This is a report of evaluation of TB surveillance System which was conducted in 2010 by Dr. Islam Saeed as part of FELTP milestones.

1. EMHJ • Vol. 19 No. 2 • 2013 Eastern Mediterranean Health Journal
La Revue de Santé de la Méditerranée orientale
Report
Evaluation of the national tuberculosis surveillance
system in Afghanistan
K.M.I. Saeed,1,3 R. Bano 2 and R.J. Asghar 3
‫تقييم النظام الوطني لرتصد السل يف أفغانستان‬
ُّ
‫خواجة مري إسالم سعيد، راشدة سيد بانو، رانا جواد أصغر‬
ً
‫اخلالصـة: يوجد يف أفغانستان نظامان لرتصد السل؛ الربنامج الوطني ملكافحة السل، ونظام املعلومات لإلدارة الصحية. وقد أجرى الباحثون تقييام‬
ُّ
‫هلذين النظامني للرتصد يف الفرتة كانون الثاين/يناير – شباط/فرباير 0102 للتعرف عىل مواطن القوة ومكامن الضعف ولصياغة التوصيات. وتم‬
ََ ُّ ُّ
‫تقييم مكونات كل نظام باستخدام الدالئل اإلرشادية ملراكز مكافحة األمراض والوقاية منها يف الواليات املتحدة األمريكية، ووجد الباحثون أن‬
‫منافع ومرونة الربنامج الوطني ملكافحة السل جيدة، وأن استقراره وحسن متثيله وجودة املعطيات فيه معتدلة، أما البساطة واملقبولية ومالءمة التوقيت‬
ْ ُ
ُّ
‫فيه فكانت سيئة؛ إذ يتجاوز التأخر يف إصدار التقارير ثالثة أشهر، وكانت القيمة التنبؤية اإلجيابية 11% واحلساسية 07%. كام وجد الباحثون أن نظام‬
‫املعلومات لإلدارة الصحية بسيط ومقبول ومستقر، ُتعدُّ تقاريره يف الوقت املناسب، وقد كان إعداد التقارير واإلمداد باملعلومات االرجتاعية جيد ًا ألن‬
َ
ٍ َ
.%68 ‫هذا النظام كان حيظى بدعم حكومي جيد. وكانت املرونة وجودة املعطيات والتمثيل معتدلة، وكانت القيمة التنبؤية اإلجيابية 01% واحلساسية‬
ُّ ِّ
.‫ومل يكشف أي من النظامني أية فاشية. واتضح للباحثني أن النظامني يمثالن ازدواجية جلهود الرتصد وأهنام ال يغطيان القطاع اخلاص‬
ٌّ
ABSTRACT Afghanistan has 2 tuberculosis surveillance systems, the National Tuberculosis Control Programme (NTP)
and the Health Management Information System (HMIS). An evaluation of these surveillance systems in January/
February 2010 was done to identify their strengths and weaknesses and to formulate recommendations. Attributes of the
programmes were evaluated using US Centers for Disease Control and Prevention guidelines. Usefulness and flexibility
of the NTP system were good; stability, representativeness and data quality were average. Simplicity, acceptability and
timeliness were poor. Reporting delays regularly exceeded 3 months. Positive predictive value and sensitivity were
11% and 70% respectively. The HMIS system was simple, acceptable and stable, with timely reporting. Reporting and
feedback were good, as this system has strong government support. Flexibility, data quality and representativeness
were average. Positive predictive value and sensitivity were 10% and 68% respectively. No outbreaks were detected by
either system. The NTP and HMIS surveillance systems are duplicative and neither covers the private sector.
Évaluation du système national de surveillance de la tuberculose en Afghanistan
RÉSUMÉ L'Afghanistan dispose de deux systèmes de surveillance de la tuberculose, le Programme national de lutte
antituberculeuse et le système d'information pour la gestion de la santé. Une évaluation de ces systèmes de surveillance
en janvier/février 2010 a été menée afin d'identifier leurs forces et leurs faiblesses et de formuler des recommandations.
