The evaluation of the first two cohorts of Guinea’s FETP-Frontline program provides opportunities to make recommendations to improve the program as well as the evaluation process itself for future cohorts. While identified in the specific context of the Guinean program, some of these recommendations may also be applicable to other similar contexts, in West Africa and beyond.
Based on the demographic characteristics of the first two FETP-Frontline cohorts in Guinea, the evaluation revealed important future considerations for the recruitment of younger, and especially female, individuals to perform key surveillance functions in Guinea. Both initial cohorts were predominantly male (80%). One reason behind this disparity is that, because FETP-Frontline is intended to strengthen district surveillance systems, selection for the first two Frontline cohorts in Guinea focused on individuals serving as the District Head of Disease Surveillance and Control. Even though, according to the National Plan for Health Development (2015–2024) , women are equally represented in the overall health workforce (51% female to 49% male), the senior levels within the Ministry of Health, including in the districts, are primarily male. In this way, gender imbalance within FETP-Frontline trainees in Guinea is linked to underlying gender disparities within the Ministry of Health, which could be addressed through proactive policies to recruit women to serve as the heads of departments, including Departments of Disease Prevention and Control at the district level.
The relatively high mean age of the first cohort as compared to the second was part of a strategy to ensure the understanding and endorsement of the program from district health office leadership. In line with the strategy, subsequent cohorts, including the second cohort, targeted additional junior staff, responsible for the everyday surveillance and field epidemiology field work. Recruitment of junior staff is important to counterbalance the large proportion of the public health workforce in Guinea that will reach the mandatory age of retirement in the next 5 years. The Ministry of Health needs to prioritize provision of key skills to younger personnel, and particularly women, to galvanize the surveillance workforce and increase gender equity; these efforts may require close coordination with the higher education sector, to ensure a robust educational pipeline that specifically encourages graduates to pursue a career in the public sector. These challenges are not unique to Guinea; between 2013 and 2017, the regional 2-year West Africa Field Epidemiology and Laboratory Training Program trained 48 individuals from 11 countries, but only eight of the graduates were women (17%). The evaluation report noted that this disparity reflects underlying imbalances in the professionals from which trainees were recruited .
The evaluation revealed that FETP-Frontline graduates in Guinea were acutely aware of the skills they had gained from the training and were able to identify when and how to carry out local-level disease surveillance tasks, including not only collecting data and reporting it through identified channels, but also analyzing data and making recommendations for improvements to stakeholders. Findings indicate that graduates from both cohorts felt their skills had improved since participating in FETP-Frontline. Moreover, tangible outputs from FETP-Frontline graduates at the workplace were observed both by their supervisors and in the health facilities in which they served. For example, all but one of the health facilities had case definitions readily available. These findings mirror outcomes observed in other countries, as reported in the limited available published literature. In Côte d’Ivoire, for example, as in Guinea, the work of graduates of the Surveillance Training for Ebola Preparedness (STEP) program, which has similarities to FETP-Frontline in curriculum content, improved the understanding of case definitions and the quality of case investigations .
However, the health facility observations did reveal some gaps. Only just over half (54%) of the visited health facilities had lists of immediately or mandatory notifiable diseases visibly posted or readily available. It is possible that the absence of these guidelines from other facilities is due to the lists having been recently updated at the time of the evaluation, resulting from Guinea’s efforts to review, update, and enhance implementation of its national IDSR framework. However, in 2017, updated IDSR guidance, including lists of reportable diseases and their notification frequency, were distributed to all health facilities in the country. Given the newness of the guidelines, it is particularly important that they should be visibly displayed in all health facilities, to ensure staff are familiarized with the requirements. Similarly, very few (16%) of the facilities had a rumor log for suspected cases and outbreaks, and indeed most of the graduates seemed to be unfamiliar with the concept of a rumor log. Some even reported that it did not seem necessary when they had access to verifiable data to use for reporting. With event-based surveillance considered an important component for IHR compliance, and also incorporated into IDSR indicators, it will be important to better integrate these other aspects of surveillance within the FETP training structure. In that way, the planned expansion of FETP in Guinea and the subsequent the increase of FETP graduates working at all levels of the public health system will serve to address some of these observed deficiencies, as decision-makers have a better understanding of the tools required for a robust surveillance system.
