Strengthening multisectoral coordination on antimicrobial resistance: a landscape analysis of efforts in 11 countries

Background Increasingly, there has been recognition that siloed approaches focusing mainly on human health are ineffective for global antimicrobial resistance (AMR) containment efforts. The inherent complexities of AMR containment warrant a coordinated multisectoral approach. However, how to institutionalize a country’s multisectoral coordination across sectors and between departments used to working in silos is an ongoing challenge. This paper describes the technical approach used by a donor-funded program to strengthen multisectoral coordination on AMR in 11 countries as part of their efforts to advance the objectives of the Global Health Security Agenda and discusses some of the challenges and lessons learned. Methods The program conducted a rapid situational analysis of the Global Health Security Agenda and AMR landscape in each country and worked with the governments to identify the gaps, priorities, and potential activities in multisectoral coordination on AMR. Using the World Health Organization (WHO) Joint External Evaluation tool and the WHO Benchmarks for International Health Regulations (2005) Capacities as principal guidance, we worked with countries to achieve key milestones in enhancing effective multisectoral coordination on AMR. Results The program’s interventions led to the achievement of key benchmarks recommended actions, including the finalization of national action plans on AMR and tools to guide their implementation; strengthening the leadership, governance, and oversight capabilities of multisectoral governance structures; establishing and improving the functions of technical working groups on infection prevention and control and antimicrobial stewardship; and coordinating AMR activities within and across sectors. Conclusion A lot of learning still needs to be done to identify best practices for building mutual trust and adequately balancing the priorities of individual ministries with cross-cutting issues. Nevertheless, this paper provides some practical ideas for countries and implementing partners seeking to improve multisectoral coordination on AMR. It also demonstrates that the WHO benchmark actions, although not intended as an exhaustive list of recommendations, provide adequate guidance for increasing countries’ capacity for effective multisectoral coordination on AMR in a standardized manner.

An evaluation of the global health security agenda steering group governance interventions

Background Member States lack of compliance with 2005 IHR implementation led to the launched of the Global Health Security Agenda. This research will provide an understanding of how the Global Health Security Agenda Steering Group (GHSA SG) governance interventions impact health system performance and global health security. This will enhance the understanding of a Steering Group's governance interventions in complex Global Health initiatives. Research questions: To what extent have GHSA SG governance interventions contributed towards enabling health system performance of WHO Member States? To what extent have GHSA SG governance interventions contributed towards the implementation of global health security among WHO Member States? Methods Correlational analysis using Spearman's rho examined the relationship between governance, health system performance and global health security variables at one point in time. A convenience non-probability sample consisting of eight WHO Member States was used. SPSS Statistics generated the bivariate correlation analyzes. Results Governance and health system performance analysis indicated a statistically significant strong positive effect size in 11 out of 18 and moderate positive effect size in the remaining seven out of 18 health system performance indicators. Governance and global health security analysis concluded three of the governance indicators had strong and moderate positive coefficients. Global health security variables demonstrated weak effects in the remaining three governance indicators. Conclusions This study presents a case for health systems embedding in global health security. Health system performance is only as effective at protecting populations when countries achieve core capacities of preparedness and response to global health threats. The associations provide stakeholders information about key characteristics of governance that influence health system performance and global health security implementation. Key messages This study provides an argument for the continued support of the GHSA 2024 Framework with implementation of global health security capabilities and meeting 2005 IHR requirements. The GHSA SG governance role remains profoundly important in establishing sustainable efforts internationally towards achieving the objectives of the GHSA in support of the 2005 IHR standards.

The 2014 Global Health Security Agenda

The Global Health Security Agenda is a comprehensive and multilateral action plan that is designed to “achieve a world safe and secure from infectious disease threats, whether naturally occurring, accidental, or deliberately released.” The Global Health Security Agenda (GHSA) involves various organizations spanning across over 50 nations. Many of these nations also have multiple agencies that have a role in furthering the objectives of the GHSA.

