Twelve [12] participants attended the workshop, seven from NCDC and five from PHE. Senior leadership including the NCDC Director, the PHE IHR project lead, managers and other directors across both organisations were present. A full list of attendees can be found in Appendix B. The questionnaire responses for the ESTHER EFFECt tool for each module of the tool is presented below, stratified by organisation (i.e. PHE or NCDC) response, alongside a summary of the facilitated discussion. Scores range from 1 to 4, with higher scores indicating better practice. NCDC and PHE scores were also compared by module using the unpaired t-test. A summary of the results can be found in Table 1 below:
Table 1
Summary of results by module for NCDC and PHE
| | Mean score NCDC | Mean score PHE | Number of components | p-value from unpaired t-test |
| Module 1 | 3.23 | 2.56 | 11 | 0.0006 |
| Module 2A | 2.04 | 1.25 | 4 | 0.002 |
| Module 2B | 2.87 | 2.7 | 4 | 0.41 |
| Module 2C | 2.78 | 2.57 | 6 | 0.30 |
| Module 2D | 2.57 | 2.48 | 5 | 0.73 |
| Module 3 | 2.73 | 3.03 | 5 | 0.128 |
| Overall | 2.69 | 2.50 | 35 | 0.001 |
Module 1 and 2A show a statistically significant difference between NCDC and PHE scores. Overall, there is also a statistically significant difference between NCDC and PHE scores, with NCDC scores being higher in every module other than Module 3: Added benefits to your institution. This difference can be seen in Fig. 1 below, with NCDC scores consistently higher than PHE scores.
Module 1: Implementation best practice
For the Implementation best practice module (Fig. 2), participants were asked to score from 1 to 4 whether best practice had been implemented on a variety of topics ranging from needs assessments to dissemination of best practice. The average score for implementation best practice from Nigeria CDC was 3.23 whereas for PHE it was 2.56. Aside from one question, both agencies scored above ‘2’ in each question indicating a high level of satisfaction for most components. Dissemination (component 1.11) was scored the lowest by both NCDC (2.83) and PHE (1.4) indicating that this was perceived to be an area for improvement, whereas Beneficiary Partner Ownership (component 1.04) scored highest by participants from both partners.
Facilitated discussion
The discussion highlighted a few factors that may have contributed to the high scores and provided some depth to the initial findings. The JEE was thought to form a solid basis for determining country needs (Component 1.01). There was also extensive discussion between PHE and NCDC, leading to agreement on the selection of activities for PHE to support.
At the beginning of the partnership, participants from both groups commented that the partnership seemed to involve fewer people who were generally, less engaged. As the partnership strengthened, both NCDC and PHE thought there was more engagement. Staff capacity has varied over time depending on issues faced in Nigeria and the UK but there was thought to be a good degree of flexibility to work around people’s availability, which was considered a key success factor. PHE was considered to be embedded as a partner within NCDC.
Engaged leadership was thought to be critical but had varied somewhat from the initial stated PHE IHR objective. It was suggested that lessons learned from stronger areas could be applied to weaker areas, possibly through more regular discussion and/or an annual leadership meeting.
The lessons learned from the partnership were disseminated organically. As a result, there was some divergence in scores between PHE and NCDC around dissemination because PHE was not aware of this work. This was considered to be an area for NCDC and PHE to improve on in order to demonstrate value for money. A formal dissemination plan was considered as an option for this.
Module 2A: Curriculum, learning and teaching development
For the Curriculum, learning and teaching development module (Fig. 3), participants were asked to score from 1 to 4 whether best practice had been implemented on a variety of topics ranging from curriculum coverage to learning and teaching methods. This was the module that received the lowest scores on average, from both NCDC (2.04) and PHE (1.25). Only 5 out of 12 participants (38%) replied to these questions. Of those who responded, the relevance of this module in relation to the NCDC and PHE partnership was thought to be low.
Facilitated discussion
During the discussion, it was highlighted that a knowledge management hub had been created within NCDC to address this module, although there may not be awareness of this throughout NCDC. Participants from both organisations suggested that there was a need to ensure that all NCDC staff were aware of this resource and that related departments from both organisations articulate and coordinate training needs.
Module 2B: Reach of capacity building activities
For the Reach of capacity building activities module (Fig. 4), participants were asked to score from 1 to 4 whether best practice had been implemented on a variety of topics ranging from critical mass to evidence-base. The average score across components was 2.88 for NCDC and 2.70 for PHE. The ability to deliver capacity building (component 2.B2) scored the lowest for both NCDC and PHE.
