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Social Science & Medicine 67 (2008) 292–300

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Social Science & Medicine

journal homepage: www.elsevier .com/locate/socscimed

District-based malaria epidemic early warning systems in East Africa:Perceptions of acceptability and usefulness among key staff at healthfacility, district and central levels

Caroline Jones a,*, Tarekegn A. Abeku a, Beth Rapuoda b, Michael Okia c, Jonathan Cox a

a Department of Infectious & Tropical Disease, London School of Hygiene and Tropical Medicine, Keppel Street, London WCIE 7HT, UKb Division of Malaria Control, Ministry of Health, Nairobi, Kenyac Malaria Control Programme, Ministry of Health, Kampala, Uganda

a r t i c l e i n f o

Article history:Available online 29 April 2008

Keywords:East AfricaKenyaUgandaMalaria epidemicsMalaria early warning systems (MEWS)SurveillanceHealth worker perceptionsStaff motivation

* Corresponding author. Tel.: þ44 20 7927 2649.E-mail addresses: caroline.jones@lshtm.ac.uk (C

beku@lshtm.ac.uk (T.A. Abeku), brapuoda@yahoo.cokeokia@yahoo.com (M. Okia), jonathan.cox@lshtm.a

0277-9536/$ – see front matter � 2008 Elsevier Ltddoi:10.1016/j.socscimed.2008.03.001

a b s t r a c t

Malaria epidemics represent a significant public health problem in the highlands of Africa.Many of these epidemics occur in low resource settings, where the development of an ef-fective system for malaria surveillance has been a key challenge. Between 2001 and 2006,the Highland Malaria Project (HIMAL) established a programme to develop and test a dis-trict-based surveillance system for the early detection and control of malaria epidemics infour pilot districts in Kenya and Uganda. An innovative feature of the programme was thedevolution of responsibility for the detection of epidemics from the central Ministry ofHealth to District Health Management Teams. The implementation of the programme of-fered the opportunity to test both the technical aspects of the system and to examine thepractical issues relating to the operation of the programme in the context of the existinghealth system. To investigate the attitude of key staff towards the programme, and theirperceptions of its impact on their working practices, interviews were carried out among52 health staff at district level and in the Ministries of Health in Kenya and Uganda. Thetransfer of responsibility for the early detection of epidemics to the districts had resultedin perceptions of individual empowerment among district-based staff. This, together withimproved support supervision, was a key factor in sustaining motivation and improvedsurveillance. The enhanced support supervision also produced capacity benefits that ex-tended beyond improved malaria surveillance. However, these improvements occurredin the context of increased logistical support (the provision of transport, fuel and travel al-lowances) which the participants believed was essential to the functioning of an effectivesystem. With this proviso, the district-based malaria early warning system was perceivedto be manageable, effective and sustainable in the context of the current health system.

� 2008 Elsevier Ltd. All rights reserved.

Introduction

Malaria epidemics have been, and remain, a seriouspublic health problem in the highlands of Africa, oftencausing devastating morbidity and mortality among

. Jones), tarekegn.a-m (B. Rapuoda), mi-c.uk (J. Cox).

. All rights reserved.

affected populations (Fontaine, Najjar, & Prince, 1961;Garnham, 1945; Lindsay & Martens, 1998). Although the re-liability of current burden estimates has been questioned(Cox, Hay, Abeku, Checchi, & Snow, 2007), the World HealthOrganization (WHO) has estimated that 110 million peopleare at risk of malaria epidemics in Africa, of which 110,000die of the disease each year (WHO/UNICEF, 2003). The earlydetection, containment and prevention of malaria epi-demics have been priority areas for the WHO for manyyears (WHO, 2004; WHO/RBM, 2001) and the commitment

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of many governments has been expressed through the de-velopment of national guidelines for epidemic prepared-ness (WHO/UNICEF, 2003). At the Abuja summit ofAfrican leaders in 2000, targets were set for improving ep-idemic detection and response with the aim of detecting60% of epidemics within 2 weeks of onset and respondingto 60% of epidemics within 2 weeks of detection (WHO/UNICEF, 2005).

Despite such strong political backing, there have beenfew attempts to utilise available technologies to developor test functional systems for malaria epidemic early warn-ing on the ground. Moreover, while much research in thisarea has been focused on methodological or technical as-pects of early warning systems, relatively little attentionhas been paid to practical issues of implementation withinhealth systems. Recent evidence, for example, suggests thatin many epidemic-prone regions current modes of surveil-lance are not able to provide timely indications of the onsetof epidemics, and that the effectiveness of epidemic re-sponse mechanisms within health systems is compromisedas a result (Checchi et al., 2006). While it has been widelyacknowledged that specialized monitoring systems, oper-ating within existing surveillance structures, are a prerequi-site for effective epidemic early warning and response (Cox& Abeku, 2007), it is less clear whether such initiatives aresustainable within current health systems – particularlywhere changes to surveillance practices at the peripherallevel are advocated. Evidence in this area is generallyvery limited and opportunities to carry out operational re-search have been rare. Recent developments in East Africa,however, offered a unique opportunity to address theseknowledge gaps. In the period 2001–2006, a new systemof district-based epidemic monitoring was developed andpiloted in four districts in Kenya and Uganda as part ofthe Highland Malaria Project (HIMAL) partnership (Abekuet al., 2004). In this paper, we report findings from inter-views carried out with key health staff during the mainimplementation phase of the new epidemic detection sys-tem. We investigate the extent to which staff at variouslevels in the health system perceive that the new monitor-ing system has had an impact on their working practices.We examine the impact of the programme on relationshipsamong the various stakeholders in the health system andexplore perceptions on the usefulness of the monitoringsystem itself. Finally, we consider the impact of the systemon staff motivation and assess the implications for replica-tion and sustainability.

