Population under Surveillance: Public Health Emergency Management (PHEM) targets all populations to be under surveillance for all 21 diseases nationally and 22 diseases (including Lehimaniasis) in the Awi zone, Amhara Region ( Table 1).
Table 1:-Population under Surveillance of Awi Zone and Visited Woredas 2020
S.No
|
Zone/Woreda Name
|
Total Population
|
Male
|
Female
|
1
|
Chagni
|
48,260
|
24,613
|
23,647
|
2
|
Ankasha Guagusa
|
108,376
|
55,272
|
53,104
|
3
|
Banja
|
99,967
|
50,983
|
48,984
|
4
|
Zigem
|
109,255
|
55,720
|
53,535
|
5
|
Guagusa Shekudad
|
108,154
|
55,159
|
52,995
|
|
Total
|
474,012
|
241,746
|
232,266
|
The Country PHEM goal all inhabitants in the country to be under PHS for all 22 immediately-reportable diseases. The Awi zone cascade the same structure, with a total population of 1,253,909 in 2020 with population conversion factor region cascade of this, 474012 population under surveillance (Table 2).
Table 2: Number of health facilities in the assessed Woreda of Awi zone, Amhara Region, June 15-25/2020.
S.No
|
Name of Woreda
|
Total Population
|
Number of HFs
|
HCs
|
HPs
|
Hospital
|
|
1
|
Chagni
|
48,260
|
2
|
2
|
0
|
|
2
|
Ankasha Guagusa
|
108,376
|
2
|
2
|
0
|
|
3
|
Banja
|
99,967
|
2
|
2
|
0
|
|
4
|
Zigem
|
109,255
|
2
|
2
|
0
|
|
5
|
Guagusa Shekudad
|
108,154
|
2
|
2
|
0
|
|
|
Total
|
474,012
|
10
|
10
|
0
|
0
|
Core functions of the PHS system
Case definition: In most of the HFs and districts, standard case definitions of the selected disease are available
Standard case definition: Malaria: A suspected case was confirmed by microscopy or RDT for Plasmodium parasites.
Community case definition: The case definition is used to be aware of the community to notify any suspected cases and to make them aware of the early diagnosis of the priority diseases under surveillance. These are sensitive (loose) case definitions that increase the case detection rate. And Malaria: Any person with fever or fever with a headache, back pain, chills, rigor, sweating, muscle pain, nausea, and vomiting or suspected case confirmed by RDT
Data Reporting: No lack of reporting forms in the past six months in every visited HFs and HOs except for four HPs. The weekly reporting rate of the visited HFs over the past 26 weeks(week 27-52/2020) before assessments were 90% (9/10) or HPs, 100%(10/10) for HCs, and 100% (5/5) for woreda. The overall reporting rate of the visited districts for the zonal health department in 2012 EFY for the same week period before the assessment was 96% of Ankesha Guasgusa District, 97% Banja, 100% Changi, 95% Guasgusa, and 95% for Zigem District, whereas the reporting rate of the zonal health department to the regional health bureau was 98%. Among the assessed HFs, 12 (60%) of them reported the highest level of hard copy because close to their receiving. For reporting of any PHS related rumors, the woreda used the phone call to the highest-level body (Zonal). There was a shortage of rumors logbooks and case-based reporting formats.
Data Analysis: In visited Woredas and health institutions, data is not described by person, place, and time. The reason for the respondents failing to analyze the PHS data by place, person, and time was due to they had no awareness regarding the analysis and its use. None of the visited health facilities analyzed the data collected from PHS at their ability. In the majority of 12 (48%) of the assessed HFs, there was a Malaria Monitoring Chart (MMC) to follow the trends of malaria cases in their catchment area.
Epidemic preparedness and management: There were a written epidemic preparedness and response plan for all visited woredas, including some HF level but not secured budget. Current Covid-19 emergency preparedness plan and response plan available at woredas 5 (100%) and 6 (50%) HCs during data collection. All visited HFs responded as there was no scarcity of urgent situation antimicrobials and provisions in the past six months, despite that there were no separately secured contingency drugs and budgets for emergency cases. Regarding the existence and activities of the epidemic management committee, there was established a committee at the woreda and visited facilities. During this assessment, it was identified that the established committee at those levels was working regularly and formulated on all necessary disciplines, especially on Covid-19.
Supporting Functions of the PHS System
Supportive Supervision: During the past six months, the Awi zonal department did not conduct supportive supervision because of time constraints and security issues in the region. Among the 10 visited HCs, 4 (40%) had not been supervised during the past 6 months at higher levels. All HCs were not regularly supervising the HPs under their catchment area. The reasons they responded were due to transportation and budget problems. Many Woredas have conducted integrated supportive supervision for HFs with a limited number of PHS indicators last year. However, during the last six months, this is not performed. Reporting system, active case searches, and other PHS activities were reviewed in supervised Woredas and HFs.
Feedback: Feedback is a critical activity in strengthening the PHS system. Among woredas and HFs assessed, 09 (60%) of them received feedback from the zonal health department and woreda HOs respectively. Because the zone uses an integrated checklist to supervise woredas and HFs, there is no separate schedule, budget, and checklist for visiting and for giving supportive supervision to their reporting sites on PHEM and PHS activities. Many Woredas give written feedback for HFs with the integration of other activities that consist of a few indicators of PHS activities quarterly. In the majority of observed woredas, the production and dissemination of written feedback for HFs are very poor.
