Implementation of the Integrated Disease Surveillance and Response (IDSR) Strategy in Somalia, 2023-2024: A Mixed Method Evaluation of Performance, Challenges, and Opportunities for Strengthening Health Security

Implementation of the Integrated Disease Surveillance and Response (IDSR) Strategy in Somalia, 2023-2024: A Mixed Method Evaluation of Performance, Challenges, and Opportunities for Strengthening Health Security | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Implementation of the Integrated Disease Surveillance and Response (IDSR) Strategy in Somalia, 2023-2024: A Mixed Method Evaluation of Performance, Challenges, and Opportunities for Strengthening Health Security Abdullahi Mohamed Mohamud, Abdirahman Mohamed Abdullahi, Marian Muse Osman, and 12 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8047769/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Somalia adopted an integrated disease surveillance and response (IDSR) in 2023 to develop an integrated and coordinated system for early detection and response to priority health conditions. This study evaluated early implementation performance, challenges and opportunities for improvement. Method A convergent mixed methods cross-sectional study was performed between January and December 2024. Quantitative indicators (reporting timeliness, completeness, and alert verification rate) were extracted from the District Health Information Software (DHIS-2) and analyzed via descriptive & inferential statistics (χ², p < 0.05) with 95% confidence intervals. The qualitative data were collected through 50 key informant interviews via an IDSR supportive supervision tool. The data were analyzed via thematic analysis. The qualitative component adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to ensure methodological rigor and transparency. Result As of 31 December 2024, all the states had functional electronic IDSR at the facility level, but community-based surveillance (CBS) and event-based surveillance (EBS) were not yet operational. All the states achieved the ≥ 80% WHO benchmark for timeliness and completeness, with the exception of Banadir (timeliness = 44%), and had at least 1 dedicated trained IDSR officer at the facility level. However, only 46.5% of public health alerts reported through IDSR have been verified (state range 33–67%). Chi-square analysis indicated significant interstate differences in timeliness (p = 0.012) and alert verification rates (p < 0.001). The qualitative findings identified six major themes influencing IDSR performance: human resource capacity, availability of surveillance tools, funding and infrastructure, data management and feedback, epidemic preparedness, and governance and ownership. The participants reported frequent shortages of IDSR materials, a lack of incentives, poor laboratory capacity, and weak community-based surveillance. Despite these challenges, IDSR improved coordination and data availability at the facility level and enhanced government ownership. Conclusion Two years of IDSR implementation have strengthened weekly aggregate facility-based reporting and surveillance coordination, but immediate case-based reporting, alert verification, data analysis capacity, outbreak investigation and response and laboratory support remain weak. Prioritizing these areas and the development of CBS & EBS is highly recommended to enhance the health security of Somalia. Integrated Disease Surveillance and Response Health Security Disease Outbreaks Public Health Surveillance Alert Verification Health Systems Strengthening International Health Regulations COREQ Mixed-methods evaluation Figures Figure 1 Figure 2 Figure 3 Introduction The Integrated Disease Surveillance and Response (IDSR) strategy is a comprehensive approach aimed at strengthening national communicable disease surveillance and response systems. A significant body of evidence supports the potential of IDSR implementation to address multiple technical, organizational and workforce challenges to increase the overall performance of communicable disease surveillance across several African nations. This evidence is related to improvements in the quality of surveillance data, sensitivity of the surveillance system (detection of potential outbreaks), community surveillance and coordination of all concerned partners. Timely communication, data sharing, efficient resource allocation and the utilization of communicable disease surveillance have also improved ( 1 ). In Somalia, a country with a weakened health system due to decades of conflicts, recurrent natural disasters and disease outbreaks, the need for an effective disease surveillance system is critical. The country faces a high burden of continuous vaccine-preventable disease outbreaks, including cholera, measles, polio and diphtheria, exacerbated by low routine immunization coverage (60% of zero-dose children) and high maternal and child mortality ( 2 ). Somalia’s health care system is organized in a five-tier system (i.e., community, health facility, district, region and national). The health information environment in Somalia is fragmented, with multiple suboptimally functioning systems for various programs, including disease surveillance. A dominant private health sector, which delivers 60% of services in urban areas, underscores disparities in healthcare access ( 3 ). Somalia frequently experiences outbreaks and infectious disease threats, resulting in large-scale morbidity, disability and death ( 4 ). In 2022 alone, Somalia reported more than 15,653 cumulative cases and 8 deaths from cholera and 351 cases of suspected acute flaccid paralysis (AFP), with 9 confirmed circulated vaccine-derived poliovirus type 2 (cVDPV2) cases from humans and the environment ( 6 ). Since 2008, Somalia has relied on the limited early warning alert and response network (EWARN), which focuses on only 15 diseases from a few sites, accounting for approximately 10–15% of all health facilities ( 7 ). Following the 2016 Joint External Evaluation (JEE), the country committed to transitioning to the broader sensitive Integrated Disease Surveillance & Response (IDSR) system. This led to the development of national guidelines, the integration of the IDSR into the DHIS-2 platform and the decommissioning of EWARN in early 2023 to eliminate the nationwide IDSR rollout. Preliminary implementation involved training trainers and cascade training for health workers across all federal MSs ( 8 ). The implementation of IDSR began as a pilot phase in early 2023, followed by the second phase in mid-2024. A total of 173 health management teams composed of state, regional and district health management teams and 771 health workers from 371 health facilities from the Federal Member States and the Banadir Regional Administration (BRA) were trained. This study aims to assess the current status, identify key challenges and explore future perspectives of the IDSR strategy in Somalia. The findings are intended to provide critical insights for strengthening the country's health security framework. Methodology Study design The study adopted a convergent mixed methods cross-sectional design, combining qualitative and quantitative approaches across 5 federal MSs and the Banadir Region Administration in Somalia. The quantitative components focused on key IDSR attributes (timeliness, completeness and alert verification). Timeliness is the percentage of weekly reports submitted by 12:30 PM on Monday out of the expected number. Completeness is the percentage of complete weekly reports submitted out of expectations. The alert verification rate is the proportion of epidemic-prone disease alerts investigated within 24 hrs out of the total alerts reported with a performance threshold of ≥ 80%. For the qualitative component, in-depth interviews with health facility officers were conducted. These discussions explored daily administrative challenges faced by core IDSR functions (case identification, recording, reporting, analysis, outbreak investigation, outbreak response and monitoring) and opportunities. Study Setting Somalia, Africa's easternmost country, is situated on the Horn of Africa and has a population of 18,686 million ( 9 ). Somalia’s weak health system implemented IDSR amid significant, with only 30% of the Somali population having health access. Somalia had a maternal mortality ratio (MMR) of 692 per 100,000 live births in 2019 and an under-five mortality rate (U5MR) of 121.5 per 1,000 live births, the highest globally. Neonatal mortality remains elevated at 40 deaths per 1,000 live births (2015), significantly exceeding regional averages( 10 ). The leading causes of child mortality include vaccine-preventable diseases (e.g., pneumonia, measles) and malnutrition, exacerbated by low immunization coverage; only 10% of children aged 12–23 months receive full vaccinations, whereas 60% do not ( 11 ). Health system gaps persist, with under half of public facilities providing routine immunization. These disparities highlight the urgent need for IDSR implementation to improve disease surveillance, outbreak investigations and responses and evidence-based planning. The Disease Surveillance and Response Unit, a division of the Health Emergencies Department of the Federal Ministry of Health-Somalia, coordinates and manages the Integrated Disease Surveillance and Response (IDSR) system. The study was conducted in public and private hospitals and health facilities across 5 federal member states (Puntland, Galmudug, Jubbaland, Hirshabelle, Southwest State) and the Banadir Regional Administration (BRA). Study population The study targeted facilities in charge, surveillance focal points, data managers, and over- and under-five consultants. These groups represent service providers and users of the strategy. The inclusion criteria required participants to meet specific eligibility standards, provide consent, and be available during the data collection period. Health professionals on annual leave, non-staff members, volunteers, and those with less than three months of IDSR experience were excluded. Participant selection and sampling For the quantitative component, data from all active health facilities (weekly aggregate, immediate case-based and public health alerts) across the states covering at least 1 year were used to ensure statistical reliability. Qualitative component: Fifty in-depth interviews (1 participant per health facility) were conducted to ensure the diversity of perspectives and representations across all states. For the quantitative data, a census approach was used. Retrospective IDSR data of all 377 health facilities were extracted from DHIS-2, ensuring a complete dataset for analysis of reporting rates and trends. Qualitative component: Purposive sampling was used to reach the target. Data collection The study employs both quantitative and qualitative methods to assess and understand the status, challenges, and opportunities of the IDSR strategy in Somalia. The researcher analyzed the existing surveillance data regularly submitted by the health facilities through DHIS-2, a central server of the Federal Ministry of Health, measuring the available indicators, including reporting completeness, timeliness and alert verification of the surveillance system. Additionally, the researcher interviewed key informants from health facilities across 5 states and the BRA. In-depth interviews were conducted on the core functions of the system via a semi-structured IDSR supportive supervision tool administered in person who specifically inquired about challenges and suggested solutions. The IDI took place face to face in private, safe locations such as health facility offices to ensure confidentiality and comfort. Time frame The study was conducted from January to December 2024, and the secondary data were extracted from the DHIS-2 by state, region and district on December 31, 2024. Data analysis The quantitative data were extracted from the national DHIS-2 and subsequently exported into SPSS version 25 (IBM Corp., Armonk, NY) and Microsoft Excel 2021 for further analysis. Descriptive statistics summarized reporting timeliness, completeness, and alert verification rates as proportions with 95% confidence intervals (CIs). For comparisons across states, the chi-square (χ²) test was used to assess associations between categorical variables such as state, reporting rate, and verification status. Statistical significance was determined at p < 0.05. The qualitative data from the 50 key informant interviews were analyzed via a reflexive thematic analysis approach, as outlined by Braun and Clarke ( 12 ). The analysis followed a six-phase process: familiarizing with the data; generating initial codes; generating initial themes; ( 4 ) reviewing potential themes; refining, defining and naming themes; and writing the report. Two members of the research team coded the data, identifying themes that were then grouped under the main core and supportive functions of IDSR while allowing new ideas to emerge. NVivo was used for coding and theme development. Themes were identified at a semantic level, with a focus on the explicit meanings of the participants' words. Visualization of the data was achieved through the creation of charts, graphs and a SWOT analysis table. Additionally, ArcGIS was used to generate maps illustrating the alert verification rate and distribution of health facilities across different regions. Ethical considerations: Individual oral informed consent was obtained from the participants before the interviews were conducted. Ethical approval for the study was also obtained from the National Institute of Health (NIH)-Somalia with reference to NIH/IRB/61/DEC/2024. Permission was received from the DHIS-2 data team and concerned health authorities in the states/regions/districts. The interviews were conducted in English with explanations of the Somali language if needed. Results • Current status of the IDSR implementation All federal member states meet or exceed the 80% target, with Hirshabelle, Galmudug, and Southwest State leading in performance, whereas BRA requires significant improvement in timeliness to align with other states (Fig. 1 ). A total of 377 health facilities across states in Somalia participated in the study. Puntland has the highest number of participants, followed by Southwest China, Jubaland, BRA and Galmudug. The state of Hirshabelle had the lowest number of participants (Fig. 2 ). The functionality of the IDSR system at the district level for verifying reported alerts across various states in Somalia in 2024 was different. Somalia reported a total of 9791 alerts and 257,771 suspected priority diseases through DSR from all states via immediate case-based and weekly aggregate forms, respectively. Among those reported, the highest number of suspected cases of influenza-like illness (ILI) was 79,023, followed by severe acute respiratory illness (62,443), acute watery diarrhea/cholera (36,564), typhoid (27,273) and Shigalosis/Bloody Diarrhea (17,459). The verification rates reveal disparities in system performance across states. Jubaland State demonstrated the highest functionality, with 2,180 reported alerts and 1,465 verified alerts, achieving a verification rate of 67%. Similarly, Southwest China exhibited strong district-level functionality, with a verification rate of 63%, verifying that 543 out of 868 alerts. Notably, regional and district surveillance officers in Jubaland State have been receiving incentives from the Bill & Melinda Gates Foundation (BMGF)-Polio Outbreak Technical Assistance project since 2022, unlike their counterparts in other federal member states. This financial support indicates that motivated and adequately compensated surveillance officers can significantly enhance the performance of the IDSR system (Table 1 ). Table 1 Public health alerts reported and verified through IDSR by state, Somalia from Jan-Dec 2024 State Reported alerts Verified alerts % verified Banadir Regional Administration 1022 480 47 Hirshabelle 2496 823 33 Jubaland 2180 1465 67 Galmudug 800 320 40 Puntland 2425 942 39 Southwest 868 543 63 Using the WHO performance benchmark of ≥ 80%, bivariate analysis revealed significant differences in timeliness (χ²=14.6, p = 0.012) and alert verification (χ²=22.5, p < 0.001), suggesting that some states consistently submitted IDSR reports earlier than others and very strong variations across states in how quickly states verify and investigate alerts (within 24 hours). Although variable, reporting completeness did not differ significantly across states (χ²=10.3, p = 0.067), suggesting generally consistent reporting coverage ( Table 2 ). Table 2 Bivariate analysis of IDSR performance indicators across states, Somalia, 2024 Indicator Chi-square (χ²) df p-value Timeliness (≥ 80%) × State 14.6 5 0.012 Completeness (≥ 80%) × State 10.3 5 0.067 Alert Verification (≥ 80%) × State 22.5 5 < 0.001 There is evidence of the overreporting of certain diseases (e.g., SARIs), whereas others are likely underreported (e.g., AFP, measles & diphtheria). Owing to the lack of verification at the health facility and district level, rare diseases such as neonatal tetanus, yellow fever, viral hemorrhagic fever, human rabies, anthrax, trypanosomiasis, leprosy and adverse events following immunization (AEFI) are overreported. Diphtheria is a good example. In 2024, health facilities reported fewer than 200 cases through the IDSR, but the Situational Report (SITREP) from FMOH reported 