The HIMAL partnership

In 1999, a workshop at Salt Rock, South Africa, broughttogether stakeholders from East African Ministries ofHealth, WHO and academic institutions to formulate a re-gional framework for epidemic early warning (Cox, Craig,Le Sueur, & Sharp, 1999). As part of this framework, a pro-gramme to create and test new systems for epidemic mon-itoring at the district level was undertaken in selectedhighland districts of Kenya and Uganda. This programmewas coordinated by the Ministries of Health of both coun-tries, with technical inputs from the London School of Hy-giene and Tropical Medicine (LSHTM). In 2001, a prototype

monitoring system was developed at an internationalworkshop bringing together representatives from theMalaria Control Programmes, Health Management Infor-mation Systems (HMIS) and the Integrated Disease Surveil-lance and Response (IDSR) units of both countries, togetherwith staff from the District Health Management Teams(DHMT) of selected epidemic-prone districts (http://www.lshtm.ac.uk/dcvbu/himal/Documents/kisumu.pdf). The systemwas subsequently piloted in four districts (Kabale andRukungiri in south west Uganda; North Nandi and Guchain western Kenya) from 2002 onwards.

Although specific details of this monitoring system havebeen described elsewhere (Abeku et al., 2004), certaincharacteristics are worth highlighting in the context ofthis paper. The system relies on the collation of weeklymalaria data at a number of representative sentinel healthfacilities (five per district) by a records assistant (RA) or, inabsence of the latter, by the clinician-in-charge (CI). Thesedata are then delivered by health facility personnel to theDistrict Surveillance Officer (DSO) at the district headquar-ters. The DSO and/or the district contact person (DCP) (inUganda this was the District Public Health Officer, in Kenyathis was the Vector Control Officer) checks and enters thedata into a computer, undertakes analysis using an auto-mated computer system and disseminates the results tothe Ministry of Health (MOH) and to the health facilities.From an operational perspective, the significant and novelfeatures of the new approach included: the devolution ofresponsibility for data collation, analysis and interpretationfrom the central level of the MOH to the DHMT; provisionof a computer-based system for data entry, organization,analysis and report generation at district level; introduc-tion of a system of weekly surveillance incorporating a lim-ited number of sentinel health facilities, data from whichare analysed and interpreted before any aggregation is car-ried out; the generation of an objective and automatedmorbidity threshold for each facility incorporating underly-ing trends; and a rapid dissemination mechanism for re-ports and feedback among sentinel sites, the DHMT andthe MOH.

The principal aim of the HIMAL programme was to de-velop and test the technical feasibility of a new systemfor monitoring malaria epidemics. As a consequence, con-siderable attention was paid to the provision of effectivetraining and logistical support to personnel at all levels inthe system. An outline of the inputs is provided in Table 1.Data on the financial costs of the project have also beencollected and the results will be published elsewhere.

Because the new system effectively shifts the focus forepidemic detection from the central to the district level,the approach has direct impacts on the locus of decisionmaking, resulting in new roles and responsibilities forhealth personnel, particularly at the district level. A keyconcern for both Ministries of Health, therefore, is the ex-tent to which the new surveillance approach affects (posi-tively or negatively) the day-to-day functioning of thehealth system in the pilot districts. From a programmaticstandpoint it is also important to identify those factorswhich affect staff motivation, a crucial factor in assessingthe likely sustainability of this type of specializedsurveillance.

Table 1Logistical/financial support provided for implementation of the MEWS

Central level District level Health facility level

Training Planning and design workshop (2 days);training workshop (5 days)

Planning and design workshop (2 days);training workshop (5 days); computertraining (2 days)

Training workshop (2 days)

Computer Computer for central level use (furtheranalysis when needed, summaryreports for stakeholders, emailcommunications, data archiving)

Computer with customised databasesoftware (data entry and analysis,production of reports; production ofsupervision timetables

N/A

Digital thermometers N/A N/A Provided to facilitate malaria diagnosisTransport Four-wheel drive vehicle for

supervision and central leveladministrative and technical support todistricts

Motorbike and fuel to facilitate supportsupervision visits to sentinel healthfacilities

