Going digital improves Disease Surveillance in Sierra Leone

By Sahr Ngaujah and Nelson Clemens

According to WHO, Sierra Leone is the first country in the Africa region to fully transform its national disease surveillance system from a paper-based system to a  web-based electronic platform. This is due to the introduction of the electronic Integrated Disease Surveillance and Response solution.

Sierra Leone was one of the hardest-hit countries during the 2014 EVD outbreak in West Africa. The country’s poor disease surveillance infrastructure highlighted the need for a robust disease surveillance mechanism. Introducing an electronic method for disease surveillance reporting became one identified remedy for improving disease surveillance in a country that was still trying to catch up with the rest of the world in terms of digital technology. 

Paper-based health data recording and reporting from across Sierra Leone’s 1300 health facilities became increasingly inadequate and inaccurate and was also characterized by late reporting, incomplete district-level reports, multiple data entry errors, and difficulty storing and retrieving data.

With an expertise in health informatics, eHealth Africa (eHA) designed the electronic Integrated Disease Surveillance and Response (eIDSR) solution and has been implementing the solution in collaboration with Sierra Leone’s Ministry of Health and Sanitation (MoHS), the U.S. Centers for Disease Control and Prevention (CDC), the World Health Organization, Focus 1000, and GIZ since 2016, with  the objective to enhance disease prevention and control through the digital capture and submission of data on epidemiologically-important diseases. The eIDSR project was funded by the CDC. 

eHA customized an open source health information tool from DHIS2 for the purpose-built digital data collection and reporting. The eIDSR tool is integrated into the national health system through its compatibility with the health information systemDHIS2, which is used in over 45 countries, especially those with vulnerable health systems like Sierra Leone. eHA developed the web form and custom mobile application, piloted both, and created a Short Message Service (SMS) submission solution for health workers to submit their weekly surveillance reports in locations where internet access is weak.

Nwanyibuife Obiako, Senior Programs Manager, eHA Sierra Leone, making a statement during the eIDSR rollout closing ceremony

As of June 2019, 2758 health care workers at the health facility and district level were trained by eHA on the use of eIDSR across Sierra Leone. These health care workers now monitor 26 disease categories digitally. Digitizing health-related data has yielded positive outcomes in Sierra Leone. eHA has supported the rollout of eIDSR to all 14 administrative districts in Sierra Leone and a ceremony was held on June 6th in Tonkolili district, with participants from the MoHS and other implementing partners, to celebrate the milestone achieved.

“Thanks to eIDSR, we have seen an improvement of multiple surveillance indicators, such as reporting completeness and timeliness. It’s evident that a critical part of this success is partnership and collaboration.”

— Nwanyibuife Obiako, Senior Programs Manager, eHA Sierra Leone

Nelson Clemens, eHA’s eIDSR Project Coordinator presenting during the eIDSR rollout closing event

The eIDSR system has also enhanced:

•  Reduced data entry errors

•  Reporting completeness, timeliness, and efficiency

Reducing data entry error

Optimal data management and quality are crucial to the delivery of high-quality healthcare services. Accurate data is essential to informed decision making and appropriate public health action. In the past, when health care workers submitted their reports, there was no opportunity for their superiors to perform data quality assurance. This sometimes resulted in erroneous data being sent to the national level, reducing the quality of data used for disease surveillance in Sierra Leone. With eIDSR, digital data is now managed in an efficient manner at District and National levels and made available to all relevant parties in the quickest way possible.

“The electronic system has reduced the number of data entry errors in half, and is capturing and verifying data 60% faster than the paper-based IDSR system.”

— CDC

Reporting completeness, timeliness, and efficiency 

The eIDSR tool was created to improve the speed of the flow of information within health systems. Through the electronic Integrated Disease Surveillance Response (eIDSR) solution, disease prevention, and control is enhanced through timely electronic capture and submission of data on epidemiologically-important diseases as data can now be submitted, reviewed and acted upon near real-time.

“...My colleague Surveillance Officers would agree with me that eIDSR has relieved our stress. eIDSR roll-out commenced in the Kambia district in November 2018. A week following the roll-out, we achieved 98% of timeliness of reporting and has not gone below 90% since.”