619 cases 2024. Several factors contribute to the lack of verification and reporting issues, including the focal person's capacity to accurately report data, inconsistencies in case definitions, and the availability of district surveillance officers (DSOs) to verify the cases. This imbalance can distort the true epidemiological picture and hinder effective public health responses (Fig. 3 ). Overall, detection and reporting functions performed relatively well, with more than 70% of facilities applying standard case definitions and reporting tools. However, performance declined in data analysis and monitoring, where fewer than one-third of facilities plotted disease trends or maps. Outbreak investigations and response capacities have varied, with notable gaps in laboratory specimen collection and supply availability. The Banadir and Southwest States presented the lowest overall IDSR percentage, whereas Puntland and Hirshabelle performed consistently above the national mean across most indicators (Table 3 ). Table 3 IDSR practice of core IDSR functions by state, Somalia, 2024 Core Function & Question JBL GM SWS BRA PL HIR Total Detection & Recording Records priority diseases per standard case definitions 95% 74% 88% 49% 100% 97% 84% Reporting Uses standard definitions to report 88% 60% 77% 46% 100% 86% 76% Records notifiable diseases on case-based forms 91% 54% 60% 79% 81% 74% 74% Analysis Plots cases/deaths on a graph 44% 23% 30% 8% 5% 51% 27% Plots distribution of cases on a map 42% 14% 26% 10% 10% 17% 20% Outbreak Investigation & Response Reports suspected outbreaks immediately 93% 66% 63% 36% 90% 74% 70% Has supplies for lab specimen collection 63% 29% 47% 15% 43% 46% 42% Has supplies for outbreak response 84% 83% 77% 79% 52% 91% 80% Monitoring Receives latest surveillance bulletin 58% 29% 33% 13% 29% 77% 41% Submitted last 3 monthly reports 91% 91% 81% 44% 71% 86% 77% Submitted last 3 reports on time 86% 91% 86% 49% 71% 89% 79% Abbreviations: IDSR: Integrated Disease surveillance & Response, BRA: Banadir Regional Administration, GM: Galmudug, HIR: Hirshabelle, JBL: Jubaland, PL:Puntland, SWS: Southwest State. • Challenges of IDSR implementation T he study identified six key themes that represent the major barriers to effective IDSR implementation ( Table 4 ). Table 4 Reflexive Thematic Analysis of Barriers to IDSR Implementation and the Proposed Solutions in Somalia, 2024 State Themes Sub-themes Illustrative Participant Quote Proposed Corrective actions Participant tittle BRA Essential IDSR tools/materials Information Technology "We have a problem with the tablet for reporting. Only register is available, no rumor logbook. Provided rumor log book & the tablet for recording and reporting Facility in-charge BRA Essential IDSR tools/materials Information Technology "I don't have user for reporting to the system" To provide user access for reporting Facility in-charge BRA Governance & government ownership Coordination "There is no regular coordination of the IDSR at district level" Regular coordination mechanism between different levels is mandatory IDSR focal point BRA IDSR Data & information Data analysis "We don't have data officer for analysis" To nominate Data officer Consultant Doctor BRA Epidemic preparedness & response Outbreak preparedness & response "There is no lab in our health center to diagnose suspected cases in case of outbreak" MOH should provide laboratory equipment to the facility OPD nurse BRA Essential IDSR tools/materials Laboratory Support "We don't have any lab test. The facility needs a basic lab to test priority disease" MOH should inform the partners to establish basic labs in all facilities Facility in-charge BRA Human resources (availability, training, motivation) Training & Outbreak Preparedness "We need training. We don't have the capacity to respond in case of outbreak. The facility is also in financial gap" Staff training should be provided Facility in-charge BRA Human resources (availability, training, motivation) Training & Outbreak Preparedness "Our staff can’t detect some diseases because we have no case definitions" Distribution of case definitions and the training of the staff. Facility in-charge BRA Governance & government ownership Coordination & Laboratory Support "Test are not available, No rumor log book and also there is no dedicated IDSR focal person" Hospital director should nominate IDSR focal point; rumor log book should be distributed. Pediatric Doctor, IDSR Focal Point BRA Human resources (availability, training, motivation) Training & Laboratory Support "No sample collection material in our center and lack of laboratory capacity" Establishment of basic laboratory in the center and distributing of materials Data officer BRA Essential IDSR tools/materials Reporting "Not yet received a user to report through DHIS-2" Provide an IDSR user soon IDSR focal point BRA Essential IDSR tools/materials Laboratory Support "Our main problem is the lack of laboratory to investigate priority disease" Distribute laboratory support materials Facility in charge Galmudug IDSR Data & information Analysis "We don't have plots of the cases to identify the trends" Training of the data officer to start the analysis OPD nurse Galmudug Human resources (availability, training, motivation) Training & Laboratory Support "The trained IDSR person left and laboratory and transportation supplies not available" Training of new person and distribution of materials Facility in charge Galmudug Human resources (availability, training, motivation) Training "Our staff have no IDSR training. Because this health center is new" Staff training as soon as possible Data officer Galmudug Essential IDSR tools/materials Detection & Laboratory Support "We don't have registration form to report from community. Sample collection supplies are not available" Provide rumor log book and on-job training Data officer Galmudug Essential IDSR tools/materials Laboratory Support "Limited supplies and sample transportation from facility to reference laboratory are the main challenges." Distribution of rumor logs; advocacy for PPE. Consultant Doctor Hirshabelle Governance & government ownership Monitoring and Evaluation "IDSR monitoring is scheduled monthly but is not practical" Monitory form should be filled following SOPs IDSR focal point Hirshabelle IDSR Data & information Analysis & Information Technology "Our facility has no IDSR related posters and list of the priority diseases" Informed staff to make plots; accelerate case-based reporting. Facility incharge, IDSR focal point Hirshabelle Essential IDSR tools/materials Laboratory Support "Lack of sample collection materials and transportation costs." Delivery of laboratory supplies planned. Facility incharge Hirshabelle Governance & government ownership Supportive Supervision "Supervision of IDSR activities is not integrated. IDSR, EPI and HMIS team visit the center separately" Integration of activities following the IDSR guideline Facility incharge Hirshabelle Funding, Infrastructure, and Technology Information Technology & Laboratory Support "Lack of tablet for sending the report and the shortage of staff" Distribution of tablets Facility incharge Hirshabelle Essential IDSR tools/materials Laboratory Support "Lack of sample collection materials and transportation costs are the main problem" Delivery of sample collection materials planned. Facility in-charge Jubbaland Human resources (availability, training, motivation) Laboratory Support & Outbreak Preparedness "The main challenge we faced is the shortage of the staff, Inadequate laboratory test. Sample transportation is another common challenge" Motivation of the staff to reduce turnover and the prioritization of the laboratory for confirmation. Facility in-charge Jubbaland Essential IDSR tools/materials Detection & Outbreak Response "Lack of IDSR case definition, register book and the rumor log book" To provide all significant IDSR tools Facility in-charge Jubbaland Essential IDSR tools/materials Detection "Our facility cannot detect some priority diseases because they have no IDSR guideline" To provide on job training OPD Nurse Jubbaland Human resources (availability, training, motivation) Training & Laboratory Support "We had an IDSR training but i think it was inadequate training" Advocate distribution of SCD, provide adequate training to the health workers Facility in–charge Jubbaland Human resources (availability, training, motivation) Training & Laboratory Support "Inadequate training and lack of laboratory unit are the main constraints" Refresher training and provide laboratory support materials . Facility in-charge Jubbaland Epidemic preparedness & response Coordination & Outbreak Preparedness "We don't receive reports from the community" To create channel for community reporting. Data officer Jubbaland Human resources (availability, training, motivation) Training "IDSR training is less training. Healthcare providers need regular training. Also, we need to train CHW" To give regular refresher training by participating community health workers. OPD nurse Jubbaland Epidemic preparedness & response Laboratory Support & Outbreak Response "Our region experiences continuous disease outbreaks. There is no coordinated, timely response. Preparation and resource mobilization take months." MOH should meet with partners to emphasize quick response. Facility in-charge Jubbaland Essential IDSR tools/materials Laboratory Support & Outbreak Preparedness "We need some laboratory tests and PPE to protect the staff and the community." To provide emergency supplies and the reagents of the priority diseases OPD nurse Puntland IDSR Data & information Analysis "We have no data person for analysis" In-charge should nominate data person Consultant Doctor Puntland IDSR Data & information Analysis & information sharing "Don't have data person who can do analysis. Another problem is the lack of feedback for the higher level" Nominating data officer will allow us to see the trends easily Facility in-charge Puntland Epidemic preparedness & response Outbreak Response "Our facility has no capacity to response incase of disease outbreak" To train staff on disease outbreak and distribute basic supplies. Facility in-charge Puntland Governance & government ownership Coordination "IDSR focal person submit weekly report on time but no feedback from the district, region or the state" To give feedback to the health center to correct the errors Facility in-charge Puntland Funding, Infrastructure, and Technology Outbreak Investigation "Some patients are unable reach the hospital during the outbreak due to lack of transportation" Building the infrastructure can improve the health system Director General Puntland Governance & government ownership Reporting & Coordination "IDSR tracker don't work properly. We report many times but not solved" To engage MoH team to fix tracker Facility in-charge Puntland Funding, Infrastructure, and Technology Detection & Outbreak Preparedness "There is civil conflict hence the facility was closed temporarily. Also medical supplies are not available" MOH should distribute medical supplies to the facilities Facility in-charge, IDSR focal point Puntland Essential IDSR tools/materials Outbreak Response "We have no any stock of emergency kits and outbreak response supplies" To plan and distribute supplies soon IDSR focal point Southwest Epidemic preparedness & response Detection & Outbreak Response "Sometimes, i can't get information from the community" To integrate IDSR with other community health programs Facility in-charge Southwest IDSR Data & information Analysis "Facility has data person but he has no the capacity to do analysis" To provide one day training to data person Facility in-charge Southwest Funding, Infrastructure, and Technology Information Technology & Outbreak Preparedness "Lack of internet availability. No one dedicated for outbreak response." MOH should provide internet all health facilities Facility in-charge Southwest Human resources (availability, training, motivation) Training & Laboratory Support "Our facility has no particular dedicated IDSR person, MCH incharge plays that role" To nominate and motivate an IDSR focal person Facility in-charge Southwest Epidemic preparedness & response Detection & Outbreak Preparedness "Do not have CHWs for earlier detection from the community" Need CHWs with their budget OPD nurse Southwest IDSR Data & information Analysis "We send the report but it is less useful without analysis and interpretation" To start the analysis of IDSR data immediately Consultant Doctor Southwest IDSR Data & information Analysis & Outbreak Response "Lack of monitoring charts and IDSR porters" To print the priority disease list and their definitions to put the walls of the center IDSR focal point Southwest Funding, Infrastructure, and Technology Information Technology & Outbreak Preparedness "We are facing lack of internet. The facility is very crowded " To request internet from the partners Facility in-charge Southwest Epidemic preparedness & response Reporting & Outbreak Preparedness "We did not submit any notifiable or immediate case-based report, so there is possibility to miss epidemic prone diseases" MOH should focus the implementation of case based immediate report Facility in-charge Southwest Essential IDSR tools/materials Detection & Laboratory Support "Only IDSR personnel and the case definitions are available. No emergency kit, all priority disease reagents are out of stock like cholera, measles, malaria reagents" MOH should come up a clear plan to distribute all basic IDSR tools/materials to identify, manage and prevent diseases. IDSR focal point Southwest Human resources (availability, training, motivation) Outbreak Preparedness "The facility is facing resource and supplies gap to respond an outbreak" MOH should distribute basic supplies Facility in-charge Human resources Well-trained and motivated surveillance staff are the keys to IDSR implementation. The lack of trained surveillance personnel was compounded by a lack of incentive and insufficient technical capacity, as most participants raised (identified by 14 interviewees). One participant simply stated, “ although we had a training and the required tools, but we are unable to submit immediate case-based reports due to a lack of incentives and staff shortage" (facility in-charge, Jubbaland state ), another respondent noted, "We do not know how to do" analysis and investigation (IDSR focal person, Puntland state) directly undermines the quality of the IDSR system. Essential IDSR tools/materials There was a strong theme of the availability of different tools/materials of the IDSR, including IDSR guidelines, case definitions, rumor logbooks, sample collection and transportation kits and tablets for reporting (specifically, 24 participants were identified). The majority of the participants reported that significant stock-outs of essential surveillance tools and commodities are very common IDSR challenges, from " we have no sample collection kits and reagent test for all priority diseases, such as Cholera, Measles & Malaria" (Lab person, Southwest State) to “ Rumor log book Is not available in our facility, also we have no IDSR case definitions to facilitate the diagnosis of the cases" (facility in charge, Jubbaland). All these factors can severely undermine the capacity of health professionals for case detection, recording, outbreak investigation and response. Funding, Infrastructure, and Technology The participants highlighted that IDSR has many systemic barriers. " A funding gap, unreliable internet & application error ” are among the challenges reported by facilities in charge in the BRA. The lack of functional supportive infrastructure, such as a public health laboratory, prevents the establishment of a resilient disease surveillance system. This was emphasized by a facility in charge of Hirshabelle State, who reported that " we have no operational laboratory at the facility level to test the suspected cases; the state-level laboratory is also inactive, so we rely on clinical diagnosis ". These insights reflect deeper structural weaknesses undermining a resilient surveillance system. Without stable funding, digital systems cannot be maintained or scaled; unreliable internet and software failures disrupt timely case reporting and analysis. The absence of functional laboratories means that suspected cases cannot be confirmed, forcing reliance on clinical diagnosis or external referrals, which delays response. IDSR data management and feedback The surveillance was further impeded by a failure in information flow, which hampered the integrated and coordinated action of the IDSR. This was manifested as a lack of downward feedback, with one facility reporting “ no regular feedback and poor communication from higher level surveillance officers (facility in charge, Southwest state) and lack of internal analytical capacity, as an IDSR focal person stated, "we don’t analyze the data currently, we need capacity building to do so” (Galmudug state). Epidemic preparedness and response A critical failure in community-based surveillance, coupled with a lack of capacity for outbreak investigation and response at the facility level, severely impedes the IDSR system. Community-based surveillance is largely nonfunctional because it is either not sensitized or nonintegration with community health worker (CHW) programs. As one respondent noted, “ the CHW focus nutrition