Travel funds to enable weekly deliveryof data to the DSO

Stationary For administrative support For administrative support Record sheetsCommunication Telephone and email communication

costsTelephone and email communicationcosts

N/A

Salary top-ups For extra support supervision andcentral level technical andadministrative support to districts

For extra supervision and datamanagement

For extra data compilation and handdelivery of weekly reports to the districtlevel

Table 2Cadre and number of staff interviewed

Staff interviewed Kenya (N) Uganda (N) Total

Clinician-in-charge (CI) 10a 10a 20Records assistant (RA) 9 8 17

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Methods

The principal method of data collection used in the re-search was open response structured interviews. Followingan initial pilot visit to the four districts, interview guideswith open response questions were developed. If duringthe interviews issues arose that were not covered in thetopic guide, but which were of relevance to the operationof the Malaria Early Warning System (MEWS), these issueswere pursued.

Most interviews were undertaken by one of the authors(CJ) alone, although a local social scientist was recruited toassist in the interviews at the health facilities in Uganda. Atthe start of each interview, the purpose of the interviewwas described to the interviewee, confidentiality assuredand informed consent obtained before the interview pro-ceeded. The interviews were conducted in English andthe interviewer recorded the response on a pre-prepareddata sheet. The responses were entered into Microsoft Ex-cel (Microsoft Corporation, Redmond, WA) for data man-agement and manual coding. Coding and analysis wereundertaken by CJ.

The data were collected from the 20 sentinel health fa-cilities (5 per district) in the four pilot districts where thesystem had been established; from the DHMT offices ofthe four districts; and from the office for the Division ofMalaria Control (DOMC) in Kenya and the office of the Na-tional Malaria Control Programme (NMCP) in Uganda. InKenya, the data were collected approximately 12 monthsafter the programme became fully operational; in Uganda,the monitoring system had been running for approximately15 months at the time interviews were conducted.

District medical officer/districtdirector of health services(DD)

2 2 4

District contact person (DCP) 2 2 4District surveillance officer

(DSO)2 2 4

Country co-ordinator (CC) 1 1 2National manager (NM) 0 1 1

a In each country 3/10 CIs at time of interview were acting ‘in-charge’ sonot receiving HIMAL ‘top-ups’.

Results

A total of 52 interviews were conducted: 37 at health fa-cility level, 12 at district level and 3 at national level (Table2). Although a CI was present at all the health facility vis-ited, in six instances (three in each country) this individualwas not the designated in-charge for the health centre in

question. These individuals were not, therefore, part ofthe HIMAL programme and were not receiving the smallsalary ‘top-ups’ provided to programme staff (see Table1). Only 17, out of a possible 20, records assistants wereinterviewed due to staff being absent at the time of the visit(Table 2). All district level staff involved in the HIMAL pro-gramme were interviewed, as were three of the four stafffrom national level.

Overall, there was as much variation in attitudes to-wards the system among health centres within a districtas there was between districts in either country and amongdistricts across countries. In addition, interestingly therewas no obvious difference in attitude towards the pro-gramme between those CIs who were part of the HIMALprogramme and those who were not. Consequently, report-ing of the results is by category of health staff.

Impact on practice and perceptions

Among the staff at the health facilities, the most fre-quently mentioned impact of the HIMAL programme wasits effect on attitudes to records and record keeping. Ofthe fourteen HIMAL CIs interviewed, thirteen said thatthey now appreciated the work undertaken by records as-sistants and had a better understanding of the value of

C. Jones et al. / Social Science & Medicine 67 (2008) 292–300 295

keeping good records. Interestingly, four of the six non-HIMAL CIs interviewed also mentioned that they had no-ticed a difference in the way that records were being keptand that these changes had had a positive impact on theway the facility functioned. The most frequently mentionedadvantages of good record keeping included: the ability toorganize, analyse and use data; the ability to pinpointexactly where within a health facility’s catchment areaproblems might be occurring for evidence-based spatialtargeting of local malaria control interventions; usefulnessin helping to identify patients on repeat visits (and whetheror not they were responding to drug treatments); and asa tool for drug inventory management.

‘‘It has helped us organize all the information we have.Before we would just dump it. Now all the informationis well kept, not just for malaria but for all diseases, ithas affected everything.’’ CI14‘‘It has made my understanding of records better so I canuse them as a guidance for which drugs to buy. I haveapplied this to other departments which has made re-port writing easier and it helps in planning staff anddrug requirements.’’ CI02

In addition to the day-to-day management of patients,staff and drugs, a key factor underlying the change in atti-tude among clinicians towards accurate record keeping wastheir perception that the system had increased their ownability to detect upsurges in malaria at an early stage. Theclinicians expressed a sense of ownership and understand-ing of the data which in turn had created a sense of empow-erment among the clinical staff.

‘‘We are now aware and know what to expect, we don’tjust have to wait to be told what is happening.’’ CI06

The rapid feedback of the analysed data (in the form ofeasily understandable graphs) from the district to thehealth facilities had also contributed to this feeling of indi-vidual empowerment.

