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Workforce capacity assessment for public health emergencies, disaster preparedness and response in the Economic Community of West African States (ECOWAS) region, April – July, 2018
Supplement article - Research | Volume 5 (2): 3. 07 Nov 2022 | 10.11604/JIEPH.supp.2022.5.2.1240

Workforce capacity assessment for public health emergencies, disaster preparedness and response in the Economic Community of West African States (ECOWAS) region, April – July, 2018

Virgil Lokossou, Kofi Mensah Nyarko, Emma Edinam Kploanyi, Delia Akosua Bandoh, Patrick Nguku, Bernard Sawadogo, Simon Nyovuura Antara, Ernest Kenu

Corresponding author: Prof Kofi Mensah Nyarko, University of Environment and Sustainable Development, Somanya, Ghana

Received: 23 Aug 2021 - Accepted: 23 Jun 2022 - Published: 07 Nov 2022

Domain: Epidemiology,Global health,International health

Keywords: workforce, public health emergency, field epidemiologists, training, FELTP Tiers

This articles is published as part of the supplement Overview of Preparedness and Response to public health emergencies in ECOWAS Region, commissioned by AFENET and WAHO.

©Virgil Lokossou et al. Journal of Interventional Epidemiology and Public Health (ISSN: 2664-2824). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cite this article: Virgil Lokossou et al. Workforce capacity assessment for public health emergencies, disaster preparedness and response in the Economic Community of West African States (ECOWAS) region, April – July, 2018. Journal of Interventional Epidemiology and Public Health. 2022;5(2):3. [doi: 10.11604/JIEPH.supp.2022.5.2.1240]

Available online at: https://www.afenet-journal.net/content/series/5/2/3/full

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Workforce capacity assessment for public health emergencies, disaster preparedness and response in the Economic Community of West African States (ECOWAS) region, April – July, 2018

Workforce capacity assessment for public health emergencies, disaster preparedness and response in the Economic Community of West African States (ECOWAS) region, April - July, 2018

Virgil Lokossou1, Kofi Mensah Nyarko2, Emma Edinam Kploanyi3, Delia Akosua Bandoh4, Patrick Nguku5, Bernard Sawadogo6, Simon Nyovuura Antara7, Ernest Kenu4

 

1ECOWAS Regional Center for Disease Surveillance and Control, Abuja, Nigeria, 2University of Environment and Sustainable Development, Somanya, Ghana, 3University of Ghana School of Public Health, Legon Accra, Ghana, 4Ghana Field Epidemiology and Laboratory Training Programme, University of Ghana School of Public Health, Accra, Ghana, 5African Field Epidemiology Network Nigeria, Abuja Nigeria, 6Burkina Field Epidemilogy and Laboratiory Training Programme, Ouagaduogu, Burkina Faso, 7African Field Epidemiology Network, Kampala, Uganda

 

 

&Corresponding author
Prof Kofi Mensah Nyarko, University of Environment and Sustainable Development, Somanya, Ghana

 

 

Abstract

Introduction: Recent outbreaks in Africa have exposed the limited regional response capacities in disease surveillance, preparedness and rapid response strategies. Workforce development is one of the major core capacities of the International Health Regulations to respond to public health emergencies. However, this was identified as a major gap in the Joint External Evaluations in most countries in the West African sub-region. Hence, we conducted an assessment of the field epidemiology workforce capacity in Member States using the global standard of five epidemiologists per million population.

 

Methods: We conducted a desk review of national surveillance and response documents to obtain information on workforce development. We also conducted face to face interviews from April to July 2018 to assess the status of each country's surveillance and response capacities in relation to health emergency preparedness and response.

 

Results: It was estimated that approximately 1,950 field epidemiologists and 11,000 frontline graduates were required to meet the global standard. As of October 2018, only 18.4% (358/1950) field epidemiologists and 22.2% (2,437/11000) frontline trainees were available in the region. Liberia recorded the highest number of epidemiologists (18/25). Apart from Ghana, none of the assessed countries had a full complement of all three tiers of field epidemiology training.

 

Conclusion: The assessment revealed a wide gap in trained field epidemiologists measuring against the required number of frontline and advanced/intermediate trainees for each State. This is an indication that more resources need to be invested into building local epidemiologic capacity to enhance health emergency preparedness for and response.