programs only, they didn’t report any priority disease " (facility in charge, Southwest State), leading to the late detection or underreporting of epidemic prone diseases. With respect to outbreak investigations and responses, even when alerts are reported, health facilities lack the fundamental capacity to respond. A medical doctor in Puntland reported the problem of logistical support, stating, “We have no supplies, cars/ambulance to verify and respond to outbreaks reported from the community” . This logistical deficit is compounded by skill gaps, as other participants, including an IDSR focal person in the same state, mentioned that they do not know how to analyze data and conduct outbreak investigations if they receive public health alerts from the community. Governance & government ownership Challenges in weak health system governance are evidenced by the absence of designated leadership at the facility and district levels, as illustrated by a quote from facility incharge, Hirshabelle state, “outbreaks of different diseases are common, and there is no outbreak coordinator in our district” . Furthermore, another facility in charge from the BRA noted that IDSR is government owned, but some health professionals are generally not aware of the importance of IDSR. " We have trained the IDSR focal person; we sent weekly reports, but there is no feedback from a higher level, and I think the reason is the lack of awareness of the importance of IDSR” . Together, these factors illustrate a systemic failure in governance that compromises the entire surveillance and response framework. Apart from the above challenges, it is apparent that IDSR implementation in Somalia during the period 2023–2024 faced many other challenges related to supportive functions, including but not limited to funding gaps, integration and coordination challenges, incomplete implementation, limited private health sector engagement, not submitting immediate case-based surveillance data, a lack of community-based surveillance (CBS), event-based surveillance (EBS) and health and, finally, weak laboratory support. • Opportunities of the IDSR The implementation of IDSR in Somalia presents a critical opportunity to implement international health regulations (IHRs), enhance a country’s health security, improve outbreak detection, and strengthen response capacities in the country. Following the WHO guidelines, Somalia can leverage IDSR to address its public health threats through coordinated, multisectoral efforts ( 4 , 13 ). The strengths, weaknesses, opportunities and threats of the IDSR in Somalia are summarized via SWOT analysis ( Table 5 ). Table 5 Summary of the strength, weakness, opportunities and threats (SWOT) on IDSR implementation in Somalia Strength (internal) Weakness (internal gaps) • Functional nationwide IDSR system established • Country Ownership, leadership and the accountability • High reporting completeness of the weekly aggregate data. • Strong partner support (WHO, World Bank and BMGF) • Mobile and DHIS2 integration for data automation • Availability of skilled health workers across states. • Institutionalizing IDSR Training • Low alert verification rates (33–67% by state) • Over-/under-reporting of diseases (e.g., SARI vs. AFP) • Limited lab capacity (10/44 priority diseases detectable) • Outdated guidelines: Missing case definitions (e.g., diphtheria). • Dual reporting: Facilities submit separate reports to MoH vs. NGOs, creating inconsistencies. • Lack of regular supportive supervision Opportunities (External Potential) Threats (External Risks) • Scaling-up Event-Based Surveillance (EBS), Community-Based Surveillance (CBS) and One Health • Strengthening Laboratory Capacity for Effective Priority Diseases Detection and Response • Incentivize the surveillance officers & focal points • Private sector engagement • Update IDSR guidelines with WHO support. • Harmonize reporting through unified digital tools (e.g., DHIS2). • Funding gaps • Political fragmentation (decentralized governance) • Security risks limiting fieldwork • High staff turnover (lack of salaries/incentives) • NGO funding priorities may distort data accuracy SARI: Severe Acute Respiratory Syndrome, DHIS: District Health Information System,, EBS: Event-Based Surveillance (EBS), CBS = Community-Based Surveillance (CBS). Discussion We assessed the core functions of IDSR policy implementation across different levels of the health system of Somalia to identify the key challenges faced in implementation and to propose strategic recommendations for moving forward. To be concise, few cardinal variables for disease surveillance performance were selected for the current study: the timeliness and completeness of reporting, the alert verification rate and the Core IDSR functions. The assessment revealed both significant achievements and critical challenges that need to be addressed to strengthen the disease surveillance system in the country. Comparisons with similar studies across Africa provide additional context and highlight common challenges and opportunities. While some indicators have improved and substantial challenges remain, this study demonstrates that significant success was achieved during the first two years of IDSR implementation in Somalia. There is a functional IDSR system in place, and advocacy and government ownership have been established, resulting in significant improvement in IDSR performance. For example, at the national level, there has been commendable progress in the implementation of the IDSR, as shown by several indicators, such as the completeness and timeliness of weekly data reporting from districts, regular weekly epidemiological bulletins, and weekly situational reports (Sitrep) in the case of outbreaks. However, there is a delay in timely detection and response to outbreaks such as diphtheria and cholera outbreaks. The data indicate that all federal member states in Somalia except BRA have met or exceeded the 80% target for reporting completeness and timeliness. This high performance can be attributed to the deployment of dedicated, trained, and compensated independent surveillance consultants by the Bill & Melinda Gates Foundation (BMGF) and McKing Consulting Corporation in all states except BRA. These consultants have been active at all levels from district to national since early 2022 until March 2025, providing essential technical guidance and support to the IDSR system and Polio eradication efforts under the Somali Emergency Action Plan (SEAP), which aimed to stop the circulation of circulated vaccine-derived Polio virus (cVDPV) type 2. This finding aligns with a study conducted in Uganda, where the IDSR system also reported high completeness rates but struggled with timeliness due to logistical challenges and underresourced health facilities ( 14 ). In contrast, the BRA in which the health centers were urban demonstrated a notable deficiency in timely reporting, similar to findings in Kenya, where urban health facilities reported delays attributed to high patient volumes and inadequate staffing ( 15 ). These delays are public health concerns, as timely data are important for effective public health interventions, particularly Banadir’s high population density and movement when an outbreak can occur anytime and anywhere due to multiple factors. The high performance of Hirshabelle and Galmudug suggests that targeted interventions, such as training and resource allocation, can significantly improve reporting practices. Continuous support and monitoring are essential to sustain these improvements and to encourage other regions to enhance their performance. The predominance of influenza-like illness (ILI) and severe acute respiratory infection (SARI) among reported cases underscores the significant burden of respiratory diseases in Somalia. This finding is consistent with studies in Ethiopia that identified respiratory infections as the leading cause of morbidity and mortality among children, highlighting the urgent need for targeted vaccination and public health interventions ( 16 ). The evidence of overreporting certain diseases and underreporting others complicates the epidemiological landscape, potentially leading to misallocation of resources. In Tanzania, similar patterns of disease reporting were observed, where health facilities reported high numbers of malaria cases but underreported nonmalarial febrile illnesses, indicating gaps in diagnostic capacity ( 17 ). Strengthening training for district surveillance officers (DSOs) and enhancing verification processes are critical to ensuring accurate data collection and reporting. The disparities in alert verification rates across states indicate varying levels of functionality within the IDSR system. Jubbaland's strong performance, bolstered by incentives from the Bill & Melinda Gates Foundation (BMGF), highlights the impact of motivation and resources on surveillance effectiveness. This finding is supported by a study in Zambia, where financial incentives for health workers improved the verification rates of reported disease outbreaks ( 18 ). In contrast, the lower verification rates in the BRA underscore the need for improved mechanisms to validate reported alerts. Similar studies in South Sudan have shown that a lack of resources and training for health personnel significantly hampers the effectiveness of disease surveillance systems ( 16 ). In addition to implementing incentive structures, strengthening the capacity of regional and district surveillance officers could enhance the verification process and foster a more robust IDSR framework. The assessment of core IDSR functions reveals that while many states demonstrate strong capabilities in detection and reporting, significant gaps remain in analysis and outbreak investigations. A study in Kenya highlighted similar disparities, where health facilities showed proficiency in reporting but struggled with data analysis and visualization, which are critical for outbreak detection ( 15 ). The ability to visualize data trends is crucial for timely decision-making; however, the low percentage of facilities capable of plotting cases on graphs or maps indicates a need for targeted training. Moreover, the readiness for outbreak investigations is inconsistent, with critical gaps in the availability of supplies for specimen collection and response. Addressing these shortcomings through strategic resource allocation and training initiatives will be vital for improving the overall effectiveness of the IDSR system. The findings regarding the frequency of disease information collection and feedback provided to communities reveal significant gaps in communication strategies, particularly in BRA. A high percentage of health facilities in this region reported never providing feedback to the community, which may hinder public trust and engagement in health initiatives. Similar challenges are faced in other East African nations, such as Uganda, where community feedback mechanisms were found to be inconsistent, leading to low participation in health programs ( 14 ). Improving communication strategies and ensuring that health facilities actively disseminate information to the community are essential for enhancing engagement and encouraging timely reporting of health issues. Community health education programs and regular feedback mechanisms will be crucial in addressing these gaps. The limitations of this study are supported by empirical studies reported throughout Africa. A systematic review of IDSR implementations in the African region revealed that weak laboratory capacity, inconsistent funding, and deficient infrastructure were among the most frequently cited barriers to effective surveillance and response systems. Recommendation & Conclusion Evidence-based solutions to the IDSR challenges are presented below. To increase alert verification rates and data analysis in low-performing states, the MOH should train district surveillance officers and data managers, provide incentives, and establish monthly verification audits at the facility and district levels. To reduce overreporting and underreporting, the MOH should review IDSR guidelines, make necessary changes (priority diseases, case definitions), implement case-based surveillance reporting and conduct regular monitoring and supportive supervision. To improve information flow, state surveillance officers should establish weekly bulletin distribution systems for all regions, districts and facility-level teams via email. To accelerate outbreak investigations and responses, federal members must preposition emergency supplies in strategic locations and distribute all necessary specimens to state laboratories. Formalize private-sector integration with reporting requirements and feedback loops. The collection, collation, and analysis of data from state and national public health laboratories will improve the government’s ability to detect and respond to new and emerging priority disease threats. To address challenges in the laboratory, the FMOH guides and aligns the staff with the institution’s objectives and vision. A strong public health leader can foster a productive work environment, enhance staff motivation, secure incentives, establish accountability mechanisms, define a clear TOR for each role and ensure fair and transparent management of training opportunities. The CBS/EBS with CHW training in high-risk districts should be rolled out when the rumor-log book is used. The successful implementation of the IDSR strategy in Somalia is crucial for timely and effective disease surveillance and response. The implementation should be conducted at public and private health facilities and at the community level, with strong advocacy and ownership from the government and technical support from international partners. Strengths & Limitations The key strength of this research is that it represents the first formal assessment of the IDSR in Somalia following its national rollout. However, this study has several limitations that should be considered when interpreting its findings. First, there is limited information due to the newly implemented system. Second, there is potential reporting bias from self-reported data. Additionally, the cross-sectional design and the use of secondary data restrict causal inference and temporal assessment of IDSR performance. Last, the health facility-level approach of participants lacks contextual depth on implementation barriers. Declarations Author contributions Abdullahi Mohamed Mohamud & Abdirahman Mohamed Abdullahi conceptualized the study, designed the methodology, performed the data analysis, visualized the results, and wrote the manuscript. Marian Muse Osman & Salad Halane contributed by providing critical reviews and editing the manuscript. Mohamed Dahir Serar, Saadaq Adan Hussein, Ridwan Ahmed Abdi, Mohamed Abdirahman Abdi & Sahra Isse Mohamed offered additional insights and technical support during manuscript preparation. Abdirahman Moallim Ibrahim, Abdullahi Abdirasak Mohamed, Mohamed Abdinor Omar, Adam Isse Adam, Falastin Mohamed Abdi & Fathi Mohamed Abukar supported data collection, validation & analysis of data. All the authors reviewed and approved the final version of the manuscript. Ethics approval and consent to participate in the Declaration Ethical approval for this study was obtained from the National Institute of Health (NIH)-Somalia with reference to NIH/IRB/61/DEC/2024. Individual oral informed consent was obtained from the participants before the interviews were conducted. All the data were anonymized to ensure participant confidentiality and privacy. Data availability The data supporting the findings of this study are available from the corresponding author upon reasonable request. Funding None. Competing Interests The authors declare that they have no competing interests. Acknowledgment None Declaration of generative AI and AI-assisted technologies in the writing process During the preparation of this work, the author(s) used Chat GPT to identify key literature in the field. After use, the author(s) reviewed, paraphrased and edited the content as needed and take (s) full responsibility for the content of the publication. References Regulations IH, Alert EW, Network R, Ewarn T, Office C, Policy. brief 5. 2021;(October):1–6. Mohamoud SA, Ali-Salad MA, Bile AS, Singh NS, Mahmud AJ, Nor B. Determinants and prevalence of zero-dose children in Somalia: Analysis of the 2020 Health Demographic Survey data. PLOS Global Public Health. 2024;4(7). Ministry of Health and Human Services, SOMALIA HEALTH SECTOR STRATEGIC. PLAN 2022–2026 (HSSP III) [Internet]. 2021 [cited 2025 Sep 5]. Available from: https://moh.gov.so/so/wp-content/uploads/2022/11/Health-Sector-Strategy-Plan-III.pdf World Health organization. The dire threat of disease in Somalia. 2021. https://www.emro.who.int/images/stories/somalia/documents/policy_brief_idsrs.pdf WHO, Bulletin E, EPI. watch. 2023;2023 (December):1–4. https://www.emro.who.int/somalia/information-resources/weekly-epi-watch.html Administration B. Ministry of Health & Human Services Federal Ministry of Health EXPANDED PROGRAM ON IMMUNIZATION (EPI) Milestone achievement Overview of Immunization in Somalia 2022 Annual Bulletin. Lubogo M, Karanja MJ, Mdodo R, Elnossery S, Osman AA, Abdi A et al. Evaluation of the electronic Early Warning and Response Network (EWARN) system in Somalia, 2017–2020. Confl Health. 2022;1–12. Federal Ministry of Health. FINAL National Technical Guidelines for IDSR in Somalia. 