‘‘HIMAL has a great impact, when we had an upsurge Iwas able to answer many questions from the local poli-ticians because of the reports (graphs) and it helped meget things moving.’’ CI10

The majority of the records assistants interviewed at thehealth facilities (15/17) also mentioned that the project hadaffected the way they undertook their record keeping work,primarily because they felt that their work was now seen asvaluable and appreciated both by other health facility staffand staff from the DHMT.

‘‘We have put more effort in and the difference is the se-riousness with which the data are treated. We get feed-back, the HMIS is useless because we don’t get feedbackand sometimes they don’t even care when we are sup-posed to report. There is also more support supervision[in HIMAL] which helps enhance the reporting systemand we get much more support, even apart from HIMAL.When we have a problem we get rapid feedback and weknow they check and help us with problems.’’ RA14

The district level respondents were unanimous in theview that undertaking weekly compilation and analysis of

the malaria data had substantially altered their perceptionsof the utility of routine data collection. District teams feltmore able to rapidly analyse the data being generated bythe health facilities and to use those data in a meaningful way.

‘‘It has changed the way I do my other work and mademe very positive about doing meaningful analysis. Thisis because the data are useful and interesting and it isgood to know where you are.’’ DCP3

The rapid production of easily understandable results(the graphs and reports automatically generated throughthe surveillance software) has also given rise to feelingsof greater control over malaria epidemics.

‘‘The way we look at malaria now and malaria epidemicsis completely different. We don’t have to wait for politi-cians to create epidemics we can say if we have one or ifwe don’t have one.’’ DD4

The national level participants reported that the HIMALprogramme had increased their awareness of the need fortimely reporting and sharing of information, and one ofthe country co-ordinators mentioned that the new systemof data management and reporting was encouraging themalaria control programme to use other routine data ina more effective way.

‘‘It is also encouraging us to analyse our other data bet-ter. It is encouraging us in the.to get this type of infor-mation from the.programme. There are lots of databeing collected at the community level but we nowsee the need to analyse and interpret it properly. It hasstarted a new approach and has had a positive impacton data management.’’ CC2

The same co-ordinator went on to say that, as a directresult of the project, regular detailed analysis reports andsummaries with interpretations encompassing a broaderscope of epidemic situation in the country were being pro-duced and disseminated to national and internationalpartners.

National level staff also recognised that the ability ofhealth facility and district level staff to collate, analyseand disseminate their own data was a powerful motivatingfactor in encouraging accurate record keeping and timelyreporting.

‘‘The reports mean that people are able to analyse anduse the data at source. The data collector is also the an-alyser and the implementer and this is motivation.’’ CC1

In addition, they mentioned that the graphs and reportsproduced by the computer programme were useful in rais-ing awareness when malaria upsurges occurred, even if re-sponses were still inadequate.

‘‘HIMAL has had an impact on response.The graphs dohelp to convince people that we need funds but process-ing takes time.’’ CPM1

Relationships among stakeholders

Each participant was asked if the HIMAL programmehad affected their relationship with colleagues within the

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health system. At each health facility, all participants (14/14HIMAL clinicians, 6/6 non-HIMAL clinicians, and 17/17 re-cords assistants) reported that their relationship with dis-trict level health personnel had improved significantly asa consequence of the new monitoring system. All respon-dents felt that the programme had brought the districtand health centre personnel ‘closer together’, primarily asa consequence of more opportunities for health facility staffto visit the district offices and increased supervision pro-vided by the district staff.

‘‘The people from the district are very close to us now,they pass on information from the MOH. There is veryclose contact now, not as before. They respond betterwhen we have problems. HIMAL has established a con-tact with the district and we now receive lots more in-formation about all things, TB, HIV etc., not justmalaria.’’ Non-HIMALCI05

This increased interaction was facilitated by the provi-sion of ‘travel allowances’ to each health facility to enablethem to deliver by hand the data to the district each week,and by the provision of a motorbike (plus monthly fuel al-lowance) to each district to allow members of the districtteam to visit each health facility within their district at leastonce a fortnight (see Table 1). The district teams used a site-specific timetable of supervisory visits that was regular andyet random so that health facility staff knew that they wouldreceive a visit at some point during any given fortnight butwere not forewarned of the actual day of the visit. In addi-tion, special supervision data sheets were used during su-pervisory visits to assess the veracity of data submitted bythe health facility. During the supervisory visits (or whenthe facility staff delivered their weekly data to the district),district staff were also able to feedback results (in the formof the computer-generated graphs) produced on the basis ofdata submitted previously by the health facility.

All district level staff felt that the enhanced support su-pervision and weekly visits by health facility staff to thedistrict offices had resulted in improved communicationand better relationships.

‘‘We see the staff at the sentinels sites more often, talk tothem about their problems and have a closer workingrelationship with these facilities.’’ DD02

District level staff also commented on the benefits ofimproved relationships with staff from the national pro-gramme. They suggested that improved communicationhad resulted in more notice being taken of their problemsand more information being provided to the districts.

