To: Dr.

Badu Sarkodie, Disease Surveillance Department and Acting Director of Public Health,
Ghana Health Service
From: John S. Janeski, MPH, DrPH
Re: Key areas of focus for the improvement of Integrated Disease Surveillance and Response
(IDSR) at the community and health facility levels in Ghana. Results and recommendations from
a doctoral dissertation titled, An Evaluation of Integrated Disease Surveillance and Response
within the Community and Health Facility in three regions of Ghana.
Date: August 12, 2014
Research conducted in the Eastern, Greater Accra, and Northern regions of Ghana during
January March 2012 provides evidence that health facility surveillance and response, while
varying in quality across type of facility and availability of human resources, was found to be
functioning but in need of improvement in key areas. Despite the availability of adequate
technical standards within the country, community level surveillance and response was not
performing beyond the core function of epidemic response. Key areas of focus for the
improvement of both levels have been identified which could contribute the achievement of a
level of surveillance and response of that described within the WHOs IDSR Technical
Guidelines (2010) and the International Health Regulations (IHR) (2005). Following are
recommendations based on evidence derived from this IDSR evaluation.
1. Community-based surveillance (CBS) volunteer responsibilities should be integrated into ALL
future community-based volunteer initiatives regardless of primary technical focus. An
exclusively surveillance-oriented volunteer scheme is likely to be an unreasonable option for
Ghana. The reduction or elimination of financial motivation (i.e. training per diem) provided
formally to CBS volunteers has resulted in a severe reduction in the interest of volunteers to
fulfill their duties. Surveillance had not successfully been implemented or had deteriorated in all
of the sampled communities except for those in which the global Guinea worm initiative had
continued to provide financial motivation and supervision. Additionally, the exclusion of CBS
volunteers in some communities from non-surveillance volunteer activities (i.e. the more
recently implemented community health agent (CBA) scheme) had further demotivated
volunteers who were not given the opportunity to participate in the new initiative.
2. Job descriptions at the national, provincial, district, and health facility levels should include
specific responsibilities reflecting what is described within the IDSR guidelines detect and
respond matrix for both the community and health facility. Two of the districts sampled were
not able to identify the Ghana Health Service (GHS) position responsible for the supervision of
CBS. The seven core functions of IDSR were strongest in facilities where a surveillance officer
was located. Clinicians on the on the other hand had not been properly sensitized as to their
responsibilities related to surveillance and response. For example, in one urban health facility a

physician had failed to report a case of measles. Community health nurses in smaller facilities
had very little knowledge of the seven functions of IDSR and standard case definitions. Very
few examples were found of laboratory samples having been collected and priority disease cases
were found within registers which had either not been investigated or had gone unreported.
3. The Public Health Division (GHS) should provide leadership dedicated to the goal of
involving all actors working at the community level to assist in the integration of surveillance
and response activities. The evaluation found little evidence of participation of entities and
individuals beyond the GHS in community-based surveillance and response. Additionally, few
of the community members/leaders sampled had knowledge of CBS. NGOs, religious
organizations, the Pharmacy Council Ghana, the Ministry of Education, and other organizations
can provide access to low or no cost assets which can be tapped into for the maintenance of
uninterrupted community level surveillance and response. As described within Ghanas
Technical Guidelines, key individuals within communities should be involved and engaged on an
ongoing basis. These include, but are not limited to, community and religious leaders, traditional
healers and birth attendants, pharmacies, and teachers. Ultimately, it would be beneficial for the
GHS to exploit all existing and future health-related activities for the integration of a surveillance
and response component.
4. Assure that all health facilities have case definitions, surveillance and response handbooks,
rumor and investigation logbooks, community level registers, reporting forms and other essential
documents. A checklist of these should be included within the health facility supervision protocol
of the next higher level. Most of the CBS volunteers sampled no longer had community level
registers. With the exception of reporting forms, nearly all of the documents created for Ghanas
IDSR by the 2000-2005 PHRPlus project were not found within the sampled facilities. The
PHRplus (2006) report should be reviewed by the Public Health Division (GHS) as a means of
standardizing the surveillance and response documents and materials for the health facility and
community. Electronic media, including training videos, access to documents via a dedicated
website and others, should be considered as options for distributing information.
5. Standardize a facility level epidemiologic reporting sheet/register which corresponds with the
standard case definitions found within Ghanas Technical Guidelines*. Some facilities were
found to be using a locally created epidemiologic reporting sheet/register as an intermediate step
between clinic registers and reporting forms. These forms did not completely match the standard
case definitions found within the Ghanas IDSR Technical Guidelines (2002). In some cases, for
example, an alternative term may have been used for a disease or condition listed in the
guidelines. Age ranges, in some cases, did correspond between the standard definitions and the
local form. Some diseases or conditions may not be included all together. Viral hemorrhagic
fever and lymphatic filariasis, two reportable conditions, were found to have been excluded from
one form sampled.

*A limited number of health facilities have an additional reporting sheet/register created within their respective
region or district. This recommendation only applies to facilities and districts which use this additional document.

6. Pursue a bottom up approach to developing surveillance and response across the country,
which focuses on implementation at the health facility and community levels. Such an approach
should involve training disease control officers and clinicians locally within their facilities to
assure that management practices, systems, tools, and knowledge are implemented and sustained
within each facility. Many clinicians reported having not retained the information received at
large centralized trainings. In some cases, upon returning to their respective facility from a large
training or workshop, the individual representing a health facility had not shared information
with colleagues. A severe reduction in or elimination of centralized trainings to which personnel
must travel is recommended. An alternative to the much sought after training per diem should be
implemented with the goal of raising the quality of surveillance within facilities and
communities. A performance based incentive may prove to be useful. An ideal model would be
to create a regional or district position responsible for traveling to facilities to provide training
and supervision for both health facility and community level surveillance and response. The
PHRPlus Report (2006) can be consulted for technical direction.