Facilitated discussion
NCDC and PHE participants both agreed that capacity building activity appeared to be in progress to but there was still scope for improvement. PHE participants suggested that NCDC capacity could be further strengthened to deliver capacity building activities in areas with weaker engagement. Participants agreed that at present, most training is designed to facilitate a ‘training of trainers’ approach. Both sets of participants questioned whether this approach was working in cascading the training throughout NCDC. It was suggested that both partners could do with a better understanding of the actual effect training was happening.
The Evidence-base (component 2.B4) was one of the only components where PHE scores are larger than NCDC scores. It was thought that the high PHE scores reflect that its guidance has been adapted to the local context. Scores from NCDC participants were more mixed in this area, varying by NCDC department. It was proposed that this may be due to a difference in the needs of different areas in adapting PHE guidance to the local context. One example provided was that laboratory functions tend not to require much adaptation whereas anti-microbial resistance guidelines must be adapted to the local context. Expanding use of the NCDC knowledge hub was suggested as one way of increasing capacity in this area.
Module 2C: Improving practice through capacity building
For the Improving practice through capacity building module (Fig. 5), participants were asked to score from 1 to 4 whether best practice had been implemented on a variety of topics ranging from teams to advocacy. Improving practice through capacity building components were generally scored high, with averages of 2.78 for NCDC and 2.57 for PHE. The exception to this was Feedback (component 2.C4) which NCDC participants scored as a 2 and PHE participants scored as 1.2.
Facilitated discussion
There was a general perception that higher scores for Changes in work practices (component 2.C3) were provided by more senior participants with a higher level and more strategic overview of organisation-wide performance. It was suggested that turnover in staff has restricted change in some departments. Focusing on this area was thought to be critical for sustainability. NCDC participants were positive that learning is being disseminated across departments leading to widespread change.
There was overall agreement that feedback could be improved, with it currently perceived as “ad hoc and reactionary”. Participants remarked that there was a need to systematise processes and suggested including a formal review process.
Component 2.C5, Access to Equipment /materials, was the only component in this module where PHE scores were higher than NCDC. There was some uncertainty around the commodities that PHE was able to offer as part of this project, which may have contributed to a lower NCDC score.
Module 2D: Whole institutional strengthening
For the Whole institutional strengthening module (Fig. 6), participants were asked to score from 1 to 4 whether best practice had been implemented on a variety of topics ranging from motivation for change to building institutional resilience. The average score across the module for NCDC participants was 2.57 and for PHE participants was 2.48. PHE participants scored Motivation for change (component 2.D1) and Systems thinking (component 2.D4) higher than NCDC participants.
Facilitated discussion
NCDC responses were widely spread for Motivation for change (component 2.D1). The PHE team and some NCDC colleagues expressed surprise at this. The discussions suggested that there is general alignment in thinking and that the spread in scores may have been due to different interpretations of the question. Low NCDC scores related to systems thinking (2.D4) partly reflect that there is further work to do to ensure that NCDC is fully embedded/mainstreamed into the One Health sphere. This is however expected to improve over time as NCDC are considering opportunities to further coordinate partners in the IHR space, inclusive of entities operating in other sectors within the ‘One Health’ sphere
Module 3: Added benefits to NCDC / PHE
For the Added Benefits to NCDC and PHE module (Fig. 7), the average score for NCDC participants was 2.73 and for PHE participants was 3.02. Questions for this module varied for both sets of participants. Though both sets of participants answered module 3.A, module 3.B was designed to explore NCDC opinions on peer support and spread/scale-up whereas module 3.C was designed to see if PHE opinions on whether there was any reverse innovation. As such NCDC participants did not answer module 3.C and PHE participants did not answer module 3.B.
In terms of Peer Support (component 3.B1) and Spread/Scale-up (component 3.B2), NCDC responses were generally positive with scores ranging from 2 to 4. Two PHE responses were positive about Reverse innovation (component 3.C1) whereas three said that it was too soon to judge this.
Facilitated discussion
Scores related to Networking and partnerships (component 3.A1) were disparate between the two groups. While, PHE were generally more positive with an average score of three, NCDC participants had mixed perceptions, with two participants giving this component a score of one. The discussion revealed that the lower scores from NCDC reflected impressions from the early stage of the partnership, which was thought to have improved and become more joined-up over time. The technical nature of the partnerships was in general viewed very positively. While this is an area where further progress is required, efforts to engage with WHO and partners across sectors, as well as at a regional level, were acknowledged. PHE participants suggested that NCDC could consider further work in coordinating between the WHO, non-governmental organisations and other partner countries, in addition to the technical working groups already in place.