— Usman Barrie, District Surveillance Officer, MoHS, Kambia district.

Disease surveillance plays an important role in disease prevention, control and elimination. 

eHA continues to work with its partners to ensure eIDSR is sustainable in Sierra Leone.

Modelling Disease Surveillance Systems that work in Chad and Niger

By Tope Falodun and Emerald Awa-Agwu

Participants in Maradi, Niger after the training

Functional disease surveillance systems provide data that can be analyzed to yield insight for planning, project execution, monitoring, and evaluation of public health interventions. For a priority disease like Polio, surveillance systems are important because they monitor the burden of the disease and alert health systems of any increase in the occurrence of the disease in any location of implementation, ahead of time.

A key element that is often missing in disease surveillance systems is intersectoral action. In the past, the responsibility of finding, investigating, reporting and monitoring AFP cases rested solely on the disease surveillance officers (DSOs). This resulted in incomplete data because the DSOs could not cover every single community, and also manual errors as DSOs had to enter reports using paper-based tools.  Recognizing this, eHealth Africa (eHA) partnered with the World Health Organization (WHO), Novel-T, the Bill & Melinda Gates Foundation (BMGF) and the Ministries of Health in eight countries including Chad and Niger to develop the Auto- Visual AFP Detection and Reporting (AVADAR) system for improving AFP case identification and reporting. The goal of the project was to support health systems in polio-endemic and high-risk countries to find, report and investigate AFP cases using available, context-appropriate resources, in this case, community members. 

By partnering with local communities and enlisting members to serve as informants and investigators, some of the pressure on disease surveillance officers who performed all three functions of finding, investigating, reporting and monitoring suspected AFP cases were relieved. In addition, AVADAR infused digital data management and reporting innovations through the mobile application. With this, community informants report cases of suspected AFP via the AVADAR  mobile application. The investigators receive alerts of these reports on their mobile devices, locate the cases, investigate and collect stool samples for further laboratory tests in cases of true AFPs.  

In 2017, AVADAR was launched in 6 pilot districts in Chad and three pilot districts in Niger. By 2018, the project expanded to an additional three districts in both Chad and Niger. In total, eHA trained 849 and 509 community informants in Chad and Niger respectively. eHA also supported the training of 177 investigators by the WHO in Chad and 178 investigators in Niger. Within these periods, eHA supervised the activities of the informants, investigators, and technical officers, and also resolved technical issues relating to the mobile application, telecommunication, and network access on Android phones.

Chad 1st level supports going through pre-test during the transition training in Bokoro, Chad

“AVADAR has had a great impact on AFP surveillance, directly and disease surveillance as a whole by improving communication and information transfer.”

— Mbaielde Felix, Head of Abirebi Health Area, Bokoro District, Chad

After almost three years of supporting the health systems in Chad and Niger through AVADAR, it was evident that the model worked. eHA successfully handed over the continuation of the project in the pilot districts to the Ministries of Health and the World Health Organization in Chad and Niger. A total of 109 first and second line technical support officers in the two countries, were trained to continue to handle and resolve any technical issues that may arise. 

At eHA, we support health systems to effectively monitor and eradicate communicable diseases like polio by developing and supporting the development of creative surveillance methods and innovative data management solutions.

“AVADAR has allowed us to communicate with the informants, the district management team and the health delegation on the report of other diseases other than the AFP.”

— Abakar Mahamat Kalbassou, Head of Abgode Health Area, Bokoro District, Chad

Expanding Cornbot to fight food insecurity

Chinedu Anarodo and Cornelius Adewale at the award ceremony

Last year, eHealth Africa’s CornBot Application was one of the finalists for the Fall Army Worm Tech Prize. The application received the Frontier Innovation Award for its ease of use and human-centric design. CornBot also received $50,000 in prize money. Six months later, CornBot’s, Chinedu Anarado and Cornelius Adewale share their progress and how they are using the prize money to expand CornBot so that the solution addresses more challenges in nutrition and food security.

Why did you develop CornBot?

One of eHA’s focus areas is Nutrition and Food Security Systems. Our goal with this program is to provide nutrition stakeholders at all levels of the value chain, with technological tools and data so that vulnerable populations in West Africa can have access to nutritious food.

