Towards a More Evidence-Informed Intervention

By Hafsat Jaafar, Sunday James and Stephanie Okpere

While cost-effective interventions exist, utilization of nutrition services and maternal care remain drastically low.

The roots of poor nutrition and maternal health lie in human behavior. Improvements in nutrition and maternal health outcomes are not possible without broad widespread changes in the everyday behaviors of people and institutions that influence them. There is a significant lack of comprehensive understanding of the various structural and sociocultural issues that pose a challenge in boosting nutritional and maternal status in Nigeria. Exploring the complex network of intrapersonal and community factors influencing the utilization of these services will aid in the development of targeted interventions to support this population.

Stakeholders who attended the KAPs study validation workshop physically

Changing behaviors for nutrition and adolescent health requires a variety of approaches. -The lack of adeptness or understanding contributes to negative nutrition behaviors. People also practice certain behaviors when they believe them. Myths, misinterpretation, cultural practices, and other drawbacks including cost, location, and availability are major quagmires that can stand in the way of change or desired behaviors.

eHA-ANRIN consortium via the Accelerating Nutrition Results in Nigeria (project) in Kaduna state is providing basic nutrition, reproductive and adolescent health counseling services in 12 LGAs in Kaduna state. In addition to this, we are conducting a Knowledge, Attitudes, and Practices ((KAP) study around nutritional behavior and adolescent health amongst women and children under 5 years of age in Kaduna State. This formative study aims to develop a multidisciplinary and comprehensive approach that would positively influence nutritional and birth spacing behavior within our target groups.

The motivation for this approach is to allow for the evaluation of outcomes towards understanding how eHA-ANRIN can increase the utilization of quality, cost-effective nutritional services for the target group. Specifically, these insights will support the development of a behavior change communication strategy as well as the development of information, education, and communication (IEC) materials by the consortium partners.

A group photo of stakeholders after the session in Kaduna State.

Considering that behavior change approaches are essential to foundational cross-cutting change strategies for the achievement of program results. eHAANRiN hopes to use a balanced approach in its programming with supply and demand-side interventions. Efforts will be made to ensure the study is robust: key influencers of nutritional and reproductive health behaviors across the various segments of the state will be part of the study. We will also work very closely with our stakeholders; the Kaduna state government, all the relevant agencies, partners, implementers amongst others in the state to ensure that their insights are also captured. BUSARA, a member of the eHA - ANRIN consortium has strong experience delivering similar studies and currently leads the delivery.

Through this study, the consortium aims to; 

• increase access to nutrition and birth-spacing commodities and tailored counseling for the target population, particularly in hard-to-reach (HTR) areas

• generate demand for commodities and counseling by deploying behavioral science techniques; 

• and integrate a data-led approach to improve the delivery of essential products and services.

In the aftermath, the KAPs study plans to pinpoint the motivation, latitude, and challenges that influence the target group’s behavior, define behavior change objectives, and the mix of intervention and behavior change communication  products and campaigns to help our target group to live a healthy and fulfilled life.

Building Local Capacity and Infrastructure for Disease Surveillance in Africa

By Chinedu Anarado

Nigeria is the only country in Africa where polio is still endemic, however, the continent is still at risk of polio returning due to low immunity levels and weak surveillance systems.  Since 2016, the AVADAR project has been implemented in 8 countries across West and Central Africa to improve the quality and sensitivity of Acute Flaccid Paralysis (AFP) surveillance by health workers and key informants within health facilities and local communities, using mobile phones and an SMS based software application. eHealth Africa trained a total of 7,847 community informants to identify and report suspected cases of AFP, which is the defining symptom of Polio.

The AVADAR mobile application

The project increased the rate of AFP detection and reporting and put the implementing countries in a better position to meet the World Health Organization’s targets for AFP surveillance. In the Democratic Republic of Congo (DRC), for example, a total of 499 true AFP cases have been reported by community informants through AVADAR, a significant improvement over traditional paper-based surveillance systems which yielded 38 cases in the same period.

The Challenge

Our goal was to model a system that would enable health systems in the implementing countries to find, report and investigate AFP cases, and that would be sustainable in the long run. It became imperative for the health systems in these countries to take ownership of and lead the implementation and expansion of the AVADAR model, and possibly replicate it for the surveillance, reporting, and investigation of other diseases of public health concern. However, without the requisite skills, most countries will fail at effectively managing the system including reporting and managing the investigation of cases, and tracking and resolving technical issues.