 

 

Introduction    Down

Epidemics of infectious diseases such as cholera, meningococcal meningitis, yellow fever and viral hemorrhagic diseases particularly Ebola virus disease (EVD) and Lassa fever continue to occur in West Africa [1-6]. The attendant devastating consequences have been detrimental to development and stability in the sub-region. The EVD outbreak from 2014 to 2016 affected six countries in the Economic Community of West African States (ECOWAS) region (Guinea, Liberia, Mali, Nigeria, Senegal, and Sierra Leone). This crisis exposed the limited regional response capacities to outbreaks in terms of disease surveillance, preparedness and rapid response strategies; this has been blamed on the lack of a well-trained health workforce, late detection and wide geographic spread of the epidemic [7,8].

 

Workforce development which includes field epidemiology and related training is one of the major core capacities of the International Health Regulations (IHR) to detect, assess, report, notify and respond to public health events and emergencies of national and international concern. This is also one of the technical areas of the Joint External Evaluation (JEE) which most countries in the West African sub-region identified as a major gap and thus planned to improve it as outlined in their respective NAPHS [9-11]. This highlights the Global Health Security Agenda call for “sufficient field epidemiologic capacity in every country to rapidly detect, respond to, and contain public health emergencies, thereby ensuring global health security”[12].

 

In the wake of the EVD outbreak in the sub-region, the 47th ECOWAS Authority of Heads of State in May 2015 endorsed the establishment of the Regional Centre for Surveillance and Disease Control (ECOWAS/RCSDC), mandating the West African Health Organisation (WAHO) to support its operationalization [13,14]. Consequently, WAHO developed the ECOWAS Regional Strategic Preparedness and Response Plan for Public Health Emergencies to build epidemiologic capacity for rapid response to epidemics and other public health emergencies.

 

Building workforce capacity in disease surveillance and rapid response strategies requires that training goes beyond the traditional approaches that emphasize only on knowledge acquisition to embrace experiential training for competency acquisition [15]. In many countries, Field Epidemiology Training Programs (FETPs) have proven to be successful models for building skilled public health workforce capacity [16]. The three-tiered approach of FELTP (advanced, intermediate and frontline) has been implemented in the region since 2007. The 2-year advanced-level program trains residents to work at national surveillance and disease control programs. Currently, there are three advanced FELTP programs in West Africa situated in Ghana, Burkina Faso, and Nigeria. The frontline-level training was intensified after the EVD outbreak in 2014 as the healthcare workforce was depleted in affected countries through the many deaths that occurred in the initial months of the outbreak [17-19]. The frontline workforce comprises the veterinarians, physicians, clinical officers, nurses, and other public health workers at primary healthcare facilities who are usually the first point of call during public health emergencies. However, they usually have minimal field epidemiology skills but if they are well trained, they can detect threats early and respond rapidly to public health emergencies [20].

 

Globally, FETPs supported by US Centers for Disease Control and Prevention (CDC) have deployed their residents to respond to over 3,300 outbreaks since 2005[21]. These practical experiences, although mostly local, have equipped trainees to respond to both national and international public health emergencies [21]. For instance, during the Ebola epidemic (2014-2016) in West Africa, FETP trainees from over nine (9) African countries actively participated in investigation and response activities; they functioned as epidemiologists, laboratory scientists, surveillance officers among others[22]. In particular, the residents and graduates of the Nigeria Field Epidemiology and Laboratory Training Program (FELTP) supported contact tracing that prevented a major EVD epidemic in the country contrary to the rapid spread in neighboring countries without FETPs [23,24]. The rapid response strategies employed to address the outbreak of EVD in Lagos, Nigeria is a clear example of how a competent public health workforce could control an epidemic even in such a densely populated city in the region [24]. Also, control of the EVD outbreak in various counties in Liberia is partly attributable to the efforts of FETP graduates. It is evident that such training when expanded would develop stronger health systems that are capable of responding to epidemics of such magnitude in the near future [22].

 

In this study, we assessed the field epidemiology workforce capacity in the 15 Member States as against the global standard of 5 epidemiologists per million population.

 

 

Methods Up    Down

Study design

 

A cross-sectional study was conducted across all 15 Member States of the ECOWAS region. Information was gathered from desk reviews on workforce development in relation to Public Health Emergency Preparedness, response, and recovery. Also, interviews with stakeholders in health in each country were conducted during field visits and or through teleconference from April to July 2018.

 

Study population

 

The Ministries of Health and other relevant public health agencies in each country were involved in the assessment. Representatives from each organization were interviewed.