When USAID called for innovations to address Fall Armyworm (FAW), a major pest that destroys various crops worth $2.4bn – $6bn annually, predisposing communities to food insecurity, we knew we had to respond. We partnered with the Washington State University (WSU) to design and build CornBot, a mobile application, that interacts with farmers in their local dialect and guides them through the process of detecting, preventing and treating FAW infestation on their farms. The application is synced to a dashboard to enable us and other stakeholders to easily aggregate data on FAW infestation and make informed decisions.

What scenario mapped the transition from CornBot to FMT?

After we received the Frontier Innovation Award and the prize money, we started thinking about what we could do to expand CornBot. During the field testing phase as well as during other field research carried out by WSU, we realized that smallholder farmers needed more than just a pest detection tool—they needed a platform where they could exchange and receive guidance and knowledge to increase their productivity. We then decided to invest the prize money in building a platform where farmers can gain additional information to enable them to yield as much as possible from their farms, in line with the Good Agricultural Practices (GAP) put forward by the Food and Agriculture Organization (FAO). So, CornBot went from an idea that helps in combating farm pests, to a platform for providing guidance on farming practices as a whole. For now, we call it the Farm Management Tool.

What do you hope to accomplish with the Farm Management Tool?

Farmers in Kano using Cornbot to identify FallArmy Worm

Overall, we want to improve the quality of livelihood among smallholder farmers and strengthen the resilience of communities against food insecurity. We know that by making small changes in their farming processes and decisions, and by adopting good agricultural practices, farmers can increase the crop yield from the same plot of land. They just do not know how to. Many of these farmers have been doing things the same way for years without ever knowing why. Our goal is to arm them with relevant information and ensure that they can produce more crops. If we can achieve this, it will be a huge success and it means that our solution is viable.  

What first steps have you taken?

We are currently working to build a mobile application. However, we held a workshop with 40 smallholder farmers in April to glean baseline data about their current agricultural practices, their level of knowledge, and current challenges, and to introduce them to our project and the concept of good agricultural practices. They have agreed to work with us for the pilot scheme and testing, as well as map out portions of their farmlands to test our concepts. We have also commenced field operations such as soil sample testing to understand the existing soil composition and what kinds of fertilizers will be needed.

The idea is to “hand-hold” the farmers throughout the planting season and see if there are significant differences from their previous outputs.

We are very excited about this platform and the possibilities that it presents for addressing food insecurity in communities across West Africa.

How eHealth Africa supports Universal Health Coverage across Africa

By Emerald Awa- Agwu

April 7 is World Health Day and this year, the World Health Organization (WHO) is focusing on Universal Health Coverage (UHC).

WHO: Universal Health Coverage - What does it mean?

Good health is crucial for developing economies and reducing poverty. Governments and decision-makers need to strengthen health systems so that people can get the healthcare and services that they need to maintain and improve their health, and stay productive.  However, improving access to health services is incomplete if people plunge further into poverty because of the cost of health care. WHO estimates that over 800 million people spend at least 10% of their household budget on health care which is indicative of catastrophic health expenditure (CHE).  CHE can mean that households have to cut down on or forfeit necessities such as food and clothing, education for their children or even sell household goods.

One of the targets of Sustainable Development Goal 3—Ensure healthy lives and promote wellbeing for all at all ages— is to achieve universal health coverage by 2030. Therefore, achieving UHC has become a major goal for health system reforms in many countries, especially in Africa.

Through our projects and solutions, eHealth Africa supports countries across Africa to strengthen the six pillars of universal health coverage.

1. Health Financing for Universal Health Coverage

WHO recommends that no less than 15% of national budgets should be allocated to health. We believe that accurate and up to date data, can ensure that available health funds are better allocated. In Nigeria,  we worked with several partners to map and collect geospatial data through the Geo-Referenced Infrastructure and Demographic Data for Development (GRID3) program. Data relating to over 22 points of interest categories including health facilities, was collected across 25 states and the Federal Capital Territory in Nigeria. This data helps decision-makers to distribute resources and plan interventions that target the people who need it most.

