At the national level, surveillance, through the SID, is part of the HEEC General Directorate. The overall structure of the SID at national level consists of 4 sub-directorates with a unit called “Supportive Activities” where training, supervision and many other activities are listed under the umbrella of this unit (Fig. 2). The EBS components (Partner-based surveillance-PEBS, CEBS, HEBS, POE, hotline and media scanning-HMS) are under the Supportive Activities unit with a focal person for each and a coordinator for all EBS activities. There was no written job description to show the roles and responsibilities of the EBS coordinator and focal persons, but there were SOPs for each project including responsibilities at different levels. At the state level a very simple structure was adopted (Fig. 3) where IBS and EBS are under the umbrella of the Surveillance Unit with 1–3 persons responsible for the work. Overall, states give less attention to EBS as compared to IBS, and EBS at the state level is equivalent to CEBS with no attempts to implement other forms of EBS (hotline, health facility and media scanning). In fact, very few EBS trained focal persons remained at states indicating high turnover attributed to political instability and low salary.

The structure of SID at national level

The structure of HEEC at state level

The surveillance and epidemic control arrangements and activities are governed by the Sudan Constitution and by the National Public Health Law, 2008 in addition to IHR, 2005, and by the establishment of HEEC General Directorate at states levels (and hence surveillance and Information department) in 2014. No law, regulation or decree is designed for EBS separately, nor is there an enforcement mechanism in place to accelerate the implementation of EBS. The government contribution was limited to meet the salaries for surveillance officers and to cover the free telephone network (with paid internet) for the state and localities staff. The Ministry of Health with WHO supplied each volunteer at the community level with a simplified registries for recording signals and events and SOPs to guide the volunteers although some volunteers never received this. As well, only a small number of volunteers experienced refresher training and supportive supervision from the state EBS surveillance officers. This reflects low institutional and political commitment to the system since its establishment.

Apart from regularly scheduled coordination meetings between implementers (Federal and States MoH) and stakeholders during an epidemic or health emergencies, there was no outlined mechanism for regular coordination at national and state levels regarding EBS implementation. There was no technical working group of key implementers or broader coordination committee of partners to manage coordination at the national level. However, the Emergency Operation Centre (EOC) daily meeting (during times of public health crises) involves partners (WHO, UNICEF, Non-health sectors) and implementation bodies, and is the forum that reviews the surveillance data and response activities. No formal link between national level and states exists apart from the requirement for immediate reports for the detected signals/ events in addition to monthly reports. Ad hoc phone calls were sometimes arranged by the national level particularly when there are rumours or notification needs triage and/or verification at the state level.

The national level has developed and availed soft and printed format guidelines and SOPs for EBS (PEBS, CEBS and POE) to direct the implementation at states level. The guidelines identified the priority events and signals, defined the role and responsibilities of each level, and stated clearly the information flow. While some states currently use the SOPs and guidelines, they also reported shortages of supply of SOPs and guidelines, while other states did not know these existed.

In 2016–17, the national level trained states’ EBS focal persons together with 18–22 partners at each state. Partners at state level include governmental sectors (animal, agriculture, police, climate and meteorology, education, public mass media), civil societies, UN agencies, international NGOs, and big development schemes. These partners differed from state to state. Furthermore, all focal persons for CEBS at states level were trained in 2018 to be trainers of trainers “TOT”, disseminating more widely to community volunteers’ knowledge of the SOPs and guidelines they had received. No formal refreshment training and no regular follow-up or supportive supervision for focal persons was provided. The exact need of personnel for EBS and the target for training was not clear at both national and states levels.

EBS has its own reporting format and data flow which was partially integrated at national and states levels. At the national level, the weekly meetings foster the information sharing and coordination between the different projects as per the current structure of SID; in these meetings, both EBS and IBS reports are presented and discussed and the final decision made about the disease/ event under discussion. The EBS monthly report compiled all the signals/ events from different states is and submitted separately to the Head of the Department.