National PHS Manual: We identified that national PHS manuals were available in 6 (60%) PHS units at the facility level. Malaria strategy was accessible in every woreda HOs and HCs. In every assessed HPs, there was no surveillance guideline. The malaria case management protocol was not available in two woredas HOs, but available at six HCs.
Training of PHS Activities: In the last six months, the regional PHEM units being partners have conducted training for zonal and Woreda PHEM focal persons on outbreak investigation, Covid-19 surveillance, and contact tracing of Covid-19. Additionally, there is at least one trained personnel at all visited HCs. However, none health extension worker was trained on surveillance activity.
Resource: All visited HFs and districts compile weekly PHS reports manually. Data were aggregated by computer only at the zonal level. Although there is a computer for PHEM in the district and 100% of the visited HCs lack skill in data management and computer application, that is why they aggregate it manually. All HFs and districts have motorcycles. However, there is not using for PHS activities.
Laboratory Diagnosis: The Amhara National Regional State has two regional investigation laboratories at Dessie and Bahir Dar, which implements confirmatory tests for most of the weekly reportable diseases. Currently, the Bahir Dar regional laboratory starts confirmatory tests for measles. The measured HFs have RDT for the diagnosis of malaria. Blood film was done in all visited HCs. The most serious problem that faced feedback from the national laboratory is delayed and not used for intervention most of the time it takes at least one month.
Attributes of the PHS system
Usefulness: The PHS serves a total population of the Awi zone. From this population, a total of 43131 cases and 1 death of malaria were reported. All gaps in reporting timeliness and completeness as well as documentation malaria PHS system were found useful to measure the burden of the disease on some level. 25 (100%) of the respondents were accepted as the PHS system and its data was helpful to detect cases early, to evaluate the extent of diseases.
Flexibility: All visited Woreda HOs, HCs and HPs responded as the PHEM system ready the reporting pads lithe to inform further new events under immediately reportable case-based conditions.
Acceptability: The suitability of the PHS scheme was determined based on the involvement of the reporting bodies. All reporting bodies allow and are fine involved in the PHS activities, The report completeness status of reporting agents is 100% for HCs and 92 % for HPs. It consists of the readiness of human on whom the PHS is based to supply precise, steady, inclusive, and well-timed information.
Representativeness: A PHS scheme is represented exactly explains the happening of a wellbeing-associated occasion over the moment and its allocation in the human by geography, person, and time. It is determined by contrasting the distinctiveness of reported dealings to all such definite dealings. The primary health care coverage of the zone was 90% and 80% for HCs and HPs respectively.
Simplicity: Within the finding of cases, all respondents (100%) concurred that the case definitions of these need infections of recognizable proof of suspected cases, are simple to get, and can be connected by all levels of wellbeing experts. The respondents at the woreda and wellbeing office levels concurred that the report took approximately 10-15 minutes to spread week after week reports through the phone although it depends on the accessibility of networking. Regarding malaria, it takes 15 minutes if it is diagnosed using microscopy and 15 minutes if the diagnosis is with RDT.
Predictive value positive (PVP): The essential center be put on diseases verification and proceedings can be of assessing provoked by evidence got from the scheme.
Data quality: Sixty (60%) HPs reported incomplete PHS reports. 10 (100%) of them reported clear records to read and understand. 8(80%) of the HCs sent a complete and recorded report to the woreda HOs. 5(100%) of the woreda HOs sent complete and clear data reports to the zonal health office. Reporting formats of weekly and immediately reportable diseases are well understood at the HC levels and HP, but there is a shortage of report formats. Lack of training some health extension workers was observed to be confused with this format.
Stability: In recent times district-level PHEM officers were assigned to perform surveillance activities in the Awi zone. The availability of PHEM focal persons at the district HO and HFs level is a good opportunity for running a PHS system even with limited resources. However, budget constraints are affecting the stability of the system, and advances modify in this system and the workforce will create the system more unsteady and supply-exhaustive.
Completeness and Timeliness:
The overall report completeness and timeliness rate was above the World Health Organization minimum target (80%) in the last five years (Fig. 1). This might be due to increasing awareness of the community and acceptance of the community, health extension workers, and other health providers on of the PHS.
In general, health care providers (HCPs) and health extension workers (HEWs) have a good understanding of the case definitions of malaria, other priority diseases, and surveillance. Report completeness and timeliness were good which above the national target both for the woreda and HFs. Laboratory diagnosis of malaria was available at all levels of the district and HFs were satisfactory. They only prepared a plan, there is no ready budget and resources to respond to any PHE. Data analysis is only done at the zonal level, there was a lack of skill and resources for data analysis at the district and facility level. Outbreak investigation and response activities were done in a good manner. Supervision activities were poor at the zonal and district level, there were no program-specific supervision activities other than integrated supportive supervision which were conducted in each quarter. This might be because of the bad direction of all parties, insufficient helpful supervision, and feedback, little or no lawful enforcement to the PHS activities, lack of incentives, appropriate training, sense of ownership, and logistics.