2. Essential Medicines and Health products

Vaccines are some of the most essential health commodities

Countries decide what medicines and health commodities are essential based on the illnesses suffered by the majority or significant sections of their population. They must also ensure that quality, safe and effective medicines, vaccines, diagnostics, and other medical devices are readily available and affordable.

When essential medicines and health products are procured, it is important to maintain proper records and to ensure that health facilities do not run out of stock. eHealth Africa created Logistics Management Information System (LoMIS), a suite of mobile and web applications, LoMIS Stock and LoMIS Deliver that address challenges in the supply of essential medicines and health products such as vaccines and drugs. In Kano State, health workers at the facility level use the LoMIS Stock mobile application to send weekly reports on the vaccine stock levels, essential drug stock levels and the status of cold chain equipment. Supervisors can view the reports in near real-time through the LoMIS Stock Dashboard and plan deliveries of medicines and health products to prevent stockouts of vaccines and essential drugs, using LoMIS Deliver. LoMIS Deliver reduces errors by automating the process of ledger entry to capture the number of vaccines on-hand at the facility and the quantity delivered.

3. Health systems governance

Health system governance according to the WHO is governance undertaken with the aim of protecting and promoting the health of the people. It involves ensuring that a strategic policy framework exists and providing oversight to ensure its implementation. Relevant policies, regulations, and laws must be put in place to ensure accountability across the health system as a whole (public and private health sector actors alike).  Effective health systems governance can only be achieved with the collaboration of stakeholders and partners who will support the government by providing reliable information to inform policy formulation and amendments. Over the years, we have worked with several partners to provide this support.

4. Health workforce

Health systems can only deliver care through the health workforce

The attainment of UHC is dependent on the availability, accessibility, acceptability, and quality of health workers1. They must not only be equitably distributed and accessible by the population, but they must also possess the required knowledge and skills to deliver quality health care that marries contextual appropriateness with best practices.

Recognizing this, eHA supports the Kano State Primary Health Care Management Board (KSPHCMB) to improve health service delivery by providing health workers in Kano State with access to texts, audio courses, and training modules through an eLearning solution. Through the eLearning web and mobile-enabled platform, health workers can gain useful skills and knowledge on a wide range of topics. Read about the pilot of the eLearning solution here.

In Sierra Leone, we work with the Ministry of Health and Sanitation (MoHS), U.S. Centers for Disease Control and Prevention (CDC) and the African Field Epidemiology Network (AFENET) to implement the Field Epidemiology Training Program (FETP). Through FETP, public health workers at the district and national level gain knowledge about important epidemiological principles and are equipped with skills in case/ outbreak investigations, data analysis, and surveillance. This positions Sierra Leone to meet the Global Health Security Agenda target of having 1 epidemiologist per 200,000 population. In addition, we support Sierra Leone’s MoHS to build additional capacity in frontline Community Health Officers (CHOs), who are based at the Chiefdom level through the management and leadership training program. CHOs are often the first point of contact for primary care for the local population and the MLTP program equips them to provide better health services and improve health outcomes at their facilities.

5. Health Statistics and Information Systems

In line with our strategy, we create tools and solutions that help health systems across Africa to curate and exchange data and information for informed decision making and future planning.  The Electronic Integrated Disease Surveillance and Response (eIDSR) solution has been used in Sierra Leone and Liberia to transform data collection, reporting, analysis, and storage for a more efficient response and surveillance of priority diseases. Its integration with DHIS2, a health information system used in over 45 countries, makes it easy for health system decision makers to visualize data and gain insight into the state of public health. Read more about our other solutions Aether and VaxTrac. In addition, we also support the Nigeria Center for Disease Control and Prevention (NCDC) by creation and maintenance of a data portal which serves as a repository for all datasets that are relevant to detecting, responding and preventing disease outbreaks in Nigeria.

6. Service delivery and safety

Staff at the Kano Lab

The Service delivery and safety pillar encompasses a large spectrum of issues including patient safety and risk management, quality systems and control, Infection prevention and control, and innovations in service delivery. With our experience working to respond to polio and ebola virus emergencies across Africa, we support health systems to mount prevention and control programs at the national and facility level. We are also committed to creating new technologies and solutions that can help health providers to develop better models of healthcare. We also construct health facilities ranging from clinics to laboratory and diagnostic facilities that utilize state of the art technology to correctly diagnose diseases such as Sickle Cell Disease, Meningitis, and Malaria.