 

Data collection tools

 

The data collection tools used in this study included a data review tool, a structured questionnaire, and an interview guide. These tools were developed based on the WHO International Health Regulation (IHR) core capacities [9]. Workforce capacity was assessed in relation to four of the sixteen (16) major areas of the WHO IHR core capacities including Rapid Response Capacity, Clinical Case Management, Availability of Epidemiology/ Surveillance and Related Capacity (Institutional Capacity), and Health Sector Workforce Development Plan. Specifically, epidemiology workforce capacity was assessed in relation to number of field epidemiologists, level of training from FETP and public health-related programs, and skill/functionality. Although functionality was not directly measured, it was assumed that the completion of the competency training served as a proxy for functionality because all FETP trainees had experience in field practice as part of the training and pre-requisite to graduation: they should have participated in at least one outbreak investigation and analysed at least one surveillance data set. This is because the role of field epidemiologists in the health system is cross-cutting in all four functions assessed. They are mostly used in West African context to strengthen surveillance, rapid response, and provide clinical case management where needed.

 

These tools were pre-tested and validated by WAHO and Ministers of Health in West Africa. Policy documents were verified where necessary during data collection.

 

Data collection

 

Data were collected from April to August 2018 in two phases. The first phase comprised the desk review of each country´s IHR capacity scores, Joint External Evaluation (JEE) report and actions implemented after JEE. Desk reviews of the national surveillance and response documents (policies, systems, plans, structures, coordination mechanisms, documents on simulation exercises, responsibilities, procedures, guidelines, and available assessment reports) were carried out at the regional and country-level.

 

Face to face interviews were conducted in the second phase using a structured questionnaire to assess the status of each country´s surveillance and response capacity as well as their respective roles in health emergency preparedness and response. Key informant interviews were conducted with country representatives from each Member State. All relevant data on the policies, plans, guidelines, and literature available on public health emergencies were assessed during data collection.

 

Data analysis

 

Data gathered from key informant interviews were transcribed and analyzed under major themes based on the WHO IHR core capacities. Data generated from desk reviews and document verification were also analyzed under these themes and triangulated with the interviews.

 

For the purposes of this study, the “field epidemiology workforce” was defined as any person working in an applied or field epidemiology role or acute public health responder role”[25]. The required number of field epidemiologists for each country was calculated using the country´s population as against the global standard of 5 epidemiologists per million population [10]. For the ECOWAS region, the population size used was 400 million at the time of assessment. This was calculated for the three FETP tiers. The estimation for the frontline FETP trained healthcare workers was based on sub-national units (districts/Local Government Areas) and depending on the country´s administrative unit´s size the requirement for frontline graduates was more than 1 graduate, preferably one in human health, animal in animal and one in environmental health per district/LGA cutting across human health, animal and environment in the all-hazard/one health approach. There were over 2000 districts/LGA in the region across the 15 countries, with a population range of 150,000 - 250,000 per district/LGA. The gaps in the number of trainees from the three tiers were quantified for each Member State. Spot maps were also drawn using the QGIS software to show the density of trained field epidemiologists by location in the region.

 

Ethical considerations

 

The Ministries of Health of all West African countries in ECOWAS gave their approval through WAHO for this assessment. Interviews were only conducted after participants gave their approval based on the explanation of the purpose of the assessment. Participants and countries had the liberty to withdraw from the assessment at any point and they were assured it would not affect them in any way as a nation.

 

 

Results Up    Down

Country-Specific Analysis for Field Epidemiologists

 

Trained workforce by FETP Tiers in Member States

 

The workforce country-specific analysis presented in Table 1 indicated a total of 358(18.4%) field epidemiologists with Advanced/Intermediate training in the ECOWAS region whereas there were 2,437(22.2%) with frontline training as of October 2018. The assessment found only 5 Member States out of the 15 that had at least one-fifth of the required number of field epidemiologists. They include Nigeria (22.7%), The Gambia (26.7%), Sierra Leone (40.0%), Ghana (45.0%), and Liberia (72.0%) which recorded the highest. The distribution of these trained field epidemiologists by country are shown in Figure 1. About half of the Member States in the region had over 20% frontline graduates. Nigeria (22%), Benin (25.0%), Liberia (32.9%), Ghana (34.9%), Sierra Leone (40.5%), Togo (47.3%), Guinea-Bissau (63.1%) and The Gambia (66%) constituted these 7 countries Table 1.

