Compliance with disease surveillance and notification by private healthcare providers in South-West Nigeria

Abstract

Background Infectious disease outbreaks with a propensity to spread over large geographic areas are happening more frequently. The advances in transportation coupled with globalization and increased travel have facilitated the propagation of infectious diseases. The Ebola Virus Disease (EVD) outbreak of 2014 exposed the challenges of responding to such outbreaks. The EVD outbreak registered in eight countries across three continents, lasted an unprecedented 22 months and infected over 20,000 people with a significant case fatality rate before it was eventually contained. Efforts aimed at controlling the international spread of diseases have been ongoing for ages. The World Health Organization in 1969 developed the International Health Regulations (IHR) which was revised in 2005. The purpose of the IHR is “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.” Several African countries implement the Integrated Disease Surveillance and Response (IDSR) strategy as their means of achieving the IHR goals. Assessments following the 2014 West Africa EVD outbreak revealed that several countries were yet to meet the targets of the IHR. A systematic review found that private health facilities were being left behind in disease surveillance systems despite serving a substantial proportion of the population across several countries including Nigeria. Thus, this study investigated the compliance with disease surveillance and notification by private health facilities in South-West Nigeria. The objectives of the study were to: i) examine the legislative/ legal framework for routine disease reporting in Nigeria (nationally and sub-nationally) and how it might affect compliance by private providers, ii) determine the level of reporting of notifiable diseases by private providers, the completeness of information and how these compare with the public sector, iii) determine the knowledge and perceptions of private healthcare providers regarding the importance of routine disease reporting in Nigeria and iv) identify the barriers to routine disease reporting by private healthcare practitioners/ facilities in Nigeria. Data Sources and Methods The study used a mixed method approach that included literature review and policy analysis, key informant interviews (KIIs) and a survey of private health facilities across the six states in South-West Nigeria. The South-West geopolitical zone was selected out of the six geopolitical zones for the study because it had majority (40%) of private health facilities. A planned secondary data analysis to determine the completeness of information and how these compare with the public sector could not be accomplished due to the non-availability of routinely reported data. Key informants were identified based on their responsibility within the Integrated Disease Surveillance and Response System and the National Health Management Information System. A sample size of 424 private health facilities was calculated. The sample was proportionally allocated to the six states based on the number of private health facilities in the state. Fourteen key informants were interviewed in all (two at the national level and 12 across the six states in the South-West). These were the National Health Management Information System (NHMIS) officer and a representative of the IHR focal point at the national level, as well as the state Health Management Information Systems Officer and State Epidemiologist in each state. There is only one State Health Management Information System Officer and one State Epidemiologist in each state. Five hundred and seven private health facilities were surveyed across the six states in the South-West. The KIIs were transcribed verbatim and read over repeatedly by the principal investigator. Themes were generated in line with the objectives of the study and supporting quotes were extracted. The health facility survey data was analyzed using the statistical programming language “R”. Analysis entailed computing frequency distributions (to determine the level of compliance with reporting notifiable diseases) and estimation of a logistic regression model (to determine factors associated with the likelihood of reporting such diseases among private providers). Results Several legal instruments were identified in Nigeria with the most recent comprehensive legal instrument for disease surveillance being the IDSR policy of 2005. The active law on disease surveillance, the Quarantine Act was enacted almost a century ago, in 1926. The IDSR policy considered the system as a component of the overall NHMIS with pronouncements aimed at avoiding duplication. The national health information system policy (2014) pronounced the establishment of a National Health Data Governance Council (NHDGC) to be chaired by the Minister of Health and proposed State Health Data Governance Councils for each state. Key informants did not believe that the legal instruments and funding for disease surveillance in Nigeria were adequate. There were no specific state laws or policies on disease surveillance though most officers indicated that all states unanimously adopted the IDSR policy at a National Council of Health (NCH) meeting several years earlier. The officers also believed that the level of implementation of existing policies and laws could be further improved upon. Only 40% (Lagos (51%), Oyo (60%) Osun (30%), Ogun (17%), Ondo (23%) and Ekiti (35%)) of the private health facilities included in the study were reporting into the disease surveillance system. About two-thirds (66%) of the facilities did not have the requisite tools for reporting, over 50% of clinicians were aware that reporting on disease surveillance was a legal responsibility and 76% of the clinicians mentioned at least two diseases that required immediate notification. Over 90% of health providers that reported that they had never attended to a condition that needed to be reported actually attended to at least a case of Malaria in the year preceding the survey. The availability of reporting tools, having an assigned health records officer, knowledge of the data collection tools by the health records officer and the attending clinician and awareness about a law or regulation on disease surveillance were significantly associated with a higher likelihood of reporting notifiable diseases by private health facilities. There were two data collection systems operating in the country: IDSR and NHMIS. These were being managed by different departments with little to no cross-departmental collaboration. About 40% of the diseases and conditions tracked through IDSR are also tracked by NHMIS. Achieving IHR goals in Nigeria is hampered by weak legal instruments. The IDSR policy of 2005, though a good first step, has not been enacted into a national law. All the states have adopted the IDSR policy at the NCH (a forum of the Minister of Health, Commissioners of Health and the Permanent Secretaries) but this body does not have constitutional powers. In addition, the Federated structure of Nigeria does not ensure that states must implement national laws and policies unless they are first domesticated as state instruments. Compliance with reporting by private health facilities was poor and varied by state. A wide range of factors influenced reporting by health facilities. Health facilities that had the data collection tools were more likely to have reported into the disease surveillance system. However, the majority of the health facilities did not have the data collection tools during the survey. Many clinicians were unaware that Malaria is a notifiable disease in the IDSR forms for monthly reporting. Such gaps in knowledge could lead to reporting incomplete information. This finding was in contrast to their high levels of awareness about immediately notifiable diseases. However, the diseases predominantly mentioned were Polio, Lassa Fever and EVD which have recently ravaged the country and have been regularly featured in print and online media. The findings of this study showed that IDSR and NHMIS systems were operating independently. However, there was a significant overlap between the two systems. The two systems are managed by the Department of Health Planning Research and Statistics and the Department of Public Health respectively and resources are not leveraged across both systems. However, officers responsible for each system reported that they lacked adequate resources for implementing them. In such situation, combining resources could have achieved more. Conclusion There are inadequate laws governing disease surveillance in Nigeria. Compliance with disease surveillance is poor, with variations across states. Parallel systems diffuse resources and breed inefficiency in the national health information system. There is an urgent need to address the shortcomings of the system in order to ensure that Nigeria adheres to IHR but most importantly can adequately identify and respond to infectious disease risks in the country. Policy Implications There is a need to strengthen the legal framework for disease surveillance at the national and state levels in Nigeria. The federal and state legislative bodies need to be further engaged on the importance of global health security as part of the protection and security mechanism for the country. Laws and policies on disease surveillance that are currently in effect need to be enforced to achieve the purpose for which they were formulated. Governance of the health information system needs to be strengthened with a view to eliminating duplication and improving efficiency within the confines of available resources. Adequate resources need to be made available for disease surveillance based on the potential impact they can have in maintaining and improving the health of the citizenry in the country.