An Evaluation of Community-Based Surveillance in the Northern Region of Ghana

This 55-page report documents the evaluation of a participatory, community-based surveillance (CBS) system that was implemented in Northern Region, Ghana.

In 1988, the Ministry of Health (with assistance from UNICEF) initiated a village-based surveillance system for guinea worm control as part of the Guinea Worm Eradication Program (GWEP). The purpose of this system, which involved village volunteers reporting the existence of guinea worm, was to detect, contain, and eradicate this parasite throughout the region. In 1996, when reports of guinea worm had reached a national low, the Ministry of Health began to broaden the scope of the GWEP village volunteers to serve other disease reporting needs. Training materials and reporting books (registers) were developed; approximately 3600 volunteers received training based on these resources. The training was designed to ensure that volunteers would be adept at detecting and tallying:

• cases of polio, cerebrospinal meningitis (CSM), guinea worm, measles
• infant deaths, pregnancy-related deaths, all other deaths
• new births (separately for males and females), and
• any unusual events.

Excerpts from the document follow:

This report documents the evaluation of the CBS system that was carried out in March 2000, funded by UNICEF....The main objective was to conduct an evaluation of the community-based surveillance programme...and make recommendations to guide the establishment of community-based surveillance activities in other parts of Ghana. In the process of doing this, the team was expected to develop and field test a methodology for assessing the role and impact of community level surveillance that could be used in other locations...

The evaluation included examination of a few specific indicators of how the CBS system actually works: the frequency of visits by CBS volunteers to households and by zonal coordinators to villages, the consistency and correctness of case definitions of events, and reporting rates overall and of different types of events. In addition, discussions with District and Sub-district staff as well as with zonal coordinators and volunteers provided some suggestions regarding funding and training....

Why the system works

Volunteer motivation

Motivation of traditional village volunteers appears to be primarily based on providing service to their communities; while motivation of volunteers in urban areas appears to be primarily based on achieving political visibility. In addition to pride in their work, volunteers outside of Tamale mentioned receipt of T-shirts and help with reading and writing as benefits. Some, but not all, knew of the recently agreed-on exemptions for their medical fees at health centers; some Subdistricts are waiting until they can provide identification cards to the volunteers. One unemployed volunteer was hoping that his voluntary work would lead to a job.

What is extraordinary is the almost universal declared willingness of volunteers to continue working ‘as long as I am needed’, as well as the negligible dropout reported by the zonal coordinators who were interviewed....An additional factor is undoubtedly the positive perception of the CBS by both communities and health system staff. In summary, recruiting volunteers for a CBS-like system outside of the Northern Region, should allow for time to select the volunteers who will remain with the system....

Reasons for success and lessons learned:

The success of CBS in the Northern Region may stem in large part from its growth out of the guinea worm eradication program (GWEP). GWEP gave the community a common, clearly visible target for action, easily identified by residents and health staff, as well as subject to effective interventions (community health education, medical management, and environmental risk reduction). Those developing CBS in other areas that are not endemic for guinea worm may need to identify other conditions with similar potential for recognition and relative ease of control (perhaps onchocerciasis or severe diarrhea; measles might also be considered, but given reasonable levels of vaccination will probably be too rare an event)...

Lack of timely reporting appears to be related to one of two situations: delays due to water barriers (rain-associated flooding and routine difficulty in traversing wide rivers), or management problems (lack of effective supervision of zonal coordinators, or lack of coordination among ministry of health staff and non-ministry of health personnel). In contrast, common findings in areas with timely reporting were frequent field visits by staff from the District and Sub-district level. In particular, frequent field visits appeared to outweigh problems related to water barriers and leads to effective CBS management...

In summary, the reasons for success of the CBS system, which are replicable, include:

• a limited number of events are tracked
• some of the events tracked are common
• some of the events are actionable
• most case definitions err on the side of over-reporting
• the volunteers’ workload is reasonable; weekly to monthly visits are feasible
• volunteers are not asked to handle money
• surveillance benefits both communities and the health system...