2023. https://www.scribd.com/document/850225726/FINAL-National-Technical-Guidelines-for-IDSR-in-Somalia-May-2023 United Nations, Nations U. World Population Prospects 2024: Summary of Results, 2024. https://population.un.org/wpp/assets/Files/WPP2024_Summary-of-Results.pdf Federal Ministry of Health. Investment Case for the Somalia Health Sector 2022–2027. https://moh.gov.so/so/pdfs/investment-case-for-the-somalia-health-sector-2022-2027 Authorities SH. Somali Service Availability and Readiness Assessment 2016 Report Foreword TBD by the Minister of Health and Labor. Mcleod S. Thematic Analysis: A Step by Step Guide. Available from: https://www.researchgate.net/publication/381926272 World Health Organization. integrated-disease- surveillance-and-response-system-a-game-changer-in-somalia . 2023. p. 1. Nansikombi HT, Kwesiga B, Aceng FL, Ario AR, Bulage L, Arinaitwe ES. Timeliness and completeness of weekly surveillance data reporting on epidemic prone diseases in Uganda, 2020–2021. BMC Public Health. 2023;23(1). Munyua PM, Njenga MK, Osoro EM, Onyango CO, Bitek AO, Mwatondo A et al. Successes and challenges of the One Health approach in Kenya over the last decade. BMC Public Health. 2019;19. Benti DG, Daba DD, Hunegna G, Abdena D, Etefa A, Adugna M. The Burden of Non-Communicable Disease and asociated factors among ART Patients in Nekemte Compressive Specialized Hospital, Western Ethiopia 2023 [Internet]. 2024. Available from: https://www.researchsquare.com/article/rs-5342438/v1 Mbugi EV, Kayunze KA, Katale BZ, Kendall S, Good L, Kibik GS et al. One Health infectious diseases surveillance in Tanzania: are we all on board the same flight? Vol. 79, The Onderstepoort journal of veterinary research. 2012. p. 500. Shen GC, Nguyen HTH, Das A, Sachingongu N, Chansa C, Qamruddin J et al. Incentives to change: Effects of performance-based financing on health workers in Zambia. Hum Resour Health. 2017;15(1). Figures. Additional Declarations No competing interests reported. Supplementary Files coreq.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 10 Nov, 2025 Editor assigned by journal 07 Nov, 2025 Submission checks completed at journal 07 Nov, 2025 First submitted to journal 06 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8047769","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":540972617,"identity":"88b8b5f2-58b0-4448-b20d-787dd8fb0cb4","order_by":0,"name":"Abdullahi Mohamed 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1","display":"","copyAsset":false,"role":"figure","size":38485,"visible":true,"origin":"","legend":"\u003cp\u003eReporting completeness \u0026amp; timeliness of IDSR by state Somalia, 2024\u003c/p\u003e\n\u003cp\u003eAll states achieved the ≥80% WHO’s benchmark for both timeliness and completeness, except BRA (timeliness=44%), with Hirshabelle, Galmudug, and Southwest State leading in performance, whereas BRA requires significant improvement in timeliness to align with other states.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8047769/v1/d29b3d8f757733ffe793c1fc.png"},{"id":95358230,"identity":"7cfa0d59-f9d3-4806-b5f4-e93b64a8cb62","added_by":"auto","created_at":"2025-11-07 07:05:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":90174,"visible":true,"origin":"","legend":"\u003cp\u003eState \u0026amp; region-wise breakdown of health facilities, Somalia, 2024\u003c/p\u003e\n\u003cp\u003eA total of 377 health facilities across the states in Somalia participated the study. Puntland state has the highest participants followed by Southwest state.\u003c/p\u003e\n\u003cp\u003eAbbreviations: BRA-Banadir Regional Administration, GM-Galmudug, HIR-Hirshabelle, JBL-Juballand, SWS-Southwest State, PT-Puntland, BRI-Bari, KRK-Karkar, LJB-Lower Jubba, GDO-Gedo, BAY-Baay, LSH-Lower Shabelle, BAN-Banadir, GDD-Galgadud, MDG-Mudug, HRN-Hiran, MSH-Middle Shabelle\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8047769/v1/18823f12d2a99fc112dac31f.png"},{"id":95524711,"identity":"86ba6142-042d-4dd9-af3a-8a7f4a13cda6","added_by":"auto","created_at":"2025-11-10 10:03:18","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1060255,"visible":true,"origin":"","legend":"\u003cp\u003eGeographic distribution of suspected measles \u0026amp; Diphtheria cases in Somalia, 2024.\u003c/p\u003e\n\u003cp\u003eHighest number of suspected measles cases were reported from Banadir region, Lower Shabelle region (Southwest state) and Gedo region (Jubbaland state). Regarding the Diphtheria cases, Nugal region (Putland state), Middle Shabelle region (Hirshabelle state), South Mudug region (Puntland state) and Banadir region reported majority of the cases. This epidemiological profile demonstrates that outbreaks of vaccine preventable diseases are widespread and not confined to any specific geographic area within the country.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8047769/v1/b7af859d0a326f2fcd49043b.png"},{"id":95530746,"identity":"1dfad743-bf7e-4291-aed9-e3cc8e23a53d","added_by":"auto","created_at":"2025-11-10 10:21:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2857450,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8047769/v1/1a2173fc-fd92-44cf-a323-f69a2fc12fba.pdf"},{"id":95358231,"identity":"a487255d-7862-45de-be21-03a4aef8a040","added_by":"auto","created_at":"2025-11-07 07:05:53","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":26306,"visible":true,"origin":"","legend":"","description":"","filename":"coreq.docx","url":"https://assets-eu.researchsquare.com/files/rs-8047769/v1/0ece0b494cb26b6b0ecefcab.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Implementation of the Integrated Disease Surveillance and Response (IDSR) Strategy in Somalia, 2023-2024: A Mixed Method Evaluation of Performance, Challenges, and Opportunities for Strengthening Health Security","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe Integrated Disease Surveillance and Response (IDSR) strategy is a comprehensive approach aimed at strengthening national communicable disease surveillance and response systems.\u003c/p\u003e\u003cp\u003eA significant body of evidence supports the potential of IDSR implementation to address multiple technical, organizational and workforce challenges to increase the overall performance of communicable disease surveillance across several African nations. This evidence is related to improvements in the quality of surveillance data, sensitivity of the surveillance system (detection of potential outbreaks), community surveillance and coordination of all concerned partners. Timely communication, data sharing, efficient resource allocation and the utilization of communicable disease surveillance have also improved (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Somalia, a country with a weakened health system due to decades of conflicts, recurrent natural disasters and disease outbreaks, the need for an effective disease surveillance system is critical. The country faces a high burden of continuous vaccine-preventable disease outbreaks, including cholera, measles, polio and diphtheria, exacerbated by low routine immunization coverage (60% of zero-dose children) and high maternal and child mortality (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSomalia\u0026rsquo;s health care system is organized in a five-tier system (i.e., community, health facility, district, region and national). The health information environment in Somalia is fragmented, with multiple suboptimally functioning systems for various programs, including disease surveillance. A dominant private health sector, which delivers 60% of services in urban areas, underscores disparities in healthcare access (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSomalia frequently experiences outbreaks and infectious disease threats, resulting in large-scale morbidity, disability and death (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In 2022 alone, Somalia reported more than 15,653 cumulative cases and 8 deaths from cholera and 351 cases of suspected acute flaccid paralysis (AFP), with 9 confirmed circulated vaccine-derived poliovirus type 2 (cVDPV2) cases from humans and the environment (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSince 2008, Somalia has relied on the limited early warning alert and response network (EWARN), which focuses on only 15 diseases from a few sites, accounting for approximately 10\u0026ndash;15% of all health facilities (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Following the 2016 Joint External Evaluation (JEE), the country committed to transitioning to the broader sensitive Integrated Disease Surveillance \u0026amp; Response (IDSR) system. This led to the development of national guidelines, the integration of the IDSR into the DHIS-2 platform and the decommissioning of EWARN in early 2023 to eliminate the nationwide IDSR rollout. Preliminary implementation involved training trainers and cascade training for health workers across all federal MSs (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe implementation of IDSR began as a pilot phase in early 2023, followed by the second phase in mid-2024. A total of 173 health management teams composed of state, regional and district health management teams and 771 health workers from 371 health facilities from the Federal Member States and the Banadir Regional Administration (BRA) were trained.\u003c/p\u003e\u003cp\u003eThis study aims to assess the current status, identify key challenges and explore future perspectives of the IDSR strategy in Somalia. The findings are intended to provide critical insights for strengthening the country's health security framework.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eThe study adopted a convergent mixed methods cross-sectional design, combining qualitative and quantitative approaches across 5 federal MSs and the Banadir Region Administration in Somalia. The quantitative components focused on key IDSR attributes (timeliness, completeness and alert verification). Timeliness is the percentage of weekly reports submitted by 12:30 PM on Monday out of the expected number. Completeness is the percentage of complete weekly reports submitted out of expectations. The alert verification rate is the proportion of epidemic-prone disease alerts investigated within 24 hrs out of the total alerts reported with a performance threshold of \u0026ge;\u0026thinsp;80%. For the qualitative component, in-depth interviews with health facility officers were conducted. These discussions explored daily administrative challenges faced by core IDSR functions (case identification, recording, reporting, analysis, outbreak investigation, outbreak response and monitoring) and opportunities.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Setting\u003c/h3\u003e\n\u003cp\u003eSomalia, Africa's easternmost country, is situated on the Horn of Africa and has a population of 18,686\u0026nbsp;million (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Somalia\u0026rsquo;s weak health system implemented IDSR amid significant, with only 30% of the Somali population having health access. Somalia had a maternal mortality ratio (MMR) of 692 per 100,000 live births in 2019 and an under-five mortality rate (U5MR) of 121.5 per 1,000 live births, the highest globally. Neonatal mortality remains elevated at 40 deaths per 1,000 live births (2015), significantly exceeding regional averages(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The leading causes of child mortality include vaccine-preventable diseases (e.g., pneumonia, measles) and malnutrition, exacerbated by low immunization coverage; only 10% of children aged 12\u0026ndash;23 months receive full vaccinations, whereas 60% do not (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Health system gaps persist, with under half of public facilities providing routine immunization. These disparities highlight the urgent need for IDSR implementation to improve disease surveillance, outbreak investigations and responses and evidence-based planning.\u003c/p\u003e\u003cp\u003eThe Disease Surveillance and Response Unit, a division of the Health Emergencies Department of the Federal Ministry of Health-Somalia, coordinates and manages the Integrated Disease Surveillance and Response (IDSR) system. The study was conducted in public and private hospitals and health facilities across 5 federal member states (Puntland, Galmudug, Jubbaland, Hirshabelle, Southwest State) and the Banadir Regional Administration (BRA).\u003c/p\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eThe study targeted facilities in charge, surveillance focal points, data managers, and over- and under-five consultants. These groups represent service providers and users of the strategy. The inclusion criteria required participants to meet specific eligibility standards, provide consent, and be available during the data collection period. Health professionals on annual leave, non-staff members, volunteers, and those with less than three months of IDSR experience were excluded.\u003c/p\u003e\n\u003ch3\u003eParticipant selection and sampling\u003c/h3\u003e\n\u003cp\u003eFor the quantitative component, data from all active health facilities (weekly aggregate, immediate case-based and public health alerts) across the states covering at least 1 year were used to ensure statistical reliability. Qualitative component: Fifty in-depth interviews (1 participant per health facility) were conducted to ensure the diversity of perspectives and representations across all states.\u003c/p\u003e\u003cp\u003eFor the quantitative data, a census approach was used. Retrospective IDSR data of all 377 health facilities were extracted from DHIS-2, ensuring a complete dataset for analysis of reporting rates and trends.\u003c/p\u003e\u003cp\u003eQualitative component: Purposive sampling was used to reach the target.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eThe study employs both quantitative and qualitative methods to assess and understand the status, challenges, and opportunities of the IDSR strategy in Somalia. The researcher analyzed the existing surveillance data regularly submitted by the health facilities through DHIS-2, a central server of the Federal Ministry of Health, measuring the available indicators, including reporting completeness, timeliness and alert verification of the surveillance system. Additionally, the researcher interviewed key informants from health facilities across 5 states and the BRA. In-depth interviews were conducted on the core functions of the system via a semi-structured IDSR supportive supervision tool administered in person who specifically inquired about challenges and suggested solutions. The IDI took place face to face in private, safe locations such as health facility offices to ensure confidentiality and comfort.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTime frame\u003c/strong\u003e\u003cp\u003eThe study was conducted from January to December 2024, and the secondary data were extracted from the DHIS-2 by state, region and district on December 31, 2024.\u003c/p\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eThe quantitative data were extracted from the national DHIS-2 and subsequently exported into SPSS version 25 (IBM Corp., Armonk, NY) and Microsoft Excel 2021 for further analysis. Descriptive statistics summarized reporting timeliness, completeness, and alert verification rates as proportions with 95% confidence intervals (CIs). For comparisons across states, the chi-square (χ\u0026sup2;) test was used to assess associations between categorical variables such as state, reporting rate, and verification status. Statistical significance was determined at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003cp\u003eThe qualitative data from the 50 key informant interviews were analyzed via a reflexive thematic analysis approach, as outlined by Braun and Clarke (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The analysis followed a six-phase process: familiarizing with the data; generating initial codes; generating initial themes; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) reviewing potential themes; refining, defining and naming themes; and writing the report. Two members of the research team coded the data, identifying themes that were then grouped under the main core and supportive functions of IDSR while allowing new ideas to emerge. NVivo was used for coding and theme development. Themes were identified at a semantic level, with a focus on the explicit meanings of the participants' words. Visualization of the data was achieved through the creation of charts, graphs and a SWOT analysis table. Additionally, ArcGIS was used to generate maps illustrating the alert verification rate and distribution of health facilities across different regions.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthical considerations:\u003c/h3\u003e\n\u003cp\u003e Individual oral informed consent was obtained from the participants before the interviews were conducted. Ethical approval for the study was also obtained from the National Institute of Health (NIH)-Somalia with reference to NIH/IRB/61/DEC/2024. Permission was received from the DHIS-2 data team and concerned health authorities in the states/regions/districts. The interviews were conducted in English with explanations of the Somali language if needed.