Implementation of an Electronic Disease Surveillance System in Guinea, 2016-2018

ObjectiveThe objective is to share the progress and challenges in the implementation of the District Health Information Software Version 2 (DHIS 2) as an electronic disease surveillance system platform in Guinea, West Africa, to inform Global Health Security Agenda efforts to strengthen real-time surveillance in low-resource settings.IntroductionThe West Africa Ebola outbreak of 2014-2016 demonstrated the importance of strong disease surveillance systems and the severe consequences of weak capacity to detect and respond to cases quickly. Challenges in the transmission and management of surveillance data were one factor that contributed to the delay in detecting and confirming the Ebola outbreak1. To help address this challenge, we have collaborated with the U.S. Centers for Disease Control and Prevention (CDC), the Ministry of Health (MOH) in Guinea, the World Health Organization and various partners to strengthen the disease surveillance system through the implementation of an electronic reporting system using an open source software tool, the District Health Information Software Version 2 (DHIS 2). These efforts are part of the Global Health Security Agenda objective to strengthen real-time surveillance2. This online system enables prefecture health offices to enter aggregate weekly disease reports from health facilities and for that information to be immediately accessible to designated staff at prefecture, regional and national levels.Incorporating DHIS 2 includes several advantages for the surveillance system. For one, the data is available in real time and can be analyzed quickly using built-in data analysis tools within DHIS 2 or exported to other analysis tools. In contrast, the existing system of reporting using Excel spreadsheets requires the MOH to manually compile spreadsheets from all the 38 prefectures to have case counts for the national level.For the individual case notification system, DHIS 2 enables a similar accessibility of information that does not exist with the current paper-based reporting system. Once a case notification form is completed in DHIS 2, the case-patient information is immediately accessible to the laboratories receiving specimens and conducting testing for case confirmation. The system is designed so that laboratories enter the date and time that a specimen is received, and any test results. The results are then immediately accessible to the reporting district and to the stakeholders involved including the National Health Security Agency and the Expanded Program on Vaccination. In addition, DHIS 2 can generate email and short message service (SMS) messages to notify concerned parties at critical junctures in the process, for example, when a laboratory result is available for a given case.MethodsThis presentation is based on review of project experience and documentation for a Global Health Security project in Guinea from 2015-2018. In addition, this includes a 2017 evaluation of the DHIS 2 pilot phase in two regions each having five prefectures.ResultsThe use of DHIS 2 for aggregate and individual case reports for disease surveillance was piloted in two regions in Guinea in 2017 for a period of six months. An evaluation of the pilot phase indicated strong capacity at the Prefecture Level to use the system for weekly aggregate disease reporting as evidenced by the high weekly reporting rates as well as an assessment of users’ capacities. Challenges observed during the pilot phase included weak follow-up and ownership by the national level MOH, weak adherence by the laboratories to enter data on the receipt and test results of laboratory samples, and individual case reports not filed in all cases. In addition, the lack of uniformity of common data elements on the forms across different diseases made analysis and data quality more challenging.Following the evaluation of the pilot phase the MOH directed that the system should be used for aggregate weekly reporting, however that the individual case reporting in DHIS 2 should wait until improvements could be made in the case report forms. Prefectures have used DHIS 2 for weekly aggregate disease reporting starting in January 2018. In addition, the MOH plans to implement electronic individual case reporting in DHIS 2 starting in October 2018.ConclusionsProgress to date includes nationwide use of DHIS 2 by all prefectures for the submission of weekly aggregate case reports. In addition, the new case report forms have been configured in DHIS 2 and a training of trainers has been conducted at the national level to begin the process of implementing the electronic case reporting nationwide.Challenges include the continuation of parallel weekly disease reporting in Excel for an extended period after adoption of DHIS 2 resulting in lower timeliness of weekly reports in DHIS 2 in some prefectures, weak use of the system for data analysis, building capacity within the Ministry of Health to maintain the system without outside assistance, sufficient resources to pay for internet access and power back-up (such as solar power) to enable the health offices to effectively use the system, weak data privacy and security procedures, and the need to strengthen management of the national DHIS 2 server.References1. Ministère de la Santé-République de Guinée, Direction Nationale de la Prevention et Santé Communautaire, Division Prevention et Lutte Contre la Maladie. Plan de Renforcement de la Surveillance des Maladies à Potentiel Epidémique en Guinée (2015-2017), August 2015.2. Global Health Security Agenda. Real-Time Surveillance Action Package: GHSA Action Package Detect 2 & 3. [cited 2018 Oct 3]. Available from: https://www.ghsagenda.org/packages/d2-3-real-time-surveillance

Streamlining Disease Surveillance System implementation in Tanzania: Lessons Learnt