Staff Motivation (3.A2) and Empowerment (component 3.A3) scores were relatively high for both NCDC and PHE stakeholders. There was consensus that NCDC staff do feel empowered and more confident as a result of the technical assistance and opportunities that PHE support has provided; demonstrated by staff taking more responsibility for functions and championing new ideas for improvement. Scores related to Staff Retention (component 3.A4) were mixed for NCDC, where it was suggested that staff did not see the partnership as influencing retention; PHE, alternatively scored this high and remarked that staff engagement in the programme has increased motivation. PHE participants also felt that the partnership with NCDC had helped PHE systematise processes and technical content. This could then potentially be something that could be fed back to NCDC staff to learn from and build on.
It was discussed that this peer support and spread/scale-up is a core focus of the partnership. Participants expressed hope that this area of work can be improved over time by PHE ensuring training content is appropriate and NCDC disseminating this training across Nigeria and West Africa.
Module 4: Improved skills
For the Improved Skills module, participants were asked to pick the top three professional skills (Fig. 8) and then the top three management / comms skills (Fig. 9) that they felt they had gained.
Professional skills
The response with the highest frequency (i.e. participants that selected the skill the most) was ‘developing policies, protocols and guidance’ with the second highest being ‘emergency preparedness and building resilience’. There was some degree of variance between responses from NCDC and PHE. For instance, PHE participants did not choose ‘multidisciplinary team working’ as a top three skill gained, however 4 NCDC participants did.
Facilitated discussion
The above mentioned highest frequency responses were thought to reflect the participants desire to improve in the aim of the IHR programme competencies. The components with the highest disparate responses were multidisciplinary team working ability to take greater personal initiative, and exposure to different healthcare systems; these were felt to reflect each organisation’s prior experience in this type of working. For instance, NCDC participants expressed a desire for improving multidisciplinary team working where they may not have had much exposure, whereas PHE participants may be more used to working in such a fashion. In general, participants agreed that their skills and confidence have increased through programme engagement. Professional skills were thought to have been gained by participants in both organisations, potentially demonstrating the mutual benefit of the partnership.
Management and communication skills
NCDC participants reported they had gained leadership skills and problem-solving skills through this engagement whereas PHE participants were more likely to say that they no appreciable improvement to report or had gained skills in managing with limited resources.
Facilitated discussion
Leadership skills were felt to have demonstrably improved in NCDC technical areas, with teams having strengthened capacity and working with greater confidence having engaged in the programme. Organisational skills and networking skills were also felt to have improved from state level engagement, which was thought to have been prioritised throughout the programme.
Recommendations / actions agreed by both institutions
As a result of the facilitated discussions, NCDC and PHE agreed upon the following recommendations and actions (Table 2). These recommendations are based on the overarching themes of the facilitated discussion.
Table 2
Recommendations and actions derived from the facilitated discussions following use of the ESTHER EFFECt tool.
| Recommendation | Proposed Action |
| Leadership: Engaged leadership has been critical to implementation but has varied somewhat by PHE IHR pillar. | - Apply lessons learned from stronger areas to weaker areas through more regular discussion and/or an annual leadership meeting. |
| Dissemination and feedback: The lessons learned from the partnership between PHE and NCDC are disseminated organically, although PHE is not always aware of this dissemination and whether the approaches (e.g. the training of trainer’s approach to capacity building) adopted are working. | - Develop a formal feedback and dissemination plan to help both parties ensure that training content is appropriate and both entities are aware of the reach of activities. - Incorporate this plan into a broader dissemination/ communications strategy. |
| Knowledge management: There is a need for a strengthened vision for knowledge management, including a training curriculum that all NCDC staff are aware of, have access to and mobilise around. | - A consistent and agreed approach to knowledge management. - Better understanding of and access to training curriculum. |
| Capacity: Further efforts should be invested into building NCDC capacity to deliver follow-on capacity building activities, particularly in the technical areas where capacity is weakest. | - Identify hurdles to capacity building. - Scope and plan how the two partners can ensure follow on capacity building is delivered, particularly in technical areas where capacity is weakest. - Review progress against the plan and evaluate effectiveness of the interventions. |
| Equipment and materials: PHE should clarify its position and ability to provide laboratory equipment and materials as soon as possible. | - PHE to update NCDC regularly regarding equipment. - Training to take account of availability of equipment and commodities. |
| Coordination: NCDC should consider opportunities to further coordinate partners in the IHR space, being inclusive of entities operating in other sectors within the ‘One Health’ sphere. | - Both partners to consider how opportunities can be worked into IHR deliverables. - Work plan to support NCDC to further coordinate with partners in the IHR space. |