Our Sokoto Meningitis Lab has been at the forefront of meningitis testing and surveillance in Northern Nigeria, offering reliable and prompt diagnoses to support the prevention of future outbreaks.

eHealth Africa continues to work with governments, communities and health workers so that everyone can obtain the quality health care, in a prompt manner and from health workers and facilities within their communities, thus achieving universal health coverage.

eHealth Africa supports Sierra Leone’s Public Health Services for better response to public health emergencies

By Uche Ajene

The first-documented most widespread and deadly outbreak of the Ebola Virus Disease (EVD) in West Africa devastated three countries: Guinea, Liberia, and Sierra Leone. The outbreak started in May 2014 and by November 2014, during the height of the outbreak, Sierra Leone recorded over 500 new cases of Ebola a week. By October 2015, a total of 8,704 EVD cases had been diagnosed, and 3,589 people had died of Ebola in Sierra Leone.

This disease caught the country’s Ministry of Health and Sanitation (MoHS) by surprise. The outbreak could not be effectively managed because the country did not have the requisite capacity (structure and staff) and systems -Standard Operating Procedures (SOPs), policies and plans, to effectively manage and mitigate the risks posed by the disease.

Ebola’s destruction on the peoples of Sierra Leone and the absence of appropriate structures to deal with future outbreaks, prompted the establishment of Public Health National Emergency Operations Center (PHNEOC) in  June 2015, as a coordination structure charged with the responsibility of providing public health emergency preparedness leadership, scientific and technical situational awareness and advice at a national level.

As Sierra Leoneans reflect on the atrocities of Ebola and other emergencies, this question becomes inevitable: Is Sierra Leone better prepared to address any future public health emergencies?

To better prepare for future outbreaks, the U.S. Centers for Disease Control and Prevention (CDC), in collaboration with the Ministry of Health and Sanitation and eHealth Africa, conducted successful trainings for health workers and other stakeholders on Public Health Emergency Management, Risk Communication,Threat and Hazard Identification and Risk Assessment (THIRA), Incident Management Systems and Public Health Operations and Management. These training sessions were done in Bo, Bombali districts and Western Area Urban with the involvement of health workers, district councillors, the national security agency and members of the agricultural sector. These trainings are geared towards improving the PHNEOC’s capacity to better prepare for health-related emergencies.

The PHNEOC/MoHS as beneficiaries have acquired increased knowledge on the method of approach in risk mitigation, analysis, preparedness, response, and recovery. For instance, EOC Focal Persons have been trained in all districts in Sierra Leone to decentralize command and control approach which has provided the necessary pace, efficiency, and structure for response efforts and foster real-time reporting and bridged the gap in communication from the districts EOC’s to the national EOC. eHA, with support from CDC, has embarked on introducing tools that seek to improve the coordination strategy of the PHNEOC such as the Virtual  Emergency Operations Center (EOC) communication platform tool. eHA has partnered with MoHS with support from CDC to train about 200 PHNEOC/MoHS staff on various public health emergency topics such as tabletop simulation exercises on Cholera and Lassa Fever; Executive Management training and Virtual EOC training.

“I have participated in several trainings, I must confess that knowledge gained in this training is exceptional and can contribute meaningfully in any future outbreak and also benefit my District Health Management Team (DHMT) with management skills.”

— Sahr Amara Moiba

Virtual EOC training participants

Sahr Amara Moiba, District Surveillance Officer and EOC focal person in Kono district, is one of the 200 beneficiaries of the EMP training.

In 2018, there was a Measles outbreak in Pujehun and Kambia district. The EOC focal persons in these districts sent in a daily situational report to the national EOC which was presented to partners during the daily briefing meetings held at the EOC.

As part of the effort to strengthen the PHNEOC preparedness and response capacity, and also improve on the country’s Joint External Evaluation scores, eHA in collaboration with MoHS with support from CDC, developed SOPs for public health response. These SOPs will help improve on the response strategy of the PHNEOC in a coordinated way.