Les caractéristiques des programmes ont été évaluées à l'aide des recommandations des Centers for Disease Control and
Prevention américains. L'utilité et la souplesse du programme national de lutte antituberculeuse étaient satisfaisantes ; la
représentativité et la qualité des données étaient moyennes. La simplicité, l'acceptabilité et la ponctualité étaient
médiocres. Le retard de transmission des notifications dépassait régulièrement trois mois. La valeur prédictive positive
et la sensibilité étaient respectivement de 11 % et 70 %. Le système d'information pour la gestion de la santé était simple,
acceptable et stable, et transmettait les notifications en temps voulu. Les notifications et les commentaires étaient
satisfaisants, car le système bénéficiait d'un appui soutenu du gouvernement. La souplesse, la qualité des données et la
représentativité étaient moyennes. La valeur prédictive positive et la sensibilité étaient respectivement de 10 % et 68 %.
Aucune flambée n'a été détectée par ces deux systèmes. Le programme national de lutte antituberculeuse et le système
d'information pour la gestion de la santé font double emploi mais aucun ne couvre le secteur privé.
1
Afghanistan National Public Health Institute, Ministry of Public Health, Kabul, Afghanistan (Correspondence to K.M.I. Saeed: km_islam2001@yahoo.com).
2
Communicable Disease Surveillance and Response Unit, World Health Organization Country Office, Kabul, Afghanistan.
3
Field Epidemiology and Laboratory Training Programme, National Institute of Health, Islamabad, Pakistan.
Received: 29/08/11; accepted: 21/02/12
200

2. ‫املجلد التاسع عرش‬ ‫املجلة الصحية لرشق املتوسط‬
‫العدد الثاين‬
Introduction describes the national tuberculosis criteria and ranked as poor, average
surveillance systems in Afghanistan, or good. The main documents of each
Tuberculosis (TB) is a public health identifies strength and weakness of the system (strategic plan, guidelines,
problem which is more common in de- systems and provides recommenda- manuals, annual reports and data-
veloping countries due to the disease’s tions for improvement. bases) were reviewed and consulta-
close links to poverty, housing status and tion with stakeholders was carried out.
access to health services. Furthermore, In addition 5 key informants from
the disease has been re-emerging in Methods each system were interviewed from
developed countries in recent decades. among the directors, managers and
Based on World Health Organization The review was undertaken during officers. Furthermore 1 or 2 staff at
(WHO) estimates, 9.27 million new January to February 2010. In order to departments of the MoPH (research,
cases of TB occurred in 2007 (139 per evaluate the TB surveillance systems at surveillance, preventive health, policy
100 000 population), compared with the national level the guidelines for the and planning and health care service
9.24 million new cases (140 per 100 evaluation of public health surveillance delivery) were interviewed; they were
000 population) in 2006 [1]. systems developed by the United States selected based on their involvement in
Centers for Disease Control and Pre- and relevance to the TB surveillance
Afghanistan is recovering from the
vention (CDC) [5] were used. These system.
aftermath of more than 2 decades of
guidelines include the following steps:
civil war; nevertheless, there is ongo-
ing security instability and economic • Engage the stakeholders in evalua-
difficulties in the country. Control of tion. Description of the TB
communicable diseases is one of the • Describe the surveillance system to surveillance systems
highest priorities for the Ministry of be evaluated.
Public Health (MoPH) because these The Afghan NTP was established in
• Focus the evaluation design.
account for 60%–80% of all curative 1954 with technical and financial sup-
outpatient visits and over half of all • Gather credible evidence regarding port from WHO. The NTP is a techni-
deaths in Afghanistan [2]. The country the performance of the surveillance cal department of the MoPH that leads
remains one of the TB high-burden system. and carries out prevention, detection,
countries with a high ratio of females • Justify and state conclusions and diagnosis and treatment of TB patients.
to males infected (1.85:1). TB control make recommendations. Its vision is a TB-free country, with
services are an integral part of the pack- • Ensure use of evaluation findings and elimination of the disease as a public
age of services delivered through the share lessons learned. health problem by 2050 [6]. The major
primary health care system at district Using the guidelines, the surveil- objectives of the programme are to
and provincial levels. The sustainability lance systems for one disease were reduce the risk of infection, morbid-
of activities is unclear, however, given taken into acount, the sampling was ity and mortality due to TB by having
the unstable security situation with its purposeful and the head of depart- 100% coverage of DOTS treatment
current reliance on donor support. ments were approached to obtain nec- by the end of year 2015 and ensuring
TB control is a priority for the coun- essary information. Both the Afghan the cure rate and detection rate of new
try, being one of the main 7 compo- NTP and HMIS were evaluated by ap- sputum smear-positive pulmonary TB
nents of the Basic Package of Health plying these guidelines. We did a desk cases at over 85% and 70% respectively.
