The rapid assessment of the status of implementation of IDSR in the three North East states in Nigeria revealed that the strategy was not functioning. The major gaps included number and types of health facilities involved in IDSR reporting; inadequate documentation of patients’ biodata and medical details in the health facility registers; and lack of personnel capacity to detect and report cases and collect, collate, analyze and interpret IDSR data. Other gaps included the inadequate capacity of key stakeholders to conduct supportive supervision; insufficient monitoring and evaluation of the system; and underuse of the tools for IDSR implementation and laboratory support networks for prompt confirmation of outbreaks of diseases, conditions and events of public health concerns.
The distribution of health facilities reporting IDSR
The health care delivery system in Nigeria is a mixture of public and private health facilities. The private health facilities make substantial contribution in meeting the health needs of the populace in the country and are important foci for public health surveillance [16, 17]. The limited participation of health care facilities especially private health facilities in IDSR implementation in this survey indicates gaps in necessary surveillance data for the country. Similar findings on the participation of private health facilities in IDSR implementation were identified in Enugu where only 25% of staff in private health facilities, compared to 70% in public health facilities, were able to identify the correct forms for monthly IDSR reporting [10, 11, 18, 19]. With these gaps, diseases with potential for outbreak may go unnoticed until it is too late leading to increase in morbidity and mortality. Additionally, inadequate data used for decision making on planning and responses to public health events of concern may lead to an inadequate or inappropriate response. Involvement of all health facilities in IDSR will broaden the sphere of disease surveillance in the country and will produce more reliable data for decision making and planning for public health interventions. As such the government should ensure an all-inclusive approach for effective participation of the health facilities in the IDSR strategy.
The source of IDSR data (health facility registers)
The quality and reliability of information generated for any surveillance system are only as good as the source of the data. Incomplete or missing data from source documents, as seen in the rapid assessment, will lead to misinformation and insufficient conclusions. For example, lack of laboratory results for most of the diseases treated at the health facilities means that they can only be classified as suspect cases and not confirmed. Additionally, as completing and extracting data from source documents to the IDSR forms is dependent on the type of registers, the process is overly complicated. For example, aggregating data from multiple registers with different designs is confusing and complicating, and the chance for error is high and there is a reduction in the quality and reliability of the information . Harmonization of the multiple health facilities registers and trainings for clinicians on confirmation of disease using laboratory test by the relevant agency of government will ease the extraction of the data and improve its quality.
IDSR reporting tools (forms)
The process of summarization of data from the health facility register to the IDSR reporting form is manual and paper-based. The LGA DSNOs are responsible for ensuring the availability of the reporting tools at the operational units. Unavailability of reporting tools will reduce the normal functioning of the IDSR strategy. The rapid assessment revealed that reporting forms were not readily available at the operational unit. The lack of form availability at the operational level could be due to virtual absence i.e. the LGA DSNO failed to distribute the commodity, or due to true absence i.e. because of failure of the state to produce. Similar findings were noted at the local government level in Yobe state, North East Nigeria where it was reported that unavailability of the reporting forms was a major challenge for the implementation of the IDSR strategy in the state. The study revealed that only 8% of the health facilities had the IDSR reporting forms . Strengthening of the IDSR system in Nigeria must include the production and distribution of all reporting tools to all operational levels. The NCDC which is the country’s institution responsible for public health surveillance should ensure the production and distribution of the reporting tools to all levels of implementation.