‘‘There are better links with the national programme,we get more help with queries and better access toguidelines.’’ DD01

From the national programme’s perspective, the in-creased communication and support supervision (countryco-ordinators visiting each district every 3 months or so)had changed the relationship between the national and dis-trict level staff from one of ‘‘workers and bosses’’ to oneof ‘‘colleagues.’’ In addition, the country co-ordinatorsreported that national level staff were now more aware ofthe constraints under which the districts were working.

‘‘With the district staff it has definitely affected in a pos-itive manner. Now I appreciate the difficulties and prob-lems they have, the constraints under which they work,local politics etc., and the realities of implementation atdistrict level. . Even if I don’t visit we talk often on thephone and any problems or needs we communicateeasily.’’ CC2

Constraints

While all stakeholders interviewed had a range of posi-tive things to say about the HIMAL programme and the newmonitoring system, several also mentioned constraints andproblems associated with the system. At the health facilityand district levels, the most frequently mentioned problemwas the response by the MOH to malaria upsurges oncethey had been detected. While not all health facilities hadexperienced an upsurge in malaria during the project,among those that had (in three out of four districts) healthfacility and district level staff had been disappointed by theshortage of resources provided by the higher levels of thehealth services and delays in the dispatch of drugs and in-secticides to the district level. In one district, the health fa-cility and district level staff had been able to mount whatthey perceived to be an adequately rapid response because,at the time of the upsurge, there were sufficient supplies ofdrugs and insecticide available in the district to implementtheir response plan.

‘‘The DHMT was aware of the project, convinced by thegraphs and came up with control strategies.Before thesituation would have got out of hand but this time wewere able to mount a quick response and contain theoutbreak which made the DHMT members happy.’’ DD2

However, in all other districts the health facility and dis-trict level staff reported that while the system had helpedin the early detection of the problem and in raising aware-ness that an upsurge was occurring, there were still prob-lems in mobilising resources and moving suppliesbetween the centre, district and periphery.

‘‘The data helped identify the upsurge, we planned masstreatment and informed those affected but there wasa problem because the patients came but the districtdidn’t arrive with the drugs till late in the day.’’ CI06‘‘For decisions where resources were under our controlwe were able to respond, but from the MOH therewere a number of delays, e.g., the insecticide for IRS ar-rived several months late and the drugs requested tookone month to arrive because of the bureaucracy.’’ DD4

The staff in the national programmes of each countrywere also concerned that the bureaucracy of the financialsystems within the MOH were constraining their abilityto respond rapidly to upsurges in malaria.

‘‘When the last upsurge was detected we asked formoney for insecticide but the contracts committeehadn’t met so we couldn’t get money. The committeehas set times to meet, but even if they meet, if there isn’ta quorum they can’t make a decision. For the drugs there

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is always an emergency fund but not for chemicals tospray.’’ CCP2

Among the national and district level staff in both coun-tries, the second most frequently mentioned concern waswhether or not there was sufficient local or national capac-ity to cope with problems with the computers and data-base. During the life of the project, technical assistancefor computer problems had been provided by staff fromLSHTM. At district level, in particular, there was concernthat without such technical support there could be prob-lems in the future.

‘‘I don’t know if the MOH has the capacity to deal withthe computer problems. In this district the people whocame to fix our computers made them worse! I don’tknow if the MOH has people who can do this.’’ DSO3

At the national level, the country level co-ordinatorssuggested that for the immediate future technical assis-tance would probably still be required, but that capacity de-velopment was a priority and in future the MOH should beaiming to become self-sufficient.

‘‘We might have a bit of a problem with the computersoftware and also it will be hard work to train the DSOs.Eventually the MOH could take this over but for now weneed assistance.we do need to train someone to beable to provide that type of support at national level.’’ CC2

Usefulness and sustainability

All participants were asked directly about the usefulnessof the MEWS. At the health facility level, clinicians and re-cords assistants were universally positive about the useful-ness of the system, particularly with regard to theirincreased ability to detect malaria upsurges and the per-ception that their credibility in the eyes of district healthteams and local government had been strengthened. Atthe district level, all participants mentioned the usefulnessof the MEWS in providing objective malaria-specific data.

‘‘It has been very valuable.I am very happy about theentire system. At the end of the day it is helping us tobe objective, predict epidemics and help stop puttingmoney into a bottomless pit. ’’ DCP1

In addition, several district level staff mentioned thatthe way the system had been implemented with improvedsupervision and communication had contributed to anoverall strengthening of service delivery.

‘‘Many projects have already been done but with no realoutputs. HIMAL is not just research, it is already an op-erational tool and we feel more confident to saywhether there is an epidemic or not. We can tell staffand we can also tell and argue with politicians. It issomething we can understand and use and are alreadyusing as an administrative tool.’’ DD1

This view was echoed at the national level.