Services for Afghanistan [3]. TB care review before interviewing managers There are 13 recording and reporting
is provided free of charge in all public in both systems. The managers of other forms which are used by the surveil-
health facilities. It is very important to relevant departments were also inter- lance department for data management.
strengthen surveillance systems in order viewed. We did not use any statistical The programme claims that data are
to find TB patients as early as possible tests of significance; however, selected collected, analysed and disseminated
and treat them properly. There are sur- indices were used and calculated as quarterly in review meetings. Originat-
veillance 2 systems which, in addition to described in the guidelines [5]. Ten ing from public health facilities, the
other activities, are responsible for TB attributes (usefulness, simplicity, flex- data flows to the provinces and then
surveillance in Afghanistan: the Health ibility, data quality, predictive value, to regions and finally to the NTP at the
Management Information System sensitivity, timeliness, acceptability, national level, where multiple national
(HMIS) [4] and the National Tuber- representativeness and stability) were indicators are calculated and reported
culosis Control Programme (NTP). evaluated in both systems. Attributes to the MoPH and WHO Regional
This paper is an evaluation report which were scored based on pre-defined Office for the Eastern Mediterranean.
201

3. EMHJ • Vol. 19 No. 2 • 2013 Eastern Mediterranean Health Journal
La Revue de Santé de la Méditerranée orientale
WHO and other
MoPH
partners
National TB
Control
Programmme
Regional level Regional level Regional level Regional level
Regional level Regional level Regional level Regional level
Provinvial levels - (34 provinces)
Data from facility levels totally
1013 till 2010
Figure 1 Flow of data at the National TB Control Programme (NTP) in Afghanistan (MoPH = Ministry of Public Health)
The flow of information is presented illustrates the flow of information. The registries (logbooks) are the source of
in Figure 1. The system is supported by system is supported by USAID and the data. HMIS collects few variables
WHO, the United States Agency for World Bank. whereas NTP uses consistent, standard
International Development (USAID), forms to collect more variables regard-
the Japan International Cooperation ing morbidity and mortality of TB
Agency, the Global Fund to Fight AIDS, Attributes of the systems including age, sex and geography. The
Tuberculosis and Malaria and some HMIS database is linked and fully inte-
other donors. A summary of the evaluation of the 10 grated with other databases at MoPH,
The Afghan health information sys- attributes from the CDC guidelines are while the NTP database is still in the
tem was upgraded to HMIS in 2003 presented in Table 1. pilot stage. Prior to sending to the na-
[4] and focuses on standard report- tional level, data are edited, analysed and
Usefulness shared with stakeholders at provincial
ing forms containing the minimum
information that needs to be collected, HMIS data are useful for planning and levels and submitted electronically to
analysed and reported routinely. The monitoring but are less useful for de- the MoPH quarterly. The HMIS is sim-
system is computerized, which allows tecting TB outbreaks, whereas proper ple, quick and easy to enter and analyse
data on priority health problems at the analysis of NTP data will detect and the data. The Microsoft Access database
local levels to be aggregated on a data- allow a response to outbreaks. TB data is familiar to staff and facilitated by a
base at the provincial and national levels collected by HMIS are poorly linked to series of simple drop-down menus.
and rapid distribution of analysis copies action, while NTP data are used by both However, data collection and flow of
to all levels. The main aims of the system national and international stakeholders. information is more complex. Taking
are better management of health servic- Based on research department state- into account the very high turnover
es and resources, facilitating supervision ments at MoPH they have not used TB of staff the officers are well-trained at
and assisting in planning, monitoring surveillance data for the development all levels. All implementers at primary
and evaluation. In HMIS data are col- and conduct of studies; however, NTP health care facilities, including govern-
lected about suspected TB cases and the surveillance data are used by the TB ment, national and international NGOs
number of slides examined. Data gener- research department and WHO for are involved in the reporting of data and
ated at the facility level are reported to various studies. timely quarterly feedback is provided to
provincial levels monthly for analysis them from the national level.