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e\u0026bull; Current status of the IDSR implementation\u003c/h2\u003e\u003cp\u003eAll federal member states meet or exceed the 80% target, with Hirshabelle, Galmudug, and Southwest State leading in performance, whereas BRA requires significant improvement in timeliness to align with other states (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA total of 377 health facilities across states in Somalia participated in the study. Puntland has the highest number of participants, followed by Southwest China, Jubaland, BRA and Galmudug. The state of Hirshabelle had the lowest number of participants (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe functionality of the IDSR system at the district level for verifying reported alerts across various states in Somalia in 2024 was different. Somalia reported a total of 9791 alerts and 257,771 suspected priority diseases through DSR from all states via immediate case-based and weekly aggregate forms, respectively. Among those reported, the highest number of suspected cases of influenza-like illness (ILI) was 79,023, followed by severe acute respiratory illness (62,443), acute watery diarrhea/cholera (36,564), typhoid (27,273) and Shigalosis/Bloody Diarrhea (17,459). The verification rates reveal disparities in system performance across states. Jubaland State demonstrated the highest functionality, with 2,180 reported alerts and 1,465 verified alerts, achieving a verification rate of 67%. Similarly, Southwest China exhibited strong district-level functionality, with a verification rate of 63%, verifying that 543 out of 868 alerts. Notably, regional and district surveillance officers in Jubaland State have been receiving incentives from the Bill \u0026amp; Melinda Gates Foundation (BMGF)-Polio Outbreak Technical Assistance project since 2022, unlike their counterparts in other federal member states. This financial support indicates that motivated and adequately compensated surveillance officers can significantly enhance the performance of the IDSR system (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePublic health alerts reported and verified through IDSR by state, Somalia from Jan-Dec 2024\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eState\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReported alerts\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVerified alerts\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e% verified\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBanadir Regional Administration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e480\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHirshabelle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2496\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e823\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJubaland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2180\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1465\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e67\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGalmudug\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e800\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e320\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePuntland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2425\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e942\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSouthwest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e868\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e543\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eUsing the WHO performance benchmark of \u0026ge;\u0026thinsp;80%, bivariate analysis revealed significant differences in timeliness (χ\u0026sup2;=14.6, p\u0026thinsp;=\u0026thinsp;0.012) and alert verification (χ\u0026sup2;=22.5, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), suggesting that some states consistently submitted IDSR reports earlier than others and very strong variations across states in how quickly states verify and investigate alerts (within 24 hours). Although variable, reporting completeness did not differ significantly across states (χ\u0026sup2;=10.3, p\u0026thinsp;=\u0026thinsp;0.067), suggesting generally consistent reporting coverage \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBivariate analysis of IDSR performance indicators across states, Somalia, 2024\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndicator\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChi-square (χ\u0026sup2;)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003edf\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTimeliness (\u0026ge;\u0026thinsp;80%) \u0026times; State\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.012\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCompleteness (\u0026ge;\u0026thinsp;80%) \u0026times; State\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.067\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlert Verification (\u0026ge;\u0026thinsp;80%) \u0026times; State\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThere is evidence of the overreporting of certain diseases (e.g., SARIs), whereas others are likely underreported (e.g., AFP, measles \u0026amp; diphtheria). Owing to the lack of verification at the health facility and district level, rare diseases such as neonatal tetanus, yellow fever, viral hemorrhagic fever, human rabies, anthrax, trypanosomiasis, leprosy and adverse events following immunization (AEFI) are overreported. Diphtheria is a good example. In 2024, health facilities reported fewer than 200 cases through the IDSR, but the Situational Report (SITREP) from FMOH reported 619 cases \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e2024.\u003c/span\u003e Several factors contribute to the lack of verification and reporting issues, including the focal person's capacity to accurately report data, inconsistencies in case definitions, and the availability of district surveillance officers (DSOs) to verify the cases. This imbalance can distort the true epidemiological picture and hinder effective public health responses (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOverall, detection and reporting functions performed relatively well, with more than 70% of facilities applying standard case definitions and reporting tools. However, performance declined in data analysis and monitoring, where fewer than one-third of facilities plotted disease trends or maps. Outbreak investigations and response capacities have varied, with notable gaps in laboratory specimen collection and supply availability. The Banadir and Southwest States presented the lowest overall IDSR percentage, whereas Puntland and Hirshabelle performed consistently above the national mean across most indicators (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIDSR practice of core IDSR functions by state, Somalia, 2024\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCore Function \u0026amp; Question\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eJBL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGM\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSWS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eBRA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eHIR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDetection \u0026amp; Recording\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRecords priority diseases per standard case definitions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e95%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e88%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e49%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e100%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e97%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e84%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReporting\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUses standard definitions to report\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e88%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e77%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e46%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e100%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e86%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e76%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRecords notifiable diseases on case-based forms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e91%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e60%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e79%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e81%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e74%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e74%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAnalysis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlots cases/deaths on a graph\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e51%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e27%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlots distribution of cases on a map\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e17%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e20%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOutbreak Investigation \u0026amp; Response\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReports suspected outbreaks immediately\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e93%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e63%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e36%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e90%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e74%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e70%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHas supplies for lab specimen collection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e63%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e47%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e43%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e46%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e42%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHas supplies for outbreak response\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e84%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e83%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e77%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e79%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e52%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e91%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e80%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMonitoring\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReceives latest surveillance bulletin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e29%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e77%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e41%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubmitted last 3 monthly reports\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e91%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e91%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e44%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e71%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e86%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e77%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubmitted last 3 reports on time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e86%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e91%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e86%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e49%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e71%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e89%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e79%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003eAbbreviations: IDSR: Integrated Disease surveillance \u0026amp; Response, BRA: Banadir Regional Administration, GM: Galmudug, HIR: Hirshabelle, JBL: Jubaland, PL:Puntland, SWS: Southwest State.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e\u0026bull; Challenges of IDSR implementation\u003c/h2\u003e\u003cp\u003e\u003cb\u003eT\u003c/b\u003ehe study identified six key themes that represent the major barriers to effective IDSR implementation \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eReflexive Thematic Analysis of Barriers to IDSR Implementation and the Proposed Solutions in Somalia, 2024\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eState\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThemes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSub-themes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIllustrative Participant Quote\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eProposed Corrective actions\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eParticipant tittle\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBRA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEssential IDSR tools/materials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInformation Technology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"We have a problem with the tablet for reporting. Only register is available, no rumor logbook.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eProvided rumor log book \u0026amp; the tablet for recording and reporting\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBRA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEssential IDSR tools/materials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInformation Technology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"I don't have user for reporting to the system\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTo provide user access for reporting\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBRA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGovernance \u0026amp; government ownership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCoordination\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"There is no regular coordination of the IDSR at district level\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRegular coordination mechanism between different levels is mandatory\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIDSR focal point\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBRA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIDSR Data \u0026amp; information\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eData analysis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"We don't have data officer for analysis\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTo nominate Data officer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eConsultant Doctor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBRA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEpidemic preparedness \u0026amp; response\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOutbreak preparedness \u0026amp; response\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"There is no lab in our health center to diagnose suspected cases in case of outbreak\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMOH should provide laboratory equipment to the facility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOPD nurse\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBRA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEssential IDSR tools/materials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLaboratory Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"We don't have any lab test. The facility needs a basic lab to test priority disease\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMOH should inform the partners to establish basic labs in all facilities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBRA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHuman resources (availability, training, motivation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTraining \u0026amp; Outbreak Preparedness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"We need training. We don't have the capacity to respond in case of outbreak. The facility is also in financial gap\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eStaff training should be provided\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBRA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHuman resources (availability, training, motivation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTraining \u0026amp; Outbreak Preparedness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Our staff can\u0026rsquo;t detect some diseases because we have no case definitions\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDistribution of case definitions and the training of the staff.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBRA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGovernance \u0026amp; government ownership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCoordination \u0026amp; Laboratory Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Test are not available, No rumor log book and also there is no dedicated IDSR focal person\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHospital director should nominate IDSR focal point; rumor log book should be distributed.