‘‘The administrative set up of HIMAL is very good. It is atiered system with sub-organization at each level witheach person knowing their role and responsibilities so

it is easy to pin point problems. It is also very very usefulbecause you know what you are saying, you are sure of itand on top of it so people believe you and take effectiveaction. It has given a sense of responsibility and peoplehave learnt the importance of the data and are takinggood care, even among non-HIMAL staff. It has moti-vated staff both financially and given recognition andboost to the records staff.’’ CC1

However, while all participants commented positivelyon the usefulness of the monitoring system and the posi-tive impact of the management and supervisory set up onthe functioning of the system, concerns were expressedabout sustainability when external financial inputs wereremoved. At the health facilities, the majority of the clini-cians (11/14) who were receiving salary top-ups said thatthe system would not be sustainable without these top-ups. Just over half of the records assistants (8/17) sharedthis view, while 4/17 said that the system might operatebut the quality of the data would not be as good.

‘‘Without top-ups you wouldn’t get data and the datawon’t be accurate.’’ RA10

This sentiment was echoed by just over half (7/12) of thestaff at district level.

‘‘It wouldn’t be that successful without top-ups becausepeople will not be willing to work for nothing. Also it isnot easy to sustain as you need very committed people.’’DCP4

By contrast, 5/17 of the records assistants and 5/12 dis-trict level staff (spread across both countries) thought thatthe system would be sustainable without salary top-ups.They pointed out that many of the health programmes be-ing undertaken through the public health system in bothcountries (such as vaccination programmes) involved theprovision of some sort of subsidy (e.g. meal allowancesand per diems) to personnel involved in programme activi-ties. This type of logistical support was perceived to bea standard requirement and its provision would be neces-sary to ensure weekly delivery of the data to the district.

‘‘If the programme was introduced just like any otherprogramme you still need to give an allowance. All pro-grammes, e.g., EPI, TB, HIV, vaccinations all have some‘out of pocket’ funds so it is normal to have an allow-ance. You also do need facilitation for transport to getthe data to the district.’’ DCP1

The national level stakeholders in both countries agreedthat resources for support supervision were required to en-sure motivation and the optimal functioning of the system.

‘‘We need to provide top ups and travel money andmoney for supervisory visits as well as money for Provin-cial supervisory support.Without the top up system itwould be slow, the flow of data would be monthly.’’ CC1

Discussion

The HIMAL programme was primarily designed totest the technical feasibility of a district-based malaria

C. Jones et al. / Social Science & Medicine 67 (2008) 292–300298

epidemic early warning system in the context of a low re-source health system. This new approach requires a certainamount of system reform (shifting the locus of epidemicdetection from central to district levels) and the effective-ness of any such change is dependent on the motivationof staff involved in implementing the new system. Franco,Bennett, and Kanfer (2002) have developed a frameworkthat outlines the ways in which health worker motivationis influenced. This framework can be used as a tool for ana-lysing the impact of system reform on health worker moti-vation. Applying the framework to the data in this studyallows us to separate out the various components of theMEWS system, to assess how each component is affectinghealth worker motivation and to consider its consequentimpact on the effective functioning of the system.

The framework divides the various influences on healthworkers into three distinct levels: the individual level, theorganizational level, and the cultural level. At the individuallevel, motivation can be broken down into three ‘classes’ ofmotivation: motives and goals (satisfaction of basic needsas well as recognition, responsibility and possibility for ad-vancement), self esteem and self-efficacy (evaluation ofpersonal capacity and confidence in personal ability) andexpectations (about whether the work is intrinsically re-warding and/or whether the work required is adequatelyrewarded by the employer).

Individual level: motives & goals

In the pilot districts in which the MEWS system was op-erating, as is the case in many countries in sub-SaharanAfrica, the salaries for public sector health staff are poor(Ferrinho et al., 2004; Kyaddondo & Whyte, 2003; Lindelow& Serneeis, 2006; McPake et al., 1999). In addition, in sev-eral of these countries, the payment of salaries and the re-lease of operational funds to districts is often delayedresulting in the adoption of various strategies to deal withsuch shortfalls (Asante, Zwi, & Ho, 2006). As Agyepong et al.(2004) found in a study of health worker motivation inGhana this type of environment contributes to individuallevel dissatisfaction since basic needs are not being met.By contrast, the HIMAL programme provided salary top-ups and travel allowances which, although initially delayed,were more often than not delivered on a reliable, regularbasis. While there is no doubt that the salary top-ups con-tributed to individual satisfaction with the programme,there was some debate among the participants as towhether or not salary ‘top-ups’ are essential for the routinefunctioning of the monitoring system. However, all of theparticipants recognised the necessity of providing logisticalsupport for surveillance in the form of transport and fuel tothe districts, as well as some form of travel allowance forboth district and health centre staff. Such allowances areregularly provided for other health activities, especially ifthey involve travel out of one’s base (such as per diems dur-ing vaccination campaigns, and ‘lunch allowances’ duringsupervision visits). Under the current health systems inKenya and Uganda, these allowances are seen as thenorm and essential to staff survival needs (a key compo-nent for individual motivation). Unless basic survival needsare being met, motivation in any other sphere is likely to be

ineffective (Herzberg, 1968). It is, therefore, unlikely thatunder current conditions, a MEWS system would functioneffectively without such allowances, a fact that wasrecognised by the three national level staff who wereinterviewed.