and feedback and afterwards the reports Simplicity Using multiple forms for data col-
go to the national level quarterly for Standard case definitions are well- lection makes the NTP system more
feedback and dissemination. Figure 2 utilized in both systems and facility complex both in its structure and mode
202

4. ‫املجلد التاسع عرش‬ ‫املجلة الصحية لرشق املتوسط‬
‫العدد الثاين‬
Other
MoPH
partners
HMIS central
database
National hospital
Quarterly
Provincial levels - (34 provinces) Provincial public hospitals
Monthly
Community level - BHCs, CHCs
and district hospitals
Figure 2 Flow of data at the Health Management Information System (HMIS) in Afghanistan (MoPH = Ministry of Public
Health, BHC = basic health centre, CHC = comprehensive health centre)
of operation. Data are sent as hard Being supported by the government for missing and illegal values (out of
copies to all levels, with delays at each and having staff in the government a predetermined range) at different
level. Vital TB indicators such as case salary system, the HMIS is sustainable, levels. Data management, including
notification rate, case detection rate, unlike a project based approach in data collection, entry, editing, analysis
TB conversion rate and treatment suc- which the funding is withdrawn when and feedback, is good due to timely
cess rate are calculated using available the project is finished. It also conforms feedback and training.
data in NTP. With proper feedback with planned new software systems in The NTP has expanded rapidly
mechanisms the main vehicle for com- which common files will link to other but there are still blank and illegal val-
munication is discussing the key issues databases such as training, expendi- ues in the forms despite checks on the
using data in the quarterly review meet- ture, pharmacy, human resources and quality of data at provincial, regional
ings at provincial, regional and national others. Variations in funding have had and national levels in quarterly re-
levels. Staff are well-trained regarding little effect on the functioning of the view meetings. It covers more com-
TB surveillance but there is still a need system. prehensive data compared with the
to conduct training at the grass-roots In contrast, the NTP system is flexi- HMIS. However, there are difficulties
level in health facilities for effective ble and able to adapt and accommodate in data management at NTP at all
TB case management. Outbreak de- changes when there is need for addi- levels, including reporting, analysis
tection and investigation throughout tional information or reporting in TB and feedback.
the country is not recorded either by forms. However, the system is consider-
HMIS or NTP. Some other issues ably donor-dependent and cessation of Acceptability
include the complex data collection funding and support is a concern for its HMIS benefits from acceptability
(many forms and ways of reporting), sustainability. For example, there was an among all MoPH, NGOs and interna-
flow of information (delays) and labo- interruption in funding for laboratory tional agencies. Data are collected from
ratory algorithms (different categories, services and no reporting was done in registries and there is no need to inter-
not just positive or negative). There are late 2008. view and collect the data for routine
also issues with the NTP conducting cases. A high rate of data reporting is
crosschecks of the national reference Data quality observed at all facilities and almost
laboratory data and random samples While the HMIS has progressed since no refusals in participation are seen.
of slides from regions which are using it was set up in 2003 in terms of quality Complete and timely data are available.
different indicators. of data, some blank cells and illegal However, HMIS is less acceptable by
values are still observed in the forms; TB-related stakeholders due to prob-
Flexibility for instance, it is known that some lems with incomplete and duplicate
HMIS seems to be less flexible for facilities have reported that they are data.
accommodating changes when there performing sputum smear examina- The NTP on the other hand
is a need for additional information or tions when in reality they do not have is not fully acceptable at all levels of
modes of operation, however, remov- microscopes available. By and large health workers due to the multitude of
ing questions (variables) is easier than the HMIS is collecting complete and forms and high workload at primary
adding new questions to the forms. valid data from registries by checking level health facilities. The system even
203

5. 204
Table 1 Comparison of attributes of the Health Management Information System (HMIS) and National TB Control Programme (NTP) in Afghanistan for monitoring tuberculosis (TB)
data
Attributea Health Management Information System National TB Control Programme
Evaluation Justification Evaluation Justification
Usefulness Poor Standard case definitions with guidelines. Poor Good Availability of comprehensive information and data are used for
coordination with NTP. Data are poorly linked to action. planning at national and international levels. Poor feedback at
EMHJ • Vol. 19 No. 2 • 2013
lower levels.
Simplicity Good Case definitions are followed and consistent forms are Poor System is complex due to complicated, multiple forms. Staff
used but limited TB data are collected. Staff are trained. training is a challenge. No integration with HMIS. Still using
System is simple and easy to understand. paper forms.