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePediatric Doctor, \u003c/p\u003e\u003cp\u003eIDSR Focal Point\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBRA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHuman resources (availability, training, motivation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTraining \u0026amp; Laboratory Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"No sample collection material in our center and lack of laboratory capacity\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eEstablishment of basic laboratory in the center and distributing of materials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eData officer\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBRA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEssential IDSR tools/materials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReporting\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Not yet received a user to report through DHIS-2\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eProvide an IDSR user soon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIDSR focal point\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBRA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEssential IDSR tools/materials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLaboratory Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Our main problem is the lack of laboratory to investigate priority disease\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDistribute laboratory support materials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGalmudug\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIDSR Data \u0026amp; information\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAnalysis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"We don't have plots of the cases to identify the trends\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTraining of the data officer to start the analysis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOPD nurse\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGalmudug\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHuman resources (availability, training, motivation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTraining \u0026amp; Laboratory Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"The trained IDSR person left and laboratory and transportation supplies not available\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTraining of new person and distribution of materials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGalmudug\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHuman resources (availability, training, motivation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTraining\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Our staff have no IDSR training. Because this health center is new\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eStaff training as soon as possible\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eData officer\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGalmudug\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEssential IDSR tools/materials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDetection \u0026amp; Laboratory Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"We don't have registration form to report from community. Sample collection supplies are not available\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eProvide rumor log book and on-job training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eData officer\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGalmudug\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEssential IDSR tools/materials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLaboratory Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Limited supplies and sample transportation from facility to reference laboratory are the main challenges.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDistribution of rumor logs; advocacy for PPE.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eConsultant Doctor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHirshabelle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGovernance \u0026amp; government ownership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMonitoring and Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"IDSR monitoring is scheduled monthly but is not practical\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMonitory form should be filled following SOPs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIDSR focal point\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHirshabelle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIDSR Data \u0026amp; information\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAnalysis \u0026amp; Information Technology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Our facility has no IDSR related posters and list of the priority diseases\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eInformed staff to make plots; accelerate case-based reporting.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility incharge, IDSR focal point\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHirshabelle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEssential IDSR tools/materials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLaboratory Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Lack of sample collection materials and transportation costs.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDelivery of laboratory supplies planned.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility incharge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHirshabelle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGovernance \u0026amp; government ownership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSupportive Supervision\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Supervision of IDSR activities is not integrated. IDSR, EPI and HMIS team visit the center separately\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eIntegration of activities following the IDSR guideline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility incharge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHirshabelle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFunding, Infrastructure, and Technology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInformation Technology \u0026amp; Laboratory Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Lack of tablet for sending the report and the shortage of staff\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDistribution of tablets\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility incharge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHirshabelle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEssential IDSR tools/materials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLaboratory Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Lack of sample collection materials and transportation costs are the main problem\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDelivery of sample collection materials planned.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJubbaland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHuman resources (availability, training, motivation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLaboratory Support \u0026amp; Outbreak Preparedness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"The main challenge we faced is the shortage of the staff, Inadequate laboratory test. Sample transportation is another common challenge\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMotivation of the staff to reduce turnover and the prioritization of the laboratory for confirmation.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJubbaland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEssential IDSR tools/materials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDetection \u0026amp; Outbreak Response\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Lack of IDSR case definition, register book and the rumor log book\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTo provide all significant IDSR tools\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJubbaland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEssential IDSR tools/materials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDetection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Our facility cannot detect some priority diseases because they have no IDSR guideline\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTo provide on job training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOPD Nurse\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJubbaland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHuman resources (availability, training, motivation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTraining \u0026amp; Laboratory Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"We had an IDSR training but i think it was inadequate training\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAdvocate distribution of SCD, provide adequate training to the health workers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in\u0026ndash;charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJubbaland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHuman resources (availability, training, motivation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTraining \u0026amp; Laboratory Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Inadequate training and lack of laboratory unit are the main constraints\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRefresher training and provide laboratory support materials .\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJubbaland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEpidemic preparedness \u0026amp; response\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCoordination \u0026amp; Outbreak Preparedness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"We don't receive reports from the community\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTo create channel for community reporting.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eData officer\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJubbaland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHuman resources (availability, training, motivation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTraining\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"IDSR training is less training. Healthcare providers need regular training. Also, we need to train CHW\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTo give regular refresher training by participating community health workers.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOPD nurse\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJubbaland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEpidemic preparedness \u0026amp; response\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLaboratory Support \u0026amp; Outbreak Response\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Our region experiences continuous disease outbreaks. There is no coordinated, timely response. Preparation and resource mobilization take months.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMOH should meet with partners to emphasize quick response.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJubbaland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEssential IDSR tools/materials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLaboratory Support \u0026amp; Outbreak Preparedness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"We need some laboratory tests and PPE to protect the staff and the community.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTo provide emergency supplies and the reagents of the priority diseases\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOPD nurse\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePuntland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIDSR Data \u0026amp; information\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAnalysis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"We have no data person for analysis\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eIn-charge should nominate data person\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eConsultant Doctor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePuntland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIDSR Data \u0026amp; information\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAnalysis \u0026amp; information sharing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Don't have data person who can do analysis. Another problem is the lack of feedback for the higher level\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNominating data officer will allow us to see the trends easily\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePuntland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEpidemic preparedness \u0026amp; response\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOutbreak Response\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Our facility has no capacity to response incase of disease outbreak\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTo train staff on disease outbreak and distribute basic supplies.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePuntland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGovernance \u0026amp; government ownership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCoordination\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e\"IDSR focal person submit weekly report on time but no feedback from the district, region or the state\"\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTo give feedback to the health center to correct the errors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePuntland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFunding, Infrastructure, and Technology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOutbreak Investigation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Some patients are unable reach the hospital during the outbreak due to lack of transportation\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eBuilding the infrastructure can improve the health system\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eDirector General\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePuntland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGovernance \u0026amp; government ownership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReporting \u0026amp; Coordination\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"IDSR tracker don't work properly. We report many times but not solved\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTo engage MoH team to fix tracker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePuntland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFunding, Infrastructure, and Technology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDetection \u0026amp; Outbreak Preparedness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"There is civil conflict hence the facility was closed temporarily. Also medical supplies are not available\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMOH should distribute medical supplies to the facilities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge, IDSR focal point\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePuntland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEssential IDSR tools/materials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOutbreak Response\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"We have no any stock of emergency kits and outbreak response supplies\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTo plan and distribute supplies soon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIDSR focal point\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSouthwest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEpidemic preparedness \u0026amp; response\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDetection \u0026amp; Outbreak Response\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Sometimes, i can't get information from the community\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTo integrate IDSR with other community health programs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSouthwest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIDSR Data \u0026amp; information\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAnalysis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Facility has data person but he has no the capacity to do analysis\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTo provide one day training to data person\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSouthwest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFunding, Infrastructure, and Technology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInformation Technology \u0026amp; Outbreak Preparedness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Lack of internet availability. No one dedicated for outbreak response.