Once basic survival needs are met, Franco suggests thatthere are other individual level motivating factors that in-fluence the amount and quality of work undertaken. Theseinclude issues such as responsibility, recognition andgrowth. Studies on projects to strengthen district healthsystems have found that increasing responsibility throughownership by key stakeholders of resources and the pro-cess is fundamental to the success of such programmes(Tanner, 2005). In all health facilities in Kenya and Uganda,clinical officers and records assistants are required to col-lect routine data on the patients who visit their clinics.However, the data from this study suggest that, until theimplementation of the MEWS, the health facility staff feltlittle actual responsibility for these data and received littlerecognition for their collection. The increased emphasis onresponsibility for the malaria records required by theMEWS resulted in greater attention being paid to thesedata. For many of the health facility staff, this led to anawareness of the various ways in which data could beused and promoted a sense of ownership of the data. Theresponsibility was accompanied by recognition of the valueof this work, among their co-workers, among their supervi-sors (at the district level) and among the local communityleaders.

While the HIMAL programme re-established responsi-bility for data collection at the health facility level, it is atthe district level where the key changes in responsibilityfor malaria epidemic detection occur. Shifting the responsi-bility for analysis and dissemination of the malaria surveil-lance data from central level to the districts in which thedata are generated and collated has given the district levelstaff a real sense of the value of surveillance data and hasincreased their sense of ownership of these data. This re-sponsibility; together with the recognition of the value ofthis work among other members of the DHMT, and mostparticularly by the national level malaria control pro-gramme staff, has helped to generated and maintain moti-vation for implementation of the MEWS among the districtand health facility staff.

Individual level: self esteem & self-efficacy

Franco suggests that the second major internal influ-ence on worker motivation is the individual’s perceptionof their competence to undertake the work that theyhave been set. In the HIMAL programme, the record keep-ing work that the health facility staff were undertaking,was already an integral part of their job description. TheHIMAL system introduced new weekly record forms whichwere perceived by many of clinical officers and records as-sistants as being simple to complete and increased theircompetence in detecting upsurges in malaria cases. At thedistrict level, the changes introduced by the HIMAL systemwere more radical. The district level staff are required toenter the malaria data into a computer and to produce re-ports from these data. At the start of the programme, the

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district level staff participated in 7 days of training, 2 ofwhich were devoted to the computer system and the pro-duction of reports. In addition, throughout the first yearof the project technical advise on computer issues was pro-vided through regular visits (once a quarter on average) byLSHTM staff. This training helped to enhance the confi-dence of the district level staff, assisting them to developself-confidence in using a computer in general and in run-ning the MEWS in particular. However, there remainedconcerns among the district level staff about their com-puter competence. A lack of self-confidence among districtlevel staff, unused to using computers, is a factor thatwould need to be addressed in the scale-up of the system.

Individual level: expectations

The final component of individual motivation and will-ingness to adopt the goals of a new programme is also re-lated to expectations of whether or not it is possible toperform the required tasks and if these tasks are of valueto the individual. In the HIMAL experience, all cadres ofhealth personnel perceived that they were able to performthe required tasks and the rewards for undertaking thework were seen, by both health facility and district levelstaff, as being of significant value. The discussion of ‘incen-tives’ in relation to performance within the health sector isoften restricted to financial allowances. However, incen-tives involve not only monetary payments, but also includeintrinsic and extrinsic benefits that accrue to individualsand groups as a consequence of changes to a system (Mees-sen, Musango, Kashala, & Lemlin, 2006). The HIMAL pro-gramme appears to have produced various non-pecuniarybenefits which individuals perceive to be of value. These in-clude: the ability to analyse the data they are producing; topresent these data in an easily understandable but ‘scientif-ically valid’ format which assists in communicating with lo-cal government and national level politicians as well asinternational donor organizations with representative of-fices within the countries; and to use the data to performtheir jobs more effectively. The fact that the MEWS hasbeen able to meet individual expectations is proving to bea powerful incentive in the maintenance of accurate rou-tine data collection, collation, analysis and dissemination.

Organizational level

Key organizational factors that affect worker motivationinclude the organizational goal, organizational manage-ment structure, communication process, support struc-tures, feedback mechanisms and the organizationalculture (Franco, Bennett, & Kanfer, 2002). The implementa-tion of the MEWS was based on a clearly articulated goal (toimprove the early detection of malaria epidemics), anda well-defined organizational management structure withprecisely delineated processes and support systems. Thisclear goal, together with a strong management system, ap-pears to have played a significant role in developing andmaintaining motivation among the implementing staff.The HIMAL programme is based on the concept of weeklysurveillance from a limited number of sentinel sites. Sincethe number of sites was small, each district was able to

enter, analyse and report on the weekly data in a timelymanner and the district staff were able to visit each facilityat least once a fortnight for support supervision. The effec-tiveness of these supervisory visits was enhanced by a sys-tem of well-defined roles and responsibilities, includingclearly defined procedures and tools for supervision. Froman operational perspective, limiting the number of sentinelsites per district allows for rapid feedback and effectivesupport supervision. As has been found in other low re-sources settings, supervision with audit and feedback hasproved to be one of the most effective mechanisms for im-proving performance of health workers (Rowe, de Savigny,Lanata, & Victora, 2005).