The Strategy

Relying on our experience with the execution of AVADAR, where some informants were groomed to take on more roles on the project, we worked with the WHO to identify champion informants who had distinguished themselves through their timeliness on the system and technical aptitude with the AVADAR devices. Some of these informants were trained to serve as investigators—who track and review reported AFP cases to confirm if they are true or not—or as technical officers, who resolve technical issues and ensure that their fellow informants are able to continue reporting suspected AFP cases.

The technical officers were grouped into two categories: first-level and second-level technical support officers. The first-level technical officers serve as the first point of contact when an informant has technical challenges with his/her device. When they are unable to resolve these issues, they escalate the challenge to the second-level technical support officers, who are usually WHO staff or investigators within the country ministries of health, with superior technical skills. The second level support officers ensure that all issues are resolved and the AVADAR system can continue to work as expected.

The Success

So far, a total of 217 first level and 57 second-level informants have been trained across all the six countries eHA supported in 2019, as well as Liberia. eHA has now ended operations in four of these six countries— Chad, the Democratic Republic of Congo, Sierra Leone, and South Sudan and the trainees are now managing the network. The technical officers were trained using a two-step approach: theory-based training that took place in a classroom setting, and field practical sessions, giving trainees the opportunity to investigate and resolve real-life technical issues in the field. eHA continues to provide support in Cameroon and Niger, leading refresher training sessions for technical support officers, and resolving advanced technical issues in the two countries.

Some AVADAR informants are also going beyond polio to detect and report other priority diseases such as Measles, Yellow Fever, and Diarrhea in their communities using AVADAR. The flexibility of the AVADAR system and its potential to be used for reporting and detecting other priority diseases leaves no doubt that these countries are better equipped to prevent future outbreaks and protect their populations.

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

Strengthening Routine Immunization using Lessons learned from Polio Emergency Support

By Joshua Ozugbakun & Emerald Awa-Agwu

In July 2016, after over two years of being polio-free, two wild poliovirus cases were discovered in Borno State, Nigeria. This launched fresh efforts to strengthen the four pillars of polio eradication including Routine Immunization (RI), Supplementary immunization activities (SIAs) (including national Immunization Plus Days (IPDs)), Surveillance and targeted mop-up campaigns.

A health worker vaccinates a child with the Oral Polio Vaccine

Partners, both local and international, collaborated with the Nigerian government at state and national level, through various interventions and projects to increase the coverage and effectiveness of IPDs and mop-up campaigns in order to increase herd immunity and stop polio transmission, especially in high-risk states like Adamawa, Borno and Yobe states. These interventions were coordinated by the State Emergency Routine Immunization Coordination Centers (SERICCs). Each SERICC is led by individual state governments and help to improve information sharing, joint programming of public health emergency management activities (planning, implementation, monitoring, and evaluation) with partners. The National Emergency Routine Immunization Coordination Center (NERICC) is responsible for strategy development and oversees the activities of all the SERICCs. With this coordination mechanism in place, the menace of polio is being tackled collaboratively and Nigeria is well underway to being declared ‘Polio Free’, a major milestone in its vaccine-preventable disease management efforts.
A major takeaway for Nigerian polio eradication stakeholders after years of battling polio is the need for data collection, management and storage systems to be upgraded. As the need to halt poliovirus transmission increased, it became increasingly obvious that paper-based data management systems were incapable of providing decision makers with the reliable, actionable data which they needed for effective programming. eHealth Africa responded to this challenge by supporting states across Nigeria to develop comprehensive, digital maps using our expertise in Geographic Information Systems (GIS). The accuracy of these maps improves the microplanning process and guarantees a greater coverage of settlements during campaigns.

Our GIS technology has improved the quality of maps used for polio campaign planning

In addition, through our Vaccinator Tracking Systems (VTS) project, GIS-encoded Android phones are used to record and store passive tracks of vaccinators as they conduct their house-to-house visits; allowing decision-makers to have an accurate picture of the settlements that have been covered during IPDS and mop-up campaigns. This data can easily be accessed through dashboards for a more detailed analysis and breakdown of coverage information.

Supporting polio emergency response activities also highlighted the need for the Nigerian health system to move from an emphasis on SIAs and campaigns to strengthening the RI and disease surveillance systems. Sound routine immunization and disease surveillance systems are necessary to sustain the herd immunity built through polio campaigns.