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMOH should provide internet all health facilities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSouthwest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHuman resources (availability, training, motivation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTraining \u0026amp; Laboratory Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Our facility has no particular dedicated IDSR person, MCH incharge plays that role\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTo nominate and motivate an IDSR focal person\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSouthwest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEpidemic preparedness \u0026amp; response\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDetection \u0026amp; Outbreak Preparedness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Do not have CHWs for earlier detection from the community\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNeed CHWs with their budget\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOPD nurse\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSouthwest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIDSR Data \u0026amp; information\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAnalysis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"We send the report but it is less useful without analysis and interpretation\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTo start the analysis of IDSR data immediately\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eConsultant Doctor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSouthwest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIDSR Data \u0026amp; information\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAnalysis \u0026amp; Outbreak Response\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Lack of monitoring charts and IDSR porters\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTo print the priority disease list and their definitions to put the walls of the center\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIDSR focal point\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSouthwest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFunding, Infrastructure, and Technology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInformation Technology \u0026amp; Outbreak Preparedness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"We are facing lack of internet. The facility is very crowded \"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTo request internet from the partners\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSouthwest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEpidemic preparedness \u0026amp; response\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReporting \u0026amp; Outbreak Preparedness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"We did not submit any notifiable or immediate case-based report, so there is possibility to miss epidemic prone diseases\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMOH should focus the implementation of case based immediate report\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSouthwest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEssential IDSR tools/materials\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDetection \u0026amp; Laboratory Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"Only IDSR personnel and the case definitions are available. No emergency kit, all priority disease reagents are out of stock like cholera, measles, malaria reagents\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMOH should come up a clear plan to distribute all basic IDSR tools/materials to identify, manage and prevent diseases.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIDSR focal point\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSouthwest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHuman resources (availability, training, motivation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOutbreak Preparedness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\"The facility is facing resource and supplies gap to respond an outbreak\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMOH should distribute basic supplies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFacility in-charge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eHuman resources\u003c/h2\u003e\u003cp\u003eWell-trained and motivated surveillance staff are the keys to IDSR implementation. The lack of trained surveillance personnel was compounded by a lack of incentive and insufficient technical capacity, as most participants raised (identified by 14 interviewees). One participant simply stated, \u0026ldquo;\u003cem\u003ealthough we had a training and the required tools, but we are unable to submit immediate case-based reports due to a lack of incentives and staff shortage\" (facility in-charge, Jubbaland state\u003c/em\u003e), another respondent noted, \"We do not know how to do\" analysis and investigation (IDSR focal person, Puntland state) directly undermines the quality of the IDSR system.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eEssential IDSR tools/materials\u003c/h2\u003e\u003cp\u003e There was a strong theme of the availability of different tools/materials of the IDSR, including IDSR guidelines, case definitions, rumor logbooks, sample collection and transportation kits and tablets for reporting (specifically, 24 participants were identified). The majority of the participants reported that significant stock-outs of essential surveillance tools and commodities are very common IDSR challenges, from \"\u003cem\u003ewe have no sample collection kits and reagent test for all priority diseases, such as Cholera, Measles \u0026amp; Malaria\"\u003c/em\u003e (Lab person, Southwest State) to \u0026ldquo;\u003cem\u003eRumor log book Is not available in our facility, also we have no IDSR case definitions to facilitate the diagnosis of the cases\"\u003c/em\u003e (facility in charge, Jubbaland). All these factors can severely undermine the capacity of health professionals for case detection, recording, outbreak investigation and response.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFunding, Infrastructure, and Technology\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe participants highlighted that IDSR has many systemic barriers. \"\u003cem\u003eA funding gap, unreliable internet \u0026amp; application error\u003c/em\u003e\u0026rdquo; are among the challenges reported by facilities in charge in the BRA. The lack of functional supportive infrastructure, such as a public health laboratory, prevents the establishment of a resilient disease surveillance system. This was emphasized by a facility in charge of Hirshabelle State, who reported that \"\u003cem\u003ewe have no operational laboratory at the facility level to test the suspected cases; the state-level laboratory is also inactive, so we rely on clinical diagnosis\u003c/em\u003e\". These insights reflect deeper structural weaknesses undermining a resilient surveillance system. Without stable funding, digital systems cannot be maintained or scaled; unreliable internet and software failures disrupt timely case reporting and analysis. The absence of functional laboratories means that suspected cases cannot be confirmed, forcing reliance on clinical diagnosis or external referrals, which delays response.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eIDSR data management and feedback\u003c/h2\u003e\u003cp\u003eThe surveillance was further impeded by a failure in information flow, which hampered the integrated and coordinated action of the IDSR. This was manifested as a lack of downward feedback, with one facility reporting \u0026ldquo;\u003cem\u003eno regular feedback and poor communication from higher level surveillance officers\u003c/em\u003e (facility in charge, Southwest state) and lack of internal analytical capacity, as an IDSR focal person stated, \"we don\u0026rsquo;t analyze the data currently, we need capacity building to do so\u0026rdquo; (Galmudug state).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eEpidemic preparedness and response\u003c/h2\u003e\u003cp\u003eA critical failure in community-based surveillance, coupled with a lack of capacity for outbreak investigation and response at the facility level, severely impedes the IDSR system. Community-based surveillance is largely nonfunctional because it is either not sensitized or nonintegration with community health worker (CHW) programs. As one respondent noted, \u0026ldquo;\u003cem\u003ethe CHW focus nutrition programs only, they didn\u0026rsquo;t report any priority disease\u003c/em\u003e\" (facility in charge, Southwest State), leading to the late detection or underreporting of epidemic prone diseases. With respect to outbreak investigations and responses, even when alerts are reported, health facilities lack the fundamental capacity to respond. A medical doctor in Puntland reported the problem of logistical support, stating, \u003cem\u003e\u0026ldquo;We have no supplies, cars/ambulance to verify and respond to outbreaks reported from the community\u0026rdquo;\u003c/em\u003e. This logistical deficit is compounded by skill gaps, as other participants, including an IDSR focal person in the same state, mentioned that they do not know how to analyze data and conduct outbreak investigations if they receive public health alerts from the community.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eGovernance \u0026amp; government ownership\u003c/h2\u003e\u003cp\u003eChallenges in weak health system governance are evidenced by the absence of designated leadership at the facility and district levels, as illustrated by a quote from facility incharge, Hirshabelle state, \u003cem\u003e\u0026ldquo;outbreaks of different diseases are common, and there is no outbreak coordinator in our district\u0026rdquo;\u003c/em\u003e. Furthermore, another facility in charge from the BRA noted that IDSR is government owned, but some health professionals are generally not aware of the importance of IDSR. \"\u003cem\u003eWe have trained the IDSR focal person; we sent weekly reports, but there is no feedback from a higher level, and I think the reason is the lack of awareness of the importance of IDSR\u0026rdquo;\u003c/em\u003e. Together, these factors illustrate a systemic failure in governance that compromises the entire surveillance and response framework.\u003c/p\u003e\u003cp\u003eApart from the above challenges, it is apparent that IDSR implementation in Somalia during the period 2023\u0026ndash;2024 faced many other challenges related to supportive functions, including but not limited to funding gaps, integration and coordination challenges, incomplete implementation, limited private health sector engagement, not submitting immediate case-based surveillance data, a lack of community-based surveillance (CBS), event-based surveillance (EBS) and health and, finally, weak laboratory support.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e\u0026bull; Opportunities of the IDSR\u003c/h2\u003e\u003cp\u003eThe implementation of IDSR in Somalia presents a critical opportunity to implement international health regulations (IHRs), enhance a country\u0026rsquo;s health security, improve outbreak detection, and strengthen response capacities in the country. Following the WHO guidelines, Somalia can leverage IDSR to address its public health threats through coordinated, multisectoral efforts (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The strengths, weaknesses, opportunities and threats of the IDSR in Somalia are summarized via SWOT analysis \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummary of the strength, weakness, opportunities and threats (SWOT) on IDSR implementation in Somalia\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStrength (internal)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWeakness (internal gaps)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Functional nationwide IDSR system established\u003c/p\u003e\u003cp\u003e\u0026bull; Country Ownership, leadership and the accountability\u003c/p\u003e\u003cp\u003e\u0026bull; High reporting completeness of the weekly aggregate data.\u003c/p\u003e\u003cp\u003e\u0026bull; Strong partner support (WHO, World Bank and BMGF)\u003c/p\u003e\u003cp\u003e\u0026bull; Mobile and DHIS2 integration for data automation\u003c/p\u003e\u003cp\u003e\u0026bull; Availability of skilled health workers across states.\u003c/p\u003e\u003cp\u003e\u0026bull; Institutionalizing IDSR Training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Low alert verification rates (33\u0026ndash;67% by state)\u003c/p\u003e\u003cp\u003e\u0026bull; Over-/under-reporting of diseases (e.g., SARI vs. AFP)\u003c/p\u003e\u003cp\u003e\u0026bull; Limited lab capacity (10/44 priority diseases detectable)\u003c/p\u003e\u003cp\u003e\u0026bull; Outdated guidelines: Missing case definitions (e.g., diphtheria).\u003c/p\u003e\u003cp\u003e\u0026bull; Dual reporting: Facilities submit separate reports to MoH vs. NGOs, creating inconsistencies.\u003c/p\u003e\u003cp\u003e\u0026bull; Lack of regular supportive supervision\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOpportunities (External Potential)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eThreats (External Risks)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Scaling-up Event-Based Surveillance (EBS), Community-Based Surveillance (CBS) and One Health\u003c/p\u003e\u003cp\u003e\u0026bull; Strengthening Laboratory Capacity for Effective Priority Diseases Detection and Response\u003c/p\u003e\u003cp\u003e\u0026bull; Incentivize the surveillance officers \u0026amp; focal points\u003c/p\u003e\u003cp\u003e\u0026bull; Private sector engagement\u003c/p\u003e\u003cp\u003e\u0026bull; Update IDSR guidelines with WHO support.\u003c/p\u003e\u003cp\u003e\u0026bull; Harmonize reporting through unified digital tools (e.g., DHIS2).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Funding gaps\u003c/p\u003e\u003cp\u003e\u0026bull; Political fragmentation (decentralized governance)\u003c/p\u003e\u003cp\u003e\u0026bull; Security risks limiting fieldwork\u003c/p\u003e\u003cp\u003e\u0026bull; High staff turnover (lack of salaries/incentives)\u003c/p\u003e\u003cp\u003e\u0026bull; NGO funding priorities may distort data accuracy\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eSARI: Severe Acute Respiratory Syndrome, DHIS: District Health Information System,, EBS: Event-Based Surveillance (EBS), CBS\u0026thinsp;=\u0026thinsp;Community-Based Surveillance (CBS).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe assessed the core functions of IDSR policy implementation across different levels of the health system of Somalia to identify the key challenges faced in implementation and to propose strategic recommendations for moving forward. To be concise, few cardinal variables for disease surveillance performance were selected for the current study: the timeliness and completeness of reporting, the alert verification rate and the Core IDSR functions.\u003c/p\u003e\u003cp\u003eThe assessment revealed both significant achievements and critical challenges that need to be addressed to strengthen the disease surveillance system in the country. Comparisons with similar studies across Africa provide additional context and highlight common challenges and opportunities.\u003c/p\u003e\u003cp\u003eWhile some indicators have improved and substantial challenges remain, this study demonstrates that significant success was achieved during the first two years of IDSR implementation in Somalia. There is a functional IDSR system in place, and advocacy and government ownership have been established, resulting in significant improvement in IDSR performance. For example, at the national level, there has been commendable progress in the implementation of the IDSR, as shown by several indicators, such as the completeness and timeliness of weekly data reporting from districts, regular weekly epidemiological bulletins, and weekly situational reports (Sitrep) in the case of outbreaks. However, there is a delay in timely detection and response to outbreaks such as diphtheria and cholera outbreaks.\u003c/p\u003e\u003cp\u003eThe data indicate that all federal member states in Somalia except BRA have met or exceeded the 80% target for reporting completeness and timeliness. This high performance can be attributed to the deployment of dedicated, trained, and compensated independent surveillance consultants by the Bill \u0026amp; Melinda Gates Foundation (BMGF) and McKing Consulting Corporation in all states except BRA. These consultants have been active at all levels from district to national since early 2022 until March 2025, providing essential technical guidance and support to the IDSR system and Polio eradication efforts under the Somali Emergency Action Plan (SEAP), which aimed to stop the circulation of circulated vaccine-derived Polio virus (cVDPV) type 2.\u003c/p\u003e\u003cp\u003eThis finding aligns with a study conducted in Uganda, where the IDSR system also reported high completeness rates but struggled with timeliness due to logistical challenges and underresourced health facilities (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In contrast, the BRA in which the health centers were urban demonstrated a notable deficiency in timely reporting, similar to findings in Kenya, where urban health facilities reported delays attributed to high patient volumes and inadequate staffing (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThese delays are public health concerns, as timely data are important for effective public health interventions, particularly Banadir\u0026rsquo;s high population density and movement when an outbreak can occur anytime and anywhere due to multiple factors. The high performance of Hirshabelle and Galmudug suggests that targeted interventions, such as training and resource allocation, can significantly improve reporting practices. Continuous support and monitoring are essential to sustain these improvements and to encourage other regions to enhance their performance.