A limitation of the evaluation was that it did not directly seek to measure impacts on the surveillance system. However, there is some evidence to suggest a positive benefit of the first two FETP-Frontline cohorts on the surveillance system in Guinea. Data collected during the training showed that the number of facilities integrated into the national surveillance system increased from 450 to 635. As is the case in many countries, the Ministry of Health in Guinea has limited control and oversight of private sector health facilities, and improving coordination with private for- and not-for-profit health providers is highlighted as a priority in the National Plan for Health Development 2015–2024 . To this end, eight FETP-Frontline graduates in Guinea reported improved integration of private clinics into the national surveillance system as a product of the program. As an example, it was a private clinic, added to the surveillance system through the first FETP-Frontline cohort, which provided the MOH with sufficient data on the 2017 measles outbreak to allow for a formal request for WHO assistance, accelerating the response effort.
There are also data to support improved performance of the surveillance system, although these improvements cannot be directly attributed to the FETP-Frontline training. Timeliness of reporting, for example, increased from 68% around the start of the FETP-Frontline program to 98% by the time of the evaluation; the graduates themselves also perceived similar benefits. When the interview team asked graduates to identify the most important outcomes FETP-Frontline had had on the surveillance system, 70% reported that the quality, completeness, and timeliness of data had improved. This aligns with similar increases observed in other countries; for example, in Benin, average timeliness of surveillance increased almost 130% after the completion of the first cohort, from 37 to 85% in 12 weeks . These data, coupled with the observations regarding the inclusion of private clinics, suggest that future evaluations could benefit from incorporating more direct measures of benefit, as well as impact, on the surveillance system, to further demonstrate the value provided by the FETP-Frontline training. Moreover, further investigations into the mechanisms and approaches used by the FETP-Frontline graduates to incentivize the participation of the private clinics could serve as useful models for other countries’ FETP and FETP-Frontline programs.
Another limitation of this evaluation of Guinea’s first two FETP-Frontline cohorts was that graduates were asked to score their pre- and post-training knowledge retrospectively, which could have resulted in recall bias. The extent of the recall bias could have been affected by the length of time after completion of the training that the questionnaires were completed, which differed between the two cohorts evaluated. Defining a set timeline for administering pre- and post-training questionnaires, and completing the post-training evaluation at a standard/routine interval after completion of the program, could reduce potential recall bias; indeed, CDC guidelines recommend conducting the evaluation no more than 6 months after the conclusion of the training, which was exceeded in the present evaluation. The possibility of desirability bias also cannot be discounted, whereby the respondents consciously or sub-consciously provided responses that would demonstrate the value of the program. The decision not to record the interviews might have helped mitigate some of this bias, as well as encourage the trainees to speak more freely, but reliance on note-taking by the interviewers might have resulted in some lost details or nuances in the recorded responses. The interview questions should also be reviewed by a survey design expert, to minimize ambiguity, leading questions, or other sources of inaccuracy, although the questionnaire was field-tested prior to deployment in the evaluation.
Given the successful implementation of FETP-Frontline across many countries since 2015 [5, 15], there may be an opportunity to develop a standardized monitoring and evaluation “toolkit”, consisting of suggested monitoring indicators aligned with IDSR, template evaluation questions, and other materials designed specifically for FETP-Frontline, which also incorporates standardized direct measures, such as the number of structures contributing to the surveillance system, as well as other indicators that could seek to examine the direct impacts on the FETP-Frontline program on the performance of the surveillance system. To our knowledge, examination of direct outcomes is a frequent omission in the evaluation of FETP and other related epidemiological workforce training programs, where the emphasis of evaluation is focused on pre- and post-training knowledge and competencies, participation in surveillance and response activities, and career progression of graduates [16,17,18,19,20]. To this end, a monitoring and evaluation toolkit could still have the flexibility to be customized to fit the specific needs and context of each country, but would standardize data collection between programs and allow for analysis of the benefits and impact of FETP-Frontline on a global, as well as national and regional, scale.