“These SOPs will help foster a coordinated response in an event of any public health emergency.”

— Mukeh Fambulleh, Program Manager of the PHNEOC

eHealth Africa supports data collection on the prevalence of Hepatitis B in three districts in Sierra Leone

By Uche Ajene

eHealth Africa (eHA) is supporting data collection on the prevalence of Hepatitis B in the Bo and Bombali districts, and Western Urban area in Sierra Leone, through its Hepatitis B Sero Survey project. U.S. Centers for Disease Control and Prevention (CDC) is funding this project.

A Sero Survey is a test of blood serum from a group of individuals to determine seroprevalence.

The African Regional Committee of the World Health Organization in 2014, endorsed a resolution to reduce chronic Hepatitis B virus (HBV) infection prevalence to <2% in children less than 5 years of age in all member states by 2020. In Sierra Leone, there is no accurate data on Hepatitis B Virus (HBV) infection among children and women of childbearing age. Hence the need for a survey to determine the prevalence of HBV infection among infants, children and women of childbearing age in order to inform the HBV vaccination policy of Sierra Leone.

In 2007, the country introduced the Hepatitis B vaccine as a component of the pentavalent vaccine provided at 6, 10 and 14 weeks of age. However, a birth dose of Hepatitis B vaccine recommended by WHO to prevent mother - to - child HBV transmission is not yet included in the routine immunization schedule.

The Hepatitis B community serosurvey conducted in the 3 districts, targeted some 2,544 infants aged 4- 24 months and their biological mothers to evaluate the risk of mother to child transmission and subsequent need for a Hepatitis B vaccine birth dose; and also 2,332 children aged 5- 9 years to assess the impact of childhood pentavalent vaccine on the prevalence of Hepatitis B virus infection among children.

Prior to collecting data, a five- day classroom and practical field training was conducted to:

• build the knowledge of the surveyors

• identify households

• counsel families ahead of the survey

• conduct a rapid diagnostic test on Hepatitis B and  the processing and tracking of venous blood specimen

As part of the training, a practical field exercise was also conducted to pretest participants’ knowledge on the classroom training.

eHA is a technology-driven organization. In a drive to discourage potential errors via paper-based methods and to present an automated approach to health data collection, eHA also trained supervisors and phlebotomists on the use of the Open Data Kit (ODK) tool. eHA provided the phones and data for the survey and installed the ODK  app (which is used for data collection in the field), the age= app for age calculation, and the  ODK dashboard. With ODK, data collection is done easily, and survey activities monitored in near real time.

A total of 3,934 forms were submitted via the ODK tool of which 3,158 (80%) of households visited were willing to participate in the survey. Out of the 2,232 households selected for children aged 2 months - 24 months, 1,704 children were enrolled which is 76% and 1,604 biological mothers of these children were also enrolled.

For the 5-9 year-olds, out of the 2,250 households selected, 80% participated with 1,811 enrolled. For children with vaccination cards, 1,186 were enrolled and 401 for the 5- 9 year- olds. A total of 551 serum samples were collected during the 6-week community serosurvey.  

eHA continues to work with the CDC and other partners with a view to increasing the early detection and reporting of government-identified priority diseases, especially when very little is known about HBV prevalence in Sierra Leone.

eHA supports skill building of Sierra Leone’s Community Health Officers

By Sibongile Chikombore and Uche Ajene

The Ebola Virus Disease (EVD) exposed the need for increasing human resource capacity in  Sierra Leone’s fragile health system. Prior to the launch of the Community Health Officers Management and Leadership Training Program (CHO-MLTP) in 2016, there was no formal training of that nature for health professionals in the country. The U.S. Centers for Disease Control and Prevention (CDC) collaborated with the Ministry of Health and Sanitation (MOHS), Njala University, Emory University, ICAP of Columbia University, and eHealth Africa (eHA) to develop a novel training program to address this need and ultimately improve health service delivery and health outcomes in Sierra Leone. CHOs working at Community Health Centers (CHCs) were targeted to be the first cadre to receive this public health management and leadership training, given their key role as first-line health service providers and chiefdom leaders.