In Kano state, the LoMIS Stock solution helps the State Primary Health Care Management Board to ensure that the vaccine supply chain is maintained. Health workers at the facility level use the LoMIS Stock application to send reports on a variety of vaccine stock indicators including vaccine utilization, vaccine potency, stock levels, wastage rates, and cold chain equipment status. Supervisors access the reports through the LoMIS Stock dashboard and are able to respond appropriately. This ensures that the RI system is maintained and that health facilities are never out of stock.

In the past, Acute Flaccid Paralysis (AFP) surveillance in health systems across Africa was passive. This meant that disease surveillance and notification officers (DSNOs) only reported or investigated suspected AFP cases that were presented at the health facility. According to the U.S Centers for Disease Control and Prevention (CDC)1, over 72% of polio cases are asymptomatic and as such, will not present at the health facility. In addition, DSNOs are unable to visit every single community to actively search for AFP cases due to logistics and security challenges. Relying on data from passive AFP surveillance causes programs to be designed based on data that excludes the asymptomatic polio cases. Auto-Visual AFP Detection and Reporting (AVADAR) reduces the burden on the DSNOs by enlisting members of the community to actively find AFP cases and report using a mobile application on a weekly basis; thus, providing accurate real-time surveillance data that can be used for program planning and implementation.

An often overlooked factor that promoted the transmission of the poliovirus was the rejection of the polio vaccine by mothers and households due to various myths and socio-cultural barriers. By engaging traditional and religious leaders as ambassadors of vaccination, more mothers and households are accepting the polio virus.

The central lesson in Nigeria’s journey so far towards polio eradication is the importance of collaboration and engagement at all levels including communities. eHealth Africa is proud to be supporting governments and health systems across Africa to respond to the polio emergency.

eHealth Africa renovates Njala University research center with CDC funding

By Sahr Ngaujah

eHealth Africa (eHA) in partnership with U.S. Centers for Disease Control and Prevention (CDC), has renovated the  Njala University research center at Tiwai Island, in a drive to support one-health surveillance activities in Sierra Leone. The project was funded by CDC, with the objective of improving knowledge and infrastructure capacity at Njala University research center to perform routine Ebola and infectious disease surveillance.

Research began on Tiwai Island in the early 1980s, with studies on primates, other mammals, forest dynamics etc. This research was vital for disease and one-health surveillance activities as Sierra Leone, ebola virus disease outbreak was traced to bats and primates. However, over the years, the facility had fallen into disrepair and was unusable. Renovation of the Tiwai Island research center commenced in November 2018. eHA has now completed renovations on the entire campus including storage room; kitchen, meeting areas, and dormitories. The facilities were equipped with solar power, which now provides uninterrupted power on a daily basis, solar powered water supply in order to ensure adequate water supply during the dry season.

“Those who had visited the Tiwai Research Center before now, would agree with me that there is much difference after the renovation. We are happy that this facility is now ready for use. Communities and stakeholders associated with Tiwai are very grateful. This was made possible through funding from the CDC and renovations by eHealth Africa.”

— Dr. Lebbie, Head of Department of Biological Science, Njala University- Head of the Njala Research Center

“CDC has been working with Njala since the Ebola outbreak. CDC has a strong relationship with the Njala team and helping them to have more capacity to do testing to look for viruses, including the Ebola virus that caused the outbreak here. We are looking for other viruses that are in the environment so that we can know more about our environment, learn to live safely with it, and prevent outbreaks from happening. We want to prevent disease outbreaks, and we’re doing that by helping the people of Sierra Leone find those viruses themselves – to study them here so that they don’t rely on outside help. We have seen great success with Njala University and their team doing this work here. CDC is eager to continue to support that effort because we’re so impressed by what’s been done already.”

— Dr. Brigette Gleason, Surveillance and Program Lead CDC Sierra Leone Country Office

These renovated structures go to benefit not only Njala University students and faculty and  Sierra Leone’s Ministry of Health and Sanitation (MoHS), but also international researchers.

“We will be inviting international auditors who will be resident here to do research; and through that, job opportunities would be opened to the community.’”