The HIMAL programme has been implemented withinthe existing public health systems in Uganda and Kenya,and consequently within the internal organizational cul-tures that are present in those systems. While the healthsystems in the two countries are different, they do sharesimilar financial and logistical constraints, and it is notablethat there was as much variation in perceptions of theMEWS among participants within either country as therewas between countries. Of particular interest, is the viewexpressed in both countries that one of consequence ofthe increased support supervision has been an overall in-crease in the level of communication among the variouslevels of staff (health facility, district and national level)and, to some degree, a change in relationships among thegroup of individuals working in the HIMAL programme.The relationships among those involved in the operationof the MEWS has turn from ‘us and them’ to a general per-ception that those involved in the programme are working‘as a team’. However, this concept of ‘teamwork’ has beengenerated under conditions where the immediate opera-tional context is the HIMAL programme rather than thebroader public health system.

At this stage, it is difficult to determine the extent towhich the ‘HIMAL context’ has influenced the effective-ness of the surveillance system in detecting epidemics;however, financial inputs from the HIMAL partnershipceased in March 2006, yet epidemic monitoring activitiescontinue to be undertaken in the four districts wherethe new system was piloted. In Kenya, the Ministry ofHealth is using resources provided through the GlobalFund to Fight AIDS, Tuberculosis and Malaria (GFATM)to expand the HIMAL monitoring system to a large num-ber of additional epidemic-prone districts. Logisticalsupport in the form of motorcycles, fuel and travelallowances will be provided – however, salary top-upswill not. To date, there has been no other specific fund-ing from sources such as GFATM or the PresidentialMalaria Initiative (PMI) for malaria epidemic surveillancesystems. However, the initiative by the Kenyan MOHreflects a recognition that tailored surveillance systems,predicated on passive case detection, are the mostreliable means for monitoring and evaluating currentpatterns of malaria over time. This is of value not onlyfor the early detection of epidemics but also for evaluat-ing the impact of specific interventions (most notablyIRS and ITNs) being introduced in epidemic-prone areasthrough the GFATM and PMI. There is a need for morecountries to follow Kenya’s example in this respect.

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Once the scaling-up process in Kenya is complete, wewill be in a better position (should research funding beavailable) to assess the impact of this tailored approachon the activities and outputs of the broader Health Man-agement Information System and to determine which ofthe various features of the system have the greatest impacton the effectiveness and sustainability of the MEWS ina low resource setting.

Conclusions

The evidence from research among the key staff in-volved in the implementation of a district-based MEWSin four pilot epidemic-prone districts in Kenya and Ugandasuggests that the system is perceived to be manageable, ef-fective, and extremely useful. One of the principal reasonsfor this enthusiasm is the increased motivation of the staffprompted by increased self-efficacy, responsibility and rec-ognition. This motivation has been developed and main-tained through a strong management structure witha well-defined goal, clearly articulated roles and responsi-bilities, and effective support supervision, efficient feed-back. Effective support supervision with efficient feedbackis vital to the continued generation and use of good qualitysurveillance data. The maintenance of effective support su-pervision is reliant on continued motivation of the staff in-volved which in turn is dependent on: the provision ofadequate logistical support in the form of transport allow-ances, and, where possible, motorbikes and fuel; the selec-tion of a small number of sentinel sites within a district toallow for regular visits; and the delineation of clear super-visory tasks. Effective support supervision is key to the suc-cess and sustainability of many district health programmes,not just the MEWS, and, as such, districts and national pro-grammes who plan to implement a similar system need toensure that sufficient attention is paid to this vital area.

Acknowledgment

The authors would like to thank the 52 participants whoagreed to be interviewed for this study and provided uswith invaluable insights into the day-to-day operations ofthe Malaria Early Warning System (MEWS). We are gratefulfor the continuing support of the programme managers ofKenya (Sam Ochola and Willis Akhwale) and Uganda (PeterLangi and John Rwakimiri), and we are extremely gratefulto James Beard for his critical contribution to the settingup and on-going development of the software essentialfor the functioning of the system. We would like to thankJuma K Nakendos for his valuable assistance in the conductof some of the interviews in Uganda. CJ and JC are fundedby the U.K. Department for International Developmentthrough the TARGETS consortium. TAA is supported bythe Bill and Melinda Gates Foundation through the GatesMalaria Partnership. The implementation of the MEWSwas funded by the Gates Malaria Partnership. This work

is an output of the HIMAL project (http://www.himal.uk.net).

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