 

The gap in workforce development

 

The assessment estimated that approximately 1,950 field epidemiologists and 11,000 frontline graduates were required to meet the global standard. Although there were trained field epidemiologists identified in almost all Member States, there was still a wide gap of 1,592(81.6%) to make up for the required 2000 graduates Table 2. Also, 8,563(77.9%) frontline graduates were required to satisfy the 11,000 target. No Member State satisfied the required number of field epidemiologists. Moreover, Cabo Verde was the only Member State that did not record any trainees from either of the three FELTP tiers. Guinea-Bissau had no Advanced/Intermediate trained epidemiologists whereas Niger recorded no frontline graduates at the time of assessment. The six Member States in the region (Guinea, Liberia, Mali, Nigeria, Senegal, and Sierra Leone) where Ebola outbreaks had occurred had inadequate numbers of field epidemiologists required to respond to epidemics and health emergencies. No country had recorded half of the required number of advanced/intermediate or frontline trainees except Liberia that had 72.0% of the required number of trained field epidemiologists. There was only 32.9% of the required number of frontline graduates at the time of assessment. The gaps in the workforce for each Member State are shown in Figure 1 and Figure 2. It was observed that countries with the lowest density of field epidemiologists were farther away from those that had higher densities which clustered together.

 

For all countries assessed, there were inadequate numbers of public health personnel especially field epidemiologists, to implement IHR core capacity requirements. Apart from Ghana, none of the assessed countries had a full complement of all three FETP (basic, intermediate, and advanced). Poor in-country coordination of activities among the available personnel in the containment of epidemics and health emergencies was also identified.

 

 

Discussion Up    Down

The assessment revealed that there was an inadequate number of trained field epidemiologists in all Member States as a wide gap was identified measuring against the required number of frontline and advanced/intermediate trainees for each state. Liberia recorded the highest number of epidemiologists. Apart from Ghana, none of the assessed countries had a full complement of all three tiers of field epidemiology training.

 

This is worrying because field epidemiologists play the critical role of initiating the rapid response process to outbreaks through disease surveillance, contact tracing, determining how the infection is transmitted, and predicting where the outbreak is headed and its magnitude [26]. They generate data that inform decisions in outbreak management. The Ebola outbreak that occurred between 2014 and 2016 was the real test of regional preparedness and response for public health emergencies. Post-outbreak assessments implicated weak health systems as a major factor underlying the widespread and prolonged nature of the EVD outbreak [27]. This was influenced by the deficit in the health workforce that tackled the outbreak [28]. It was evident from this epidemic that the affected countries were caught off guard and unprepared [29] Two years post-outbreak, the six affected countries in the region still had inadequate numbers of field epidemiologists. It would have been expected that these countries would record far higher numbers drawing from their experience yet only one of them (Liberia) had over half of the required number of trained field epidemiologists. Generally, there were more frontline than advanced trainees in these countries. The gap identified by this assessment corroborates the need for long-term efforts to improve health systems especially in field epidemiological capacity in Member States towards a more rapid response to and management of future outbreaks [30]. Competency training in field epidemiology especially for health care workers who are at the frontline is crucial as the lack of it delayed an appropriate response during the outbreak with some of them leaving their post because of the fear of being infected [26,31,32]. It is not necessarily new response methods that are required, rather, an adequate workforce and coordination [33]. There is evidence of the poor coordination at the district level in managing the EVD control activities in Guinea [34]. Poor in-country coordination of activities among the few available personnel in the containment of epidemics and health emergencies was still a problem identified by this assessment. The workforce data should be regularly reviewed not only to assess the attainment of targets but to identify opportunities for refinement to serve the public health priorities of the country.

 

Until amended, the current IHR definition of a public health emergency of international concern (PHEIC) implies that outbreaks must necessarily overstep a national border before they warrant an international response [9,35]. Although the WHO has identified the need to transform organizational culture and delivery, that will not be sufficient to prevent and mitigate future outbreaks. This reiterates the need to build local capacity in preparation for imminent epidemics without overly relying on international interventions. This requires full political support from Member States for implementing the IHR core capacities for public health [36]. Such commitment to improving preparedness capability must reflect in fiscal budgetary changes and allocation as well as capacity building [37]. A failure in this regard only renders local economies of Member States vulnerable to a similar fate suffered by the high-transmission countries (Guinea, Liberia and Sierra Leone) who together lost over $2 billion due to the EVD outbreak in just two years [38] As at the time of assessment, there was no budgetary allocation for public health emergency preparedness.

