NPHI Stories: "A Culture of Responding": Training Course Pays Off for Mozambique
A request for help might not seem like a significant milestone for a country’s public health system. But in the case of a cholera outbreak in Tete Province in early 2017, it represented an important step forward for Mozambique.
In 2016, Mozambique’s National Institute of Health (Instituto Nacional de Saúde, INS) held a training workshop for the country’s provincial health leadership, specifically Provincial Medical Officers (PMOs). Cynthia Semá Baltazar, Head of INS’s Surveillance Department, said the idea behind the training was to develop a “high-level, intensive training to give [PMOs] real, practical tools for real topics,” to strengthen early detection, investigation, and rapid response to outbreaks and health-related emergencies at provincial and district levels.
A critical link in the chain
PMOs are critical to identifying and responding to outbreaks. Mozambique has one PMO assigned to each of its 11 provinces (including the City of Maputo). The PMO’s role includes managing reporting of public health information from local to provincial to national levels; coordinating public health response to health threats at the provincial level; and implementing public health interventions, among other responsibilities. However, PMOs are often appointed with only a few years of clinical experience under their belts — and very little understanding of the public health concepts and skills critical to their role in disease surveillance.
Dr. Stélio Dimande, PMO from Inhambane Province, who attended the INS training, notes that he was appointed to his PMO role without any prior investigation experience. “In 2008 or 2009, there was an outbreak of cholera, and at that time I did not know how to deal with the outbreak. I just heard from my colleagues what should be done,” he said.
According to INS Director Dr. Ilesh Jani, this lack of public health understanding at the provincial level led to inaction during past outbreaks, as well as overdependence on national-level support. Mozambique had an increasing need for PMOs and other health professionals to be trained in leadership, early warning, outbreak management, and use of epidemiological tools — all of which are core functions of an NPHI.
An idea that became a reality
To answer the urgent need, INS developed a two-week Epidemiology and Leadership course with support from CDC and the International Association of National Public Health Institutes (IANPHI). INS designed and implemented the course in collaboration with the National Directorate of Public Health (Direção Nacional de Saúde Pública) and the Brazilian Association of Field Epidemiology Professionals (Associação Brasileira de Profissionais de Epidemiologia de Campo), a long-time technical assistance partner for INS and program facilitator.
During the workshop, participants gained skills in critical analysis and rapid reporting; evaluation of surveillance data; using routine data for action; field investigation; the role of laboratories during outbreaks and emergencies; biosafety and biosecurity in the management of outbreaks and emergencies; health communication; management and leadership; and drug supply chain management.
After the program, many PMOs noted that some of their previous understanding about outbreaks had been incorrect. According to Baltazar, “Some of the PMOs thought they knew how the outbreak investigation worked [before the training], but during the training, they realized that they didn’t — and that they weren’t reporting correctly.”
Training leads to fast action
Three months after the training, an outbreak in Inhambane Province demonstrated the value of the course. The difference following the training, according to Dr. Dimande, was notable. “Three months after I took the course, we had an outbreak of diarrhea,” he said. “The team was assembled very quickly, and everything that was taught to me during the course was put into practice.”
After participating in the workshop, cholera outbreaks in early 2017 further put these lessons to the test. In Tete Province, an assessment of the risk that the outbreak would spread led to a request for over 700,000 doses of oral cholera vaccine from WHO’s International Coordination Group (ICG). A widespread vaccination campaign was then conducted in the province, offering a clear example of an outbreak investigation leading to a public health intervention for its control.
The improved confidence and public health understanding has helped provinces become more “autonomous, and take more responsibility for outbreak investigation,” said Dr. Jani, creating “a culture of responding.”
Moving forward, IANPHI and CDC will help build upon the PMO training through support for additional capacity building at the provincial and national levels. All of this will contribute to developing a high-performing disease monitoring system that works in collaboration with INS to detect potential health threats from the ground up.