Flexibility Average Difficult to add or remove variables. Proper storage of Good System is flexible and can accommodate changes easily. Some
data with link to other databases. System is not able to changes are ongoing. Rapid expansion.
accommodate changes easily
Data quality Good Data are taken from registries and checked properly. Average System covers all necessary indicators. Hard copies with
Appropriate data management. Demographic and blank and missing values. Poor rechecking with improper data
socioeconomic status information are insufficient. Low management.
unknown, blank and missing values.
Acceptability Good High level of awareness of stakeholders with respect Poor WHO recommended forms are used but health workers lack
to procedures and their ownership. No refusal and awareness about procedures. Delayed reporting and sometimes
almost 95% reporting rate. All public health facilities no reporting shows refusals.
participate.
Sensitivity Good Estimated sensitivity (2008 data) 68% is close to global Good Estimated sensitivity (2008 data) 73% is consistent with global
target. targets
Positive predictive Average Estimated PPV (2008 data) 14%. Average Estimated PPV (2008 data) 11%.
value
Representativeness Average Public health facilities are covered but data missing Average Majority of public health facilities are covered but data missing
from private sector. System favours rural areas with little from private sector. Age and sex information is available with
attention to urban settings and secondary hospitals. data for multiple TB indicators.
Poor recording of demographic and behavioural
variables.
Timeliness Good Monthly collection at provincial level and reporting and Poor Report and feedback is supposed to be done quarterly but
feedback is timely (quarterly) and there is no time lag. delays with time lag are easily identifiable. Quarterly review
Inconsistency in feedback and not annual reports. meeting is mechanism for reporting and feedback.
Stability Good Data management without failure. System is fully Average Donor support is available for long-term. Development of
functional with sustainable technical and financial electronic database is in progress. Data reporting and feedback
support. Database is stable despite regular electricity is done by hard copies. Staff training on data management is
power interruptions. needed.
a
Eastern Mediterranean Health Journal
Using classification of the Centers for Disease Control and Prevention [5].
WHO = World Health Organization; PPV = positive predictive value.
La Revue de Santé de la Méditerranée orientale

6. ‫املجلد التاسع عرش‬ ‫املجلة الصحية لرشق املتوسط‬
‫العدد الثاين‬
lacks acceptability within the TB We can calculate sensitivity at the level For each TB suspect a sputum sample
programme among those working of all TB cases or at the level of sputum is collected and 2 to 3 AFB slides are
at grass-roots levels, such as heads of smear-positive cases. examined both for diagnosis and follow
health facilities. Additionally private Total TB suspected cases (preva- up. The following 2008 data from the
sector acceptability is another issue. lence): 40 000 NTP were identified:
WHO, however, is more supportive of
Total TB suspected cases detected : Total AFB slides examined: 268 614
NTP and uses the data for its regional
28 300 Total AFB slides positive: 30 447
and global reports. A weak point is
that quarterly data sent to the NTP for Sensitivity (first level) PPV (30 447/268 614) ×100 = 11%
analysis are delayed and incomplete. (28 300/40 000) × 100 = 71%
Using data from smear-positive cases Representativeness
On the other hand, quality control
practices are good as laboratory slides shows almost the same sensitivity: HMIS covers public facilities includ-
are collected from facilities randomly Total TB sputum smear-positive cas-
ing government and NGOs; however,
for crosschecking. es estimated: 17 885 15% of the country is not covered by
public health facilities and a consid-
Sensitivity of the surveillance Total TB sputum smear-positive cas- erable proportion of the population
system es detected: 13 136
are utilizing the private sector, are
We defined sensitivity as the ability of Sensitivity (second level) not seeking medical care and/or are
the surveillance system to truly detect (13 136/17 885) × 100 = 73% seeking care through other means. In
cases of TB in the country (sensitiv- Predictive value positive of addition the system is not collecting
ity = cases detected/cases existing × the surveillance system sufficient information about the demo-
100). No survey has been conducted graphic and socioeconomic status of
We defined predictive value positive
to establish the exact burden of TB in the population. It therefore cannot be
(PPV) as the proportion of acid-fast ba-
Afghanistan and the system is using said that the system is representative
cilli (AFB)-positive slides out all slides
WHO estimates for case detection and of the whole population. Nevertheless,
examined by laboratory facilities (PPV
other indicators. HMIS covers fewer variables and is
= true positives/all positives × 100).