ObjectiveTo support streamlining of VPD surveillance into integrated diseases surveillance and response (IDSR) system in TanzaniaIntroductionTanzania adopted IDSR as the platform for all disease surveillance activities. Today, Tanzania’s IDSR guidelines include surveillance and response protocols for 34 diseases and conditions of public health importance, outlining in detail necessary recording and reporting procedures and activities to be taken at all levels. A total of 15 disease-specific programs/sections in the Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC) are linked to the IDSR, though the extent to which each program uses IDSR data varies. Over the years, IDSR procedures and the structures that support them have received significant government and external resources to maintain and strengthen detection, notification, reporting and analysis of surveillance information. However, with the imminent phasing out of programs (such as the Polio eradication program) that have supported IDSR strengthening and maintenance in the past, resources for surveillance will become more limited and the government will need to identify additional resources to sustain the country’s essential surveillance functions.Maternal and Child Survival Program (MCSP), a USAID Funded Program supported MOHCDGEC managing active and passive surveillance systems in improving coordination and strengthen the system taking into consideration declining resources as well as transitioning to polio end game where most of the financial resources were derived from to support vaccine preventable diseases surveillance. The support complements other Global health security agenda (GHSA) on the key thematic areas (Prevent, Detect and Report) support to the MOHCDGEC and working with the newly formed Emergency Operations Center (EOC) to improve response.MethodsBetween February and November 2018, the MOHCDGEC and MCSP undertook activities to generate information for future plans to strengthen Tanzania’s disease surveillance system to address the Global Health Security Agenda (GHSA): 1) desk review of country’s disease surveillance 2) meetings with stakeholders involved in surveillance; 3) workshop where stakeholders discussed and developed strategies for streamlining disease surveillance; 4) asset mapping to identify assets (human, financial, physical 5) stakeholders meeting to further discuss and agree on future strategies, activities.ResultsThe Disease surveillance system review found the functions for surveillance being implemented at different levels (Figure 1). These include identifying cases; reporting suspected cases, conditions, or events; investigating and confirming suspected cases, outbreaks and events. To facilitate decision making at different levels, it was found that analysing and response are done at all levels. A total of 15 disease-specific programs/sections in the MOHCDGEC are linked to the IDSR, though the extent to which each program uses IDSR data varies.Key strengths and opportunitiesThe government’s adoption of the IDSR platform and the fact that the MOHCDGEC has a dedicated department to monitor IDSR performance has been a great achievement of the program. The system is fully adaptable to support all disease surveillance with clear supervisory structures in place at regional and council levels. At the operational level there is presence of full-time, competent and dedicated government employees and exhibiting awareness of their responsibilities, and resourcefulness. The entire surveillance program benefits from government and external funding for disease-specific surveillance-related programs (e.g. funds for polio eradication and malaria program).Despite the achievements, there are notable challenges faced by the program including disease-specific programs often requiring additional information and opting to set up parallel surveillance systems rather than integrating with the IDSR; surveillance activities often not being considered high priority at council level relative to curative service and/or surveillance not being a line item in budgets; electronic data transmission platforms not being able to support transmission of all e-IDSR data with the result that health facility data (including diseases for immediate notification) may not get reported in weekly transmissions; high turnover of surveillance staff and unsystematic orientation of newly-deployed staff; discrepancies in reported HMIS, IDSR, and disease-specific program data indicating data quality issues.Asset mapping: At the time of the review, the number of staff available varied widely between programs, with the national laboratory and the National AIDS Control program (NACP) reporting the highest number at council level and Immunization and Vaccine Development (IVD) having significant number of persons supporting vaccine preventable disease surveillance. At the time of the review, most of the funds were allocated in capacity building through training and supportive supervision compared to core surveillance function.Key inteventions to streamlining and harmonizing of surveillance Supported the roll out of electronic IDSR to ensure real time surveillance through DHIS2Supported proceedures to establishement of surveillance expert working group (EWG);Development of Term of reference for EWG to guide implementation of IDSR activitiesDevelopment of transition plan highlighting key stakeholders and the support they provide to strengthening surveillance in the country;Development of workplan to guide implementation of agreed recommendations which includes;1. Coordinating activities of all stakeholders involved in surveillance,2. Developing or advocating for an interoperable and harmonized reporting system through DHIS2 that will accommodate the needs ofthe various disease- and event-surveillance programs,3. Promoting synergies at national level so that active surveillance is expanded as appropriate to other diseases and supports casebased surveillance,4. Building capacity of RHMTs/CHMTs in leadership and management to manage human and financial resources and prioritizesurveillance;5. Coordinating and strengthening disease and event-surveillance at community level by having at least one trained focal person at thecommunity for all disease surveillance.ConclusionsStreamlining and strengthening of the surveillance system could be achieved by existing coordination structures within MOHCDGEC. Strengthening IDSR by implementing an interoperable of reporting systems including integration of laboratory data will achieve harmonization, consistency in data and appropriate response. At the Regional and council level, priority activities identified include strengthening coordination, orientation and training for financial and human resources management for surveillance aimed at strengthening surveillance and response teams. The IDSR should strengthen active surveillance to adopt case based surveillance as deemed appropriate for more diseases. A proposed plan for implementing key activities to achieve integration and streamlining of disease surveillance has been developed and it is hoped that resources will be made available for immediate implementation.