Capacities of the IDSR focal persons
The functionality of the surveillance system requires a chain of staff who have been adequately trained and are adequately supported. For example, if a clinician fails to document the right diagnosis or any of the variables in the patient treatment cards the recorder will not have the correct data available to input into the health facility register. Similarly, if a recorder fails to document the diagnosis of the patient in the health facility register extraction of the data into the IDSR reporting form will be in adequate and incorrect. The surveillance focal persons at the health facility level are responsible for detecting diseases for immediate reporting guided by the case definitions, completing the form for immediate reporting and transmitting the same to the LGA DSNOs for immediate actions. They are also responsible for the completion of the weekly and monthly forms. Extraction of the data from the register depends on the knowledge of the surveillance focal person on the national disease surveillance reporting system, case definition for each of the priority diseases, IDSR data management, production of IDSR information product for action, the IDSR forms and their uses and to whom to send the report [20,21,22]. A study in South East Nigeria, revealed that although the awareness of disease surveillance was as high as 90% among healthcare workers, only 33.3, 31.1, and 33.7% of them knew the specific uses of forms meant for immediate, weekly and monthly reporting respectively . Their finding is similar to results of this rapid survey.
Training has been recognized as one of the veritable means to improve knowledge and a motivation for a positive attitudinal change of staff towards their work. Impact of training on staff knowledge on IDSR was confirmed by a study in Uganda, which found that increased staff knowledge on detection of IDSR priority diseases, reporting, data analysis and interpretation, preparedness and responses including increased staff confidence to perform IDSR tasks . The benefits of IDSR training at the health facility level were also confirmed by a second study in Uganda where trainees cited some of the important benefits to include increased awareness and change in attitude about disease surveillance . As important as training is in the improvement of knowledge and attitude, supportive supervision helps trainees to improve their performance. Supportive supervision is a key mechanism to ensure staff perform their tasks and activities according to set standards. It provides the opportunity for cordial interaction between the superior officer and their subordinate. When proper supervision is not in place it can negatively impact surveillance systems. Nyaaba et al. noted that poor supervision and lack of feedback to lower levels in the surveillance hierarchy as a major challenge for the disease surveillance system in Ghana .
Adequate infrastructure is another necessary component in surveillance systems. The rapid assessment noted that office support equipment such as computers and printers for the surveillance teams both at the state and LGA levels were lacking in two of the three states surveyed. This lack of infrastructure negatively impacted basic data analysis, writing of reports and reproduction of forms. Access to adequate mobile technology will increase access to electronic surveillance which will be a more efficient and effective data collection method than the current paper-based IDSR reporting in Nigeria. Access to mobile technology will also overcome another current gap in transmitting information through paper forms. The simplest means of transportation for the state and LGA surveillance officers to the lower levels are motorbikes. However, due to the insurgency in the North East the government baned the use of motorbikes. This ban has negatively impacted the retrieval of IDSR data and the ability to perform supportive supervision [10, 11, 21]. It is obvious that paper-based reporting leads to serious limitations in the transmission of the data from the point of generation to the higher level (LGA). An electronic system deployed to the health facilities level is a better option to enhance timely reporting of the IDSR data for action. The government should explore the use of the electronic system for reporting of IDSR and develop the capacities of the focal persons on its usage to improve the system.
Laboratory support for disease surveillance
The survey revealed limited utilization of a laboratory for confirmation of diseases prior to treatment at the health facilities. Symptomatic or empirical treatment leads to poor patient management and is a major cause of late detection and delay in outbreak reporting. This practice undermines the critical role of laboratory services to confirm suspected cases which is the backbone of the integrated diseases surveillance and response. Poor utilization of this critical element of the surveillance system was identified as one of the barriers for effective implementation of the IDSR strategy in Tanzania . Furthermore, in response to disease outbreak, the laboratory provides the scientific evidence for the prevention and control of infectious diseases and no outbreak investigation and response is complete without the laboratory supports . A well-functioning public health laboratory service for confirming suspected cases is the backbone of IDSR strategy. The government should ensure the availability of laboratories for the prompt confirmation of disease especially those with epidemic potential across the country.
The major limitation of this survey was the security issues prevalent in the states involved in the study. The security challenge influenced the selection of the study sites in each state as the insurgency was still active at the time of the survey. The survey team had to limit their visits to sites that were close to the state capital that are relatively safe and accessible. This could have influenced the results of the study because the facilities in the capital or close to the capital are more likely to benefit from supervision from the surveillance team.