trying to cover the private sector and
HMIS data HMIS data military health facilities as well in efforts
Based on HMIS case definitions for TB After a review of data and interviews towards improving the representative-
the patient is recorded as suspect and he with HMIS staff at the central level in ness of the data.
or she is sent for sputum examination, 2008 data at HMIS we calculated the NTP has expanded its DOTS cov-
but the HMIS is not able to trace the PPV in 2 ways. First, it was based on the erage exponentially and is now collect-
contacts. The following is a calculation proportion of AFB slides that were posi- ing data from 1013 facilities, which are
of the system sensitivity using data from tive out of all slides examined for AFB: almost 90% of Basic Package of Health
the HMIS database for 2008:
Total AFB slides examined: 283 831 Services facilities. The system is col-
Total TB suspected cases reported: lecting sufficient information regarding
146 981 Total AFB slides positive: 28 951
age and sex of cases along with their
Total sputum smear-positive cases PPV (28 951/282 831) × 100 = 10% residential areas. There are 2 sources of
estimated: 17 885 Secondly, we can calculate the propor- information: basic management units
tion of TB cases starting treatment (i.e. (facilities) and laboratory registries.
Total TB sputum smear-positive cas- true positives) out of those identified as
es detected: 12 229 Similar to the HMIS, the NTP misses
suspected TB: data from private sector and military
Sensitivity (12 229/17 885) × 100
Total TB cases suspected: 146 981 health facilities.
= 68%
Total TB cases started treatment : Timeliness
NTP data
21 487
The NTP system is collecting epide- Timeliness was quantified as delays
miological and laboratory data from all PPV (21 487/146 981) × 100 = 15% more than 3 months. At the community
facilities covered by DOTS. The contact NTP data level the amount of time it takes for cli-
tracing is another problem which is not There are possibilities of laboratory ex- ents in the community to seek medical
done by the system and reduces its amination for AFB at facilities but that care is very difficult to determine. In
sensitivity. We calculated sensitivity just is not possible to do culture except at HMIS data are taken from health facili-
at the routine reporting level in 2008. the NTP reference laboratory in Kabul. ties and sent to the provinces monthly.
205

7. EMHJ • Vol. 19 No. 2 • 2013 Eastern Mediterranean Health Journal
La Revue de Santé de la Méditerranée orientale
At the provincial level data are ana- Due to delays in reporting of data where many cases come and are
lysed and shared with all stakeholders timely information is not available managed.
and after cleaning data are forwarded within the NTP. Data are collected at Both systems have approximately
as soft copies to the national level health facilities and laboratory facilities equal sensitivity and PPVs. The low
at the end of each quarter without in hard copies for each quarter and prevalence of smear-positive cases in
delays. More than 95% of facilities are are entered into a Microsoft Excel as the population has affected the PPV,
sending their reports regularly. Col- well as a new Access database. These lowering it to 10%. Both systems are
lection and examination of sputum databases are very simple for data able to show the seasonal and secu-
is also timely at facilities. Feedback is entry and analysis and few resources lar trend of TB cases, which generate
provided after the quarterly data col- are needed for maintenance of the hypotheses and trigger research ques-
lection from central HMIS to those database. Corruption of databases due tions.
facilities in which problems are identi- to viruses is always a concern. The Despite a review of the literature
fied in analysis. system needs to be made electronic at we could not find any similar evalu-
NTP is collecting information all levels particularly at provincial and ations for comparison, but some
quarterly using laboratory and facility regional levels. unpublished reports of public surveil-
quarterly formats. It is also reporting lance evaluations from the Field Epi-
treatment outcome and conversion demiology and Laboratory Training
of sputum-smear positive cases. How- Discussion Programme in Pakistan provide simi-
ever, the quarterly reports are not lar results regarding TB surveillance
sent on time from facilities to the HMIS is a very good system which
systems.
provincial level or from the province provides timely information through
daily recording and monthly and The following points are recom-
to the regions or from the regions to mended based on findings of this
the national level. Delay in reporting quarterly reporting and feedback.