 

The recent EVD epidemic has revealed that we are only as safe as the least prepared States [39] Findings from the assessment indicated that Cabo Verde was the only Member State that did not record any trainees from either of the three FELTP tiers. Guinea-Bissau had no Advanced/Intermediate trained epidemiologists whereas Niger recorded no frontline graduates. Although the Ebola outbreak did not occur in any of these countries, there are other epidemics that have occurred in previous years. Cabo Verde experienced a Zika virus outbreak in 2015 with unprecedented magnitude in Africa and it was the first to be associated with microcephaly in the continent. Earlier in 2009, there was also an unprecedented epidemic of dengue virus in the same island country. Although these were single outbreaks, they resulted in sequential epidemic waves due to the unique epidemiological setting in Cabo Verde thus accentuating the need for an improved and integrated surveillance system to address imminent outbreaks in the country [40,41] Such surveillance systems can only be implemented by skilled field epidemiologists. A chickenpox outbreak lasting for over 6 months was also reported in Guinea-Bissau [42] as well as a meningitis outbreak in Niger [43]. Two of these three countries: Cabo Verde and Niger, as well as the other Member States with lower densities of field epidemiologists were identified in this assessment to be farther away from those with higher densities which clustered together. Therefore, it is imperative that Member States support each other in improving epidemiological capacities as local and across border efforts are concerted in ensuring adequate preparedness [39].

 

The contribution of FETP trainees in mitigating the EVD outbreak in Nigeria and Liberia[22-24] shows the critical role being played by the three FETPs in the region. However, apart from Ghana, none of the assessed countries has a full complement of all three FETP tiers (basic/frontline, intermediate, and advanced). The competency training offered by FETPs combines veterinary and public health prediction-based surveillance to help identify zoonotic diseases before transmission to humans and their adequate management [44,45]. Also, frontline health workers are trained to be able to detect health threats early and respond rapidly to public health emergencies.[46] Moreover, programme ownership by ministries of health and local universities ensures the integration of graduates into the health system [18]. Another advantage of these programmes is that they are under a networking body (AFENET) that ensures coordination across countries in Africa hence fostering cross-border collaborations between trainees which can be harnessed in the event of a public health emergency. This highlights the need for more of these training programmes to be established in other Member States to widen coverage.

 

Study limitations

 

The assessment did not cover the utilization /deployment of FETP trainees within the systems. Also, interviews were only conducted at the national level hence we could not provide a detailed description from training institutions and FETP trainees of the underlying factors related to the deficiencies in epidemiology workforce capacity. These could be considered in future assessments of epidemiologic capacity.

 

 

Conclusion Up    Down

The assessment revealed that there was an inadequate number of trained field epidemiologists in all Member States as a wide gap was identified measuring against the required number of frontline and advanced/intermediate trainees for each State. This is an indication that more resources should be invested into building local epidemiological capacity to enhance preparedness for and response to public health emergencies.

 

We recommend that the ECOWAS/RCSDC and other multinational public health workforce organizations that support FETPs worldwide engage relevant stakeholders, such as country representatives, regional public health organizations, and other funding institutions, to discuss ways of attaining the field epidemiology workforce targets through collaborative efforts.

What is known about this topic

  • West Africa has recorded recent outbreaks exposing limited regional response capacities in disease surveillance, preparedness and rapid response strategies
  • Recent outbreaks in Africa have been blamed on inadequate workforce in the region

What this study adds

  • There is a wide gap in trained field epidemiologists measuring against the required number of frontline and advanced/intermediate trainees for each State
  • Some countries have no trainees from either of the three FELTP tiers./li>
  • xxx

 

 

Competing interests Up    Down

Authors declare no competing interest.

 

 

Authors' contributions Up    Down

VL, DAB, KMN, BS, EK participated in the Conceptualisation, data collection, report writing, drafting the manuscript, and finalizing manuscript writing. EEK AND SNA participated in drafting and finalizing manuscript writing. All authors read and approve the final version of the manuscript.

 

 

Acknowledgments Up    Down

We would like to acknowledge all countries and institutions who participated and assisted us through the data collection process.

 

 

Tables and figures Up    Down

Table 1: Country Specific Analysis for Field Epidemiologists

Table 2: Country Specific Analysis for Field Epidemiologists

Figure 1: Map Showing the Gap and Available advanced FELTPs

Figure 2: Map showing the Gap and available frontline FELTPs

 

 

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Research

Workforce capacity assessment for public health emergencies, disaster preparedness and response in the Economic Community of West African States (ECOWAS) region, April – July, 2018

Research

Workforce capacity assessment for public health emergencies, disaster preparedness and response in the Economic Community of West African States (ECOWAS) region, April – July, 2018

Research

Workforce capacity assessment for public health emergencies, disaster preparedness and response in the Economic Community of West African States (ECOWAS) region, April – July, 2018


The Journal of Interventional Epidemiology and Public Health (ISSN: 2664-2824). The contents of this journal is intended exclusively for public health professionals and allied disciplines.