The aim of the MLTP is to emphasize public health systems thinking and basic management principles needed to run effective health facilities and outreach services. The emphasis of the project is also to strengthen interpersonal communication and engagement with community leaders in order to develop practical and sustainable solutions to longstanding public health challenges.

In Sierra Leone, the Peripheral Health Units (PHU) comprise of  Community Health Centres (CHCs), Community Health Posts (CHPs) and Maternal and Child Health Post (MCHPs). CHCs are headed by a Community Health Officer (CHO). The CHC is usually located at chiefdom headquarter level and provides services to a population ranging from 5,000-10,000 people. The CHP and MCHP are both usually located at smaller villages serving about 5000 or fewer people. They are manned by Community Health Assistants (CHAs) or Dispensers and Maternal and Child Health Aides (MCH-Aides) respectively.

CHO functions at the health center largely include administrative and clinical duties. The clinical responsibilities include treatment and appropriate referrals of medical, surgical and obstetric emergencies. They also supervise the activities of other PHUs in the chiefdom and report to the District Health Management Team (DHMT).

A total of ninety-nine (99) out of one hundred and seventy (170) CHOs across eight (8) districts (Bo, Kambia, Koinadugu, Bombali, Kenema, Kailahun, Western Area Urban and Rural) have been trained so far out of 12 targeted districts nationwide. The CHOs are trained in cohorts, comprised of CHOs from two districts.

As part of the effort towards sustainability and smooth transitioning of the CHO MLTP, selected staff from MOHS and Njala University are being trained as Trainers. Saidu Mansaray, CHO at Kroobay Community Health Center, is one of 99 CHOs who has been trained by eHA through the CHO-MLTP and was subsequently nominated to be part of the key individuals to form the Ministry of Health and Sanitation (MoHS), Training of Trainers (TOT) team. eHA conducted three TOT sessions for MOHS and Njala University staff who are the key MLTP implementing partners in Sierra Leone.

“I was part of the third cohort studies for the Sierra Leone CHO-MLTP. I was fortunate to be announced as one of the outstanding candidates in the CHO-MLTP Program.’”

— Saidu Mansaray

The CHO MLTP has eleven (11) modules covered over a six-month period, with one of the key modules on Quality Improvement (QI). Before a CHO is eligible to graduate, he/she is expected to implement a QI project on either Improving Human Immunodeficiency Virus (HIV) or Hypertension Screening at their respective health facilities over a three month (minimum) period. The QI aims to address gaps or challenges in health service delivery at facility level on HIV or Hypertension during the MLTP, but the knowledge gained can be later used to apply the QI principles on other health challenges at the facility.

Through implementation of the QI, the CHO and PHU staff are able to work together as a team to brainstorm root causes of the health challenge being faced at the  facility, come up with interventions, and prioritize interventions (based on ease of implementation and how important they are on a scale of one to five). From the prioritization matrix, the QI team from each facility then implements the interventions (also known as “change ideas”) within their own capacity, using the limited resources available.

Saidu implemented an HIV screening QI project at his health facility, where HIV testing rates were low. Prior to the implementation of the QI project, only 26% of eligible persons over 15 years old were tested for HIV. Saidu recognized that increased HIV testing would be necessary to ensure that members of his community know their HIV status and could receive appropriate care. Since the implementation of the QI project at his health facility, the HIV testing rate of eligible persons over 15 years has increased to 81%, and patients found to be positive have also started receiving HIV management care.

“This training has further helped me to manage both logistics and human resources at the facility. I am now able to use the little resources I have in my facility to produce the best of results.”

— Saidu Mansaray

Saidu was also nominated to be a TOT participant after showcasing good leadership skills during his MLTP training in cohort three, has attended 3 TOT sessions organized by eHA. In December 2018, Saidu and other CHOs participated in the 3rd ToT session and was captured actively participating during the TOT workshop facilitating and presenting group work assignments to colleagues - see pictures attached below. After the TOT, Saidu and other TOT participants are expected to mentor other CHOs undergoing the MLTP nationwide.

“I am also currently being trained to pass on the skills learned from the CHO-MLTP Program to others.”

— Saidu Mansaray