [RRT]. This RRT will first do an on-spot check of the data that was sent. For example, if it is Typhoid Fever or Cholera that has been reported, we will go there as a team to investigate and verify what they [DHMTs] have sent. Then if they is need to support them materially, then we do that. But usually what is there is that we have logistics and supplies that are set aside for such things. So, if they [DHMTs] need any further support from the provincial health office that is, financially or materially then we come in to help.” (Key informant – LPHO).
Feedback
“It is usually when there is something wrong that is when you get that feedback. And also, when you have a meeting and you present your data that is when you will hear some comments on your data. But not immediately that somebody views your data, and gives you feedback. ” (Key Informant DHMT).“[with regard to us] sending data [feedback] to the health facilities we have not been doing that, but we are supposed to do it. But what we do normally is that when we see some strange disease trend from some of our reporting facilities, we call them – we notify them. ” (Key Informant DHMT).
Support functions
Training
“…remember this thing came with donor funding – but what is there now is that where we see gaps we just do an on-site orientation. For example, if we see that a particular DHMT is not doing fine in terms of reporting we do an onsite orientation there and then just to impart knowledge on the IDSR.” (Key informant - LPHO)
Logistical support
…transportation is one of the biggest challenges affecting our work here at the district. If we as a unit can have our own transport instead of relying on pool vehicles [it] would make our work much easier. (Key Informant DHMT)
Supervisory visits, monitoring and evaluation
“Supervisory activities are not done due to funding. For 2015 only one was done [at a provincial level.” (Key informant – LPHO).
Quality attributes
Representativeness of IDSR surveillance data
“Majority of the health institutions that submit the weekly reports are the public health centres. However, we are still struggling to incorporate the private health facilities, we have had meetings with these institutions but for them to send data here they are finding it a problem. But for a few like Lusaka Trust Hospital whenever they have a case that is notifiable, they call, they have my number and we go there and collect information and then we disseminate to the relevant authorities.” (Key Informant – DHMT).
IDSR system stability
“In most cases, there is internet only when they is power, however, we are heavily load-shaded here at the office. Hence, in most of the cases, we have to rely on our own internet mostly through mobile phones … for districts the situation is quite bad. Since most of them depend on their grants to pay for such services as internet connectivity … at the moment, grants are a bit erratic, there isn’t much funding from the central government. Worse even at the centre level, for they just use their own initiative to send these reports”. (Key Informant – LPHO)