— Dr Lebbie

The Importance of High-Quality AFP Surveillance Data in the Fight to Eradicate Polio

Polio is targeted for eradication because the presence of the virus anywhere means that children everywhere are at risk. The Global Polio Eradication Initiative (GPEI) focuses on strengthening Acute Flaccid Paralysis (AFP) surveillance worldwide to detect and respond to the poliovirus, to build herd immunity to protect the population and to halt the transmission of the virus. The data on the spread of AFP is invaluable especially for polio-endemic countries like Afghanistan, Pakistan, and Nigeria because it helps in determining whether they can finally be certified polio-free.

There are four steps involved in AFP surveillance and the Auto- Visual AFP Detection and Reporting (AVADAR) project responds to the first step—finding and reporting children with AFP—in eight priority countries in Africa. In many of these countries, disease surveillance and notification officers (DSNOs) at the health facilities are unable to actively find AFP cases for reasons ranging from difficulty in accessing settlements to security challenges. AVADAR trains community informants to search for and report the presence and/or absence of children with AFP in their community, using a mobile application. The application also has an embedded video that shows a child with AFP so that community informants can better recognize an AFP case. This reduces the burden on the DSNOs and allows them to focus on confirming if the case is truly AFP or not.

How AVADAR works

To ensure that AFP surveillance is conducted impactfully and that the AFP surveillance data collected is accurate, timely and of high quality, the GPEI defined five global indicators: Completeness of reporting, Completeness of case investigation, Completeness of follow-up, Sensitivity of surveillance and Laboratory performance.

Global Polio Eradication Initiative: AFP Surveillance indicators

AVADAR was designed by eHealth Africa, Novel-T, the World Health Organization (WHO) and other partners, to contribute to the achievement of the above targets. Below are the measures that have been put in place to ensure the collection and use of high-quality data to track and reports suspected AFP cases, and to inform decision making for polio eradication.

• Coverage: To decide where to site an AVADAR system, WHO carries out an assessment of the target country/districts to identify rural, hard-to-reach and underserved communities which are typically more predisposed to poliomyelitis. The AVADAR system, equipped with geospatial tracking capabilities is then deployed to community informants/ AFP reporters. This unique feature of the application helps to validate the location of the suspected AFP case, independent of the reporter.  

• Reporting: The AVADAR application allows informants to deliver reports anywhere and anytime in order to prevent data loss and to ensure near real-time, accurate reporting.  The app is designed to be used by people with basic literacy levels and is available in eighteen local African languages for ease of understanding. A report is better able to provide insight and enhance planning or decision making when it is timely. One of the key weekly metrics captured on the AVADAR dashboard is the number of complete results that were submitted as at when due, thus ensuring that all informants are actively engaged. Informants are expected to look out for and report cases of children aged 15 years and below, who have any form of physical deformity on the limbs or arms. In the event that no AFP case has been sighted within a week, the informant must send a ‘no report’, to validate his presence on the system.  

  AVADAR has improved the rate of AFP reporting compared to the traditional system of AFP reporting. For example, between June 2017 and June 2018 in the Lake Chad Basin countries(Chad, Niger, Nigeria, and Cameroon), the AVADAR system recorded 589 supsected cases against the 213 cases recorded by the traditional AFP Surveillance system.

• Verification: Paralysis in children can be caused by several agents including the Poliovirus. After the community informants submit their reports of suspected AFP cases, trained health workers carry out further investigations to confirm if they are true AFP cases. The WHO has designated laboratories all over target countries that are certified to test fecal samples and isolate the poliovirus. AVADAR weekly reports show how many suspected AFP cases were reported, how many were tested and the number of cases confirmed to be true AFP cases. This sort of data measures the cost of a single confirmed AFP case, the prevalence and incidence of AFP in target areas, thus enhancing the quality of AFP surveillance data for decision making.

AVADAR dashboard

Having data on the spread of AFP in a geographic location helps with planning towards its containment. Since Poliomyelitis is mainly oral-fecally transmitted, sanitization and sensitization of the environment and inhabitants respectively can help reduce the spread of polio.  AFP data gathered across different locations has been used in making an informed decision on determining the number of health workers that can effectively manage its spread to neighboring communities. On the contrary, no data or false data could lead to health workers focusing their energy in wrong locations thereby risking the spread of polio and the extension of its existence.

Without reliable and accurate AFP surveillance data, true progress towards polio eradication cannot be measured. AVADAR’s impact in high-risk countries across Africa demonstrates how context-appropriate interventions and solutions can transform disease surveillance and emergency management systems.