NTP is collecting comprehensive in- evaluation.
is therefore a concern. Furthermore,
feedback is not provided timely and formation but with delays in reporting • Attention should be given to in-
properly. All data are sent as hard cop- and feedback. So timeliness, as a key tegrate both systems in order to
ies from the lower level to the central surveillance system metric, is better avoid duplication and to strengthen
NTP, which is not acceptable in the in the HMIS than the TB surveillance mechanisms for coordinating with
current challenging conditions of Af- system under the NTP. Unfortunately related departments to use HMIS
ghanistan. Timeliness therefore is a the information is only occasionally data for action.
concern for the NTP. linked to action in HMIS while an- • Taking the lesson learnt from ac-
nual data is mostly used for planning at ceptability and sustainability of
Stability the national and international level at HMIS the surveillance system at
The HMIS is able to collect, manage NTP. The HMIS system has a high de- NTP should search for mecha-
and provide data properly without gree of acceptability among stakehold- nisms for improving its acceptability
failure from all its facilities and its fully ers because it has been developed with among health workers. There is a
operational with its monthly report- the involvement and participation of need to reconsider the variables in
ing at the provincial levels and quar- various HMIS taskforces. The NTP both the HMIS and NTP surveil-
terly reporting at the central level. All surveillance system is less acceptable lance systems.
stakeholders are entitled to receive the due to its complexity and multitude • The system should assess the reli-
HMIS analysis folder for their own of forms. ability of data sources or triangulate
analysis of data including TB. The HMIS is collecting fewer vari- the data with other data sources.
Microsoft Access database is simple ables regarding TB compared with Refresher training of health workers
and user-friendly, is well developed the NTP. There is poor coordination at the lower levels on guidelines and
and few resources including human or sharing of information between case definitions of TB will increase
and non-human are required for its the 2 surveillance systems regarding their skills and improve the quality
maintenance. It takes very little time to TB and this causes duplication of of data reported.
enter, edit, transfer, analyse, store and effort, wastage of resources and in- • Better adherence to guidelines is
retrieve the data. Problems in extrac- complete information. Both systems needed in both of the systems in
tion of information do occur, however, are collecting data from all public terms of collecting 3 samples to
due to occasional breakdown in the health facilities and both are missing be sent to laboratories for confir-
electricity power supply. data from the private sector facilities mation. NTP should collect infor-
206

8. ‫املجلد التاسع عرش‬ ‫املجلة الصحية لرشق املتوسط‬
‫العدد الثاين‬
mation on contacts and enhance • Establishment and protection of data- Acknowledgements
contact tracing. bases from power outrages and com-
• Both systems should try to strengthen puter viruses will improve the stability This study was supported by Field
public–private partnerships and incor- of the systems. Double entry of data Epidemiology and Laboratory Pro-
porate private sector data into their will enhance the data quality and pre- gramme, National Institute of Health,
systems in order to increase the utiliza- vent missing and erroneous data. More Islamabad, Pakistan. In addition the
tion and representativeness of findings. efforts are needed to ensure the stabil- National TB Control Programme
ity and sustainability of the systems. and Health Management Information
• The concept of timeliness and prompt
reporting should be applied equally • The general coordination, integra- System at Ministry of Public Health
to both systems and for dissemina- tion, decentralization and expansion were supportive in the evaluation.
tion of reports as well. The end users of activities need to be strengthened I would like to thank all who were
should receive the reports in hard and in order to avoid duplication and pro- involved in this study in one way or
soft copies as soon as possible. vide information for action. another.
References
1. WHO report 2009. Global tuberculosis control: epidemiology, 5. Updated guidelines for evaluating public health surveillance
strategy, financing. Geneva, World Health Organization, 2009 systems: recommendations from the guidelines working
(WHO/HTM/TB/2009.411). group. Morbidity and Mortality Weekly Report, 2001, 50 No.
2. Health Management Information System. Data analysis. Kabul, RR-3.
Afghanistan, Ministry of Public Health, 2009. 6. Annual report and statistics of tuberculosis in Afghanistan—2008.
3. Basic Package of Health Services (BPHS). Kabul, Afghanistan, Afghanistan. Kabul, Afghanistan, National TB Control Program,
Ministry of Public Health, 2006. Ministry of Public Health, 2008.
4. National Health Management Information System procedures
manual. Kabul, Afghanistan, Ministry of Public Health, 2006.
207