\u003c/p\u003e\u003cp\u003eThe predominance of influenza-like illness (ILI) and severe acute respiratory infection (SARI) among reported cases underscores the significant burden of respiratory diseases in Somalia. This finding is consistent with studies in Ethiopia that identified respiratory infections as the leading cause of morbidity and mortality among children, highlighting the urgent need for targeted vaccination and public health interventions (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe evidence of overreporting certain diseases and underreporting others complicates the epidemiological landscape, potentially leading to misallocation of resources. In Tanzania, similar patterns of disease reporting were observed, where health facilities reported high numbers of malaria cases but underreported nonmalarial febrile illnesses, indicating gaps in diagnostic capacity (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Strengthening training for district surveillance officers (DSOs) and enhancing verification processes are critical to ensuring accurate data collection and reporting.\u003c/p\u003e\u003cp\u003eThe disparities in alert verification rates across states indicate varying levels of functionality within the IDSR system. Jubbaland's strong performance, bolstered by incentives from the Bill \u0026amp; Melinda Gates Foundation (BMGF), highlights the impact of motivation and resources on surveillance effectiveness. This finding is supported by a study in Zambia, where financial incentives for health workers improved the verification rates of reported disease outbreaks (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn contrast, the lower verification rates in the BRA underscore the need for improved mechanisms to validate reported alerts. Similar studies in South Sudan have shown that a lack of resources and training for health personnel significantly hampers the effectiveness of disease surveillance systems (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In addition to implementing incentive structures, strengthening the capacity of regional and district surveillance officers could enhance the verification process and foster a more robust IDSR framework.\u003c/p\u003e\u003cp\u003eThe assessment of core IDSR functions reveals that while many states demonstrate strong capabilities in detection and reporting, significant gaps remain in analysis and outbreak investigations. A study in Kenya highlighted similar disparities, where health facilities showed proficiency in reporting but struggled with data analysis and visualization, which are critical for outbreak detection (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe ability to visualize data trends is crucial for timely decision-making; however, the low percentage of facilities capable of plotting cases on graphs or maps indicates a need for targeted training. Moreover, the readiness for outbreak investigations is inconsistent, with critical gaps in the availability of supplies for specimen collection and response. Addressing these shortcomings through strategic resource allocation and training initiatives will be vital for improving the overall effectiveness of the IDSR system.\u003c/p\u003e\u003cp\u003eThe findings regarding the frequency of disease information collection and feedback provided to communities reveal significant gaps in communication strategies, particularly in BRA. A high percentage of health facilities in this region reported never providing feedback to the community, which may hinder public trust and engagement in health initiatives.\u003c/p\u003e\u003cp\u003eSimilar challenges are faced in other East African nations, such as Uganda, where community feedback mechanisms were found to be inconsistent, leading to low participation in health programs (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Improving communication strategies and ensuring that health facilities actively disseminate information to the community are essential for enhancing engagement and encouraging timely reporting of health issues. Community health education programs and regular feedback mechanisms will be crucial in addressing these gaps.\u003c/p\u003e\u003cp\u003eThe limitations of this study are supported by empirical studies reported throughout Africa. A systematic review of IDSR implementations in the African region revealed that weak laboratory capacity, inconsistent funding, and deficient infrastructure were among the most frequently cited barriers to effective surveillance and response systems.\u003c/p\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eRecommendation \u0026amp; Conclusion\u003c/h2\u003e\u003cp\u003eEvidence-based solutions to the IDSR challenges are presented below.\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo increase alert verification rates and data analysis in low-performing states, the MOH should train district surveillance officers and data managers, provide incentives, and establish monthly verification audits at the facility and district levels.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e To reduce overreporting and underreporting, the MOH should review IDSR guidelines, make necessary changes (priority diseases, case definitions), implement case-based surveillance reporting and conduct regular monitoring and supportive supervision.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo improve information flow, state surveillance officers should establish weekly bulletin distribution systems for all regions, districts and facility-level teams via email.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo accelerate outbreak investigations and responses, federal members must preposition emergency supplies in strategic locations and distribute all necessary specimens to state laboratories.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eFormalize private-sector integration with reporting requirements and feedback loops.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThe collection, collation, and analysis of data from state and national public health laboratories will improve the government\u0026rsquo;s ability to detect and respond to new and emerging priority disease threats.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo address challenges in the laboratory, the FMOH guides and aligns the staff with the institution\u0026rsquo;s objectives and vision. A strong public health leader can foster a productive work environment, enhance staff motivation, secure incentives, establish accountability mechanisms, define a clear TOR for each role and ensure fair and transparent management of training opportunities.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThe CBS/EBS with CHW training in high-risk districts should be rolled out when the rumor-log book is used.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThe successful implementation of the IDSR strategy in Somalia is crucial for timely and effective disease surveillance and response. The implementation should be conducted at public and private health facilities and at the community level, with strong advocacy and ownership from the government and technical support from international partners.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eStrengths \u0026amp; Limitations\u003c/h2\u003e\u003cp\u003eThe key strength of this research is that it represents the first formal assessment of the IDSR in Somalia following its national rollout. However, this study has several limitations that should be considered when interpreting its findings. First, there is limited information due to the newly implemented system. Second, there is potential reporting bias from self-reported data. Additionally, the cross-sectional design and the use of secondary data restrict causal inference and temporal assessment of IDSR performance. Last, the health facility-level approach of participants lacks contextual depth on implementation barriers.\u003c/p\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAbdullahi Mohamed Mohamud \u0026amp; Abdirahman Mohamed Abdullahi conceptualized the study, designed the methodology, performed the data analysis, visualized the results, and wrote the manuscript.\u003c/p\u003e\n\u003cp\u003eMarian Muse Osman \u0026amp; Salad Halane contributed by providing critical reviews and editing the manuscript. Mohamed Dahir Serar, Saadaq Adan Hussein, Ridwan Ahmed Abdi, Mohamed Abdirahman Abdi \u0026amp; Sahra Isse Mohamed\u0026nbsp;offered additional insights and technical support during manuscript preparation. Abdirahman Moallim Ibrahim, Abdullahi Abdirasak Mohamed, Mohamed Abdinor Omar, Adam Isse Adam, Falastin Mohamed Abdi \u0026amp; Fathi Mohamed Abukar supported data collection, validation \u0026amp; analysis of data. All the authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;to participate\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ein the\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDeclaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the National Institute of Health (NIH)-Somalia with reference to NIH/IRB/61/DEC/2024. Individual oral informed consent was obtained from the participants before the interviews were conducted. All the data were anonymized to ensure participant confidentiality and privacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eavailability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of generative AI and AI-assisted\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003etechnologies\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;in the writing process\u003c/strong\u003e During the preparation of this work, the author(s) used Chat GPT to identify key literature in the field. After use, the author(s) reviewed, paraphrased and edited the content as needed and take (s) full responsibility for the content of the publication.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRegulations IH, Alert EW, Network R, Ewarn T, Office C, Policy. brief 5. 2021;(October):1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMohamoud SA, Ali-Salad MA, Bile AS, Singh NS, Mahmud AJ, Nor B. Determinants and prevalence of zero-dose children in Somalia: Analysis of the 2020 Health Demographic Survey data. PLOS Global Public Health. 2024;4(7).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health and Human Services, SOMALIA HEALTH SECTOR STRATEGIC. PLAN 2022\u0026ndash;2026 (HSSP III) [Internet]. 2021 [cited 2025 Sep 5]. 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Somali Service Availability and Readiness Assessment 2016 Report Foreword TBD by the Minister of Health and Labor.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcleod S. Thematic Analysis: A Step by Step Guide. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchgate.net/publication/381926272\u003c/span\u003e\u003cspan address=\"https://www.researchgate.net/publication/381926272\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. integrated-disease-\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003esurveillance-and-response-system-a-game-changer-in-somalia\u003c/span\u003e\u003cspan address=\"http://surveillance-and-response-system-a-game-changer-in-somalia\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 2023. p. 1.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNansikombi HT, Kwesiga B, Aceng FL, Ario AR, Bulage L, Arinaitwe ES. Timeliness and completeness of weekly surveillance data reporting on epidemic prone diseases in Uganda, 2020\u0026ndash;2021. BMC Public Health. 2023;23(1).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMunyua PM, Njenga MK, Osoro EM, Onyango CO, Bitek AO, Mwatondo A et al. Successes and challenges of the One Health approach in Kenya over the last decade. BMC Public Health. 2019;19.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBenti DG, Daba DD, Hunegna G, Abdena D, Etefa A, Adugna M. The Burden of Non-Communicable Disease and asociated factors among ART Patients in Nekemte Compressive Specialized Hospital, Western Ethiopia 2023 [Internet]. 2024. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchsquare.com/article/rs-5342438/v1\u003c/span\u003e\u003cspan address=\"https://www.researchsquare.com/article/rs-5342438/v1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMbugi EV, Kayunze KA, Katale BZ, Kendall S, Good L, Kibik GS et al. One Health infectious diseases surveillance in Tanzania: are we all on board the same flight? Vol. 79, The Onderstepoort journal of veterinary research. 2012. p. 500.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShen GC, Nguyen HTH, Das A, Sachingongu N, Chansa C, Qamruddin J et al. Incentives to change: Effects of performance-based financing on health workers in Zambia. Hum Resour Health. 2017;15(1).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u003cdiv class=\"InlineMediaObject\"\u003e\u003c/div\u003eFigures.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Integrated Disease Surveillance and Response, Health Security, Disease Outbreaks, Public Health Surveillance, Alert Verification, Health Systems Strengthening, International Health Regulations, COREQ, Mixed-methods evaluation","lastPublishedDoi":"10.21203/rs.3.rs-8047769/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8047769/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eSomalia adopted an integrated disease surveillance and response (IDSR) in 2023 to develop an integrated and coordinated system for early detection and response to priority health conditions. This study evaluated early implementation performance, challenges and opportunities for improvement.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e\u003cp\u003eA convergent mixed methods cross-sectional study was performed between January and December 2024. Quantitative indicators (reporting timeliness, completeness, and alert verification rate) were extracted from the District Health Information Software (DHIS-2) and analyzed via descriptive \u0026amp; inferential statistics (χ\u0026sup2;, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) with 95% confidence intervals. The qualitative data were collected through 50 key informant interviews via an IDSR supportive supervision tool. The data were analyzed via thematic analysis. The qualitative component adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to ensure methodological rigor and transparency.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e\u003cp\u003eAs of 31 December 2024, all the states had functional electronic IDSR at the facility level, but community-based surveillance (CBS) and event-based surveillance (EBS) were not yet operational. All the states achieved the \u0026ge;\u0026thinsp;80% WHO benchmark for timeliness and completeness, with the exception of Banadir (timeliness\u0026thinsp;=\u0026thinsp;44%), and had at least 1 dedicated trained IDSR officer at the facility level. However, only 46.5% of public health alerts reported through IDSR have been verified (state range 33\u0026ndash;67%). Chi-square analysis indicated significant interstate differences in timeliness (p\u0026thinsp;=\u0026thinsp;0.012) and alert verification rates (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The qualitative findings identified six major themes influencing IDSR performance: human resource capacity, availability of surveillance tools, funding and infrastructure, data management and feedback, epidemic preparedness, and governance and ownership. The participants reported frequent shortages of IDSR materials, a lack of incentives, poor laboratory capacity, and weak community-based surveillance. Despite these challenges, IDSR improved coordination and data availability at the facility level and enhanced government ownership.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eTwo years of IDSR implementation have strengthened weekly aggregate facility-based reporting and surveillance coordination, but immediate case-based reporting, alert verification, data analysis capacity, outbreak investigation and response and laboratory support remain weak. Prioritizing these areas and the development of CBS \u0026amp; EBS is highly recommended to enhance the health security of Somalia.\u003c/p\u003e","manuscriptTitle":"Implementation of the Integrated Disease Surveillance and Response (IDSR) Strategy in Somalia, 2023-2024: A Mixed Method Evaluation of Performance, Challenges, and Opportunities for Strengthening Health Security","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-07 07:05:49","doi":"10.21203/rs.3.rs-8047769/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-10T05:44:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-07T12:08:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-07T12:07:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-11-06T11:55:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c580d34f-3b6f-414c-aae6-ef3a84cf2707","owner":[],"postedDate":"November 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-08T07:38:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-07 07:05:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8047769","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8047769","identity":"rs-8047769","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}