“One of the most important features of the AVADAR system is the engagement of over a hundred community informants per county. They are trained and equipped for the first time to provide timely reports that can be accessed at all levels from the county to the national level and beyond, thereby allowing suspected cases to be investigated in an accurate and efficient way.”

— Dr Sylvester Maleghemi, WHO Polio Eradication Initiative Team Lead, South Sudan

Increasing Sierra Leone's efficiency in disease detection with eIDSR

By Sahr Ngaujah

In a continued effort to increase the capacity of  Sierra Leone’s health systems, eHealth Africa (eHA) has partnered with the U.S. Centers for Disease Control and Prevention (CDC)  to support the government of Sierra Leone by increasing the early detection and reporting of government-identified priority diseases using the Electronic Integrated Disease Surveillance Response (eIDSR) framework.

eHA developed a mobile electronic Integrated Disease Surveillance and Response (eIDSR) application in response to requirements stipulated by the Sierra Leone Ministry of Health and Sanitation (MoHS).  This eIDSR app enables the MoHS Surveillance system to accurately record and share health facility-level information from the district to the national level. From health workers in hard-to-reach rural areas up to health officials in the major urban centers, eIDSR connects the health system to generate a clear and accurate picture of the health landscape.

In the first quarter of 2018, eHA introduced two new features to the eIDSR app; data approval and sms compression. These new features align with  Joint External Evaluation (JEE) as stipulated by the International Health Regulations (2005).) Since June 2007, countries—including Sierra Leone, have been making efforts to strengthen their core capacities.

Prior to  the introduction of the electronic data processing system, Sierra Leone’s Integrated Disease Surveillance and Response (IDSR) system relied on a paper based process  where the disease surveillance data summary was compiled in a spreadsheet and then mailed to appropriate authority every Monday. This manual system helped to monitor diseases in Sierra Leone. However the time constraints reduced efficiency. The paper-based method was also prone to human error, resulting in questionable credibility and completeness of information.

“Before the introduction of eIDSR, most National health information from the Primary Health Care Unit were written hard copy. It took a lot of time for data staff to capture written hard copy data into the soft health management system. Data processing with the paper based system was time consuming and error prone. Transitioning to eIDSR would improve the quality and timeliness of health information.”

— Dr. Tom Sesay, District Medical Officer (DMO), Port Loko - Northern Sierra Leone

One new feature  implemented in the eIDSR app is data approval. In the past, health care workers who were responsible for submitting necessary reports and data would enter the data  and there was no opportunity for superiors 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.

The new data approval feature now prompts the district staff to review and validate all data received from the health facilities before it is seen by other users. eHA also provides daily monitoring of the approval process and quickly resolves any challenges that may arise.

With this new feature in place and the support provided,  the quality of data used for disease surveillance is improved significantly and human errors are minimized.

Training health care workers on the new features in the eIDSR app in Freetown, Sierra Leone

One of the biggest challenges experienced during the roll out of eIDSR was internet connectivity. There are many  facilities that do not have internet access to upload their data on site. The initial solution to that challenge was to provide an alternative for the facilities to upload their data into the national server; that alternative was using Short Message Service (sms)  to submit their data.

In the first version of the eIDSR application, seven (7) SMSs were required to upload the eIDSR weekly reporting form by SMS. With this sms compression upgrade the number is now reduced to one.  The introduction of SMS compression has resulted in facility staff saving time needed to find locations in the community where they can have internet access or strong network connection for 7 SMS submissions. It also cuts down on costs as less SMSs are needed to complete the upload into the national server. Through the sms compression, health facility staff are not  likely to leave their facilities to upload their data. The few that might have to leave will not likely have to walk long distances to have their data uploaded.

“eIDSR has built the capacities of our health workers most of whom had little experience in the use of smartphones. eIDSR has contributed to improving our interaction with our facility staff.”

— Albert Kamara, District Surveillance Officer, Port Loko

eHA has now trained 142 health care workers at the Western Area Urban  District Health Management Team (DHMT) in Freetown, Sierra Leone. This training of trainers session was aimed at cascading the new upgrade to other health workers. These two new features in the eIDSR application are adding immediate value to Sierra Leone’s health systems, by simply automating work.These are best practices for future generations to uphold and retain.