The FMOH developed signals to be detected by the EBS. The CEBS for instance is expected to detect and report unusual, unexpected signals with particular emphasis on acute respiratory symptoms, haemorrhagic fever, acute diarrhoea, jaundice, acute neurological symptoms, guinea worm, floods, draught, displacement, conflicts, and death among animals. As part of CEBS, the trained community volunteers report signals and events immediately when detected. The Ministry of Health has no unified form for reporting but the volunteer is expected to describe what is happening, where, when, who and how many affected, how many have died …etc. Each group of volunteers assigns one person to be the coordinator. When the community volunteers detected a signal, they report either to volunteer coordinator or directly to the locality level using telephone, direct contact, or through another person. The contribution of partners (including other governmental sectors like animal sector) was limited to the detection and reporting of signals to state health authorities. On some occasions, partners (e.g., animal sector) report to its relevant authority at the national level and this authority informed the national health authority. No system exists to capture rumours, official media reports about unusual or unexpected events apart from phone calls from individuals to the emergency call centres (ECC) at national and state levels (using the emergency numbers). With the exception of Gedarif state (out of 6 states visited), there were no official rumours logbooks or databases for the registration of suspected public health events from informal sources, making the follow-up of signals after detection very difficult. Efforts were ongoing to enhance follow-up based on the OSM (Online Signal Module). Some volunteers and focal persons used a notebook for registration, but it was not standardized to an official format. There are no weekly or monthly reports required from volunteers, only monthly reports from the state level). Volunteers are expected to report when there is a signal; therefore “no report means zero signals!!” as stated by one surveillance officer in a state.

States report to the national level immediately when there is a signal or event. By the end of the month, states are expected to compile all reported signals and events and send to Federal MOH using a structured format which covers the what, where, when, who, and how of the signal or event. The focal points for EBS and CEBS at the national level compile reports from all states and issue their monthly reports. The contents of these reports are discussed as part of “Surveillance and Information Department” and “HEEC General Directorate” formal meetings. Few states showed a monthly EBS or CEBS reports but there are separate reports for each event. There was no attempt observed to use database for signals/ events reporting at the state level.

Once the locality surveillance officer receives a notification from a community volunteer or another source, they inform the state and started arrangements for triage, verification, and risk assessment, if needed. This process depends on the locality resources and, in most cases, is completed jointly with the state team. The team sends a written report to the Director General of Health at the state, and if the event represents a public health event of concern, the director informs the Federal MOH. The state conducts verification, risk assessment, and response, which is carried out by trained rapid response teams (RRTs). The training process of RRTs was accelerated by the COVID-19 pandemic (Fig. 4).

Role of each level and the information flow in EBS

After visiting the states and analysing study data the assessment teams gave a score for each state out of 100 expressed as a percentage. In 14 out of the 21 items, the overall score was high, more than 50, (Fig. 5). However, the assessment teams expressed concerns about the lack of a structured collaboration with partners: on most occasions there was no collaboration, or it was weak. Moreover, in 2 states there was no EBS unit or focal persons. Most states did not have a written organogram or define roles and responsibilities for EBS staff. Although the current personnel were trained in surveillance and in EBS, the trained personnel were not sure about their capability to do the assigned work. Free access to the internet was limited and supportive supervision from the state to localities and to frontline personnel was lagging (See Table 2 in the appendix).

Respondents reported self-assessment related to detection, reporting, verification, risk assessment, perception, planning, satisfaction related to EBS at states level

The above-mentioned findings were confirmed by the data obtained from 53 surveillance officers working at the state level. Around 60% of respondents reported to have a list of signals with standard definition. More than 75% of respondents stated there was a presence of a community-based system to capture an unusual, unexpected or new event. Ninety percent of the information captured was through the call centre, volunteers or health care workers (See Table 3 in the appendix).

All the 53 respondents reported detecting signals/ events in the last year (the reported information is initially a signal, but when the occurrence is verified, it is reported by them as event). Over two-thirds of the respondents stated having personal notes in which they recorded information about signals such as date, time, place, source of information, initial cause, description of the signal/ event, and number of cases/ deaths occurred as a result. Less attention was given to having a unique serial number to signal/ event (37.7%). The other important finding was that states were inadequate in the following areas: database development (54.7%), electronic system (39.6%), list of experts (47.2%) and presence of a public health laboratory (35.8%). A total of 33 (62.3%) respondents knew the recommended time for verification, but two thirds (67.9%) stated having a risk analysis and even more reported conducting risk analysis (86.8%) using Federal MOH or WHO tools. Unfortunately, only 30 out of 53 candidates were involved in the analysis of the last risk reported in their states. Generally, limited numbers of respondents (41.5%) attempted to analyse paper-based EBS and IBS data at state level as shown in Table 1.

Respondents also reported their self-assessment related to detection, reporting, verification, risk assessment, perception, planning, implementation and monitoring of EBS at states level (Fig. 5). Many of them stated that states have a list of signals/ events for immediate notification (84.9%) and knew the time for notification (77.4%). The lower level notified to higher level (e.g., a community volunteer notifies to the locality focal person, who in turn reports to the state focal person) immediately or within 24 h using the telephone in most of the cases.. Most states reported signals and events to the national level immediately; however, limited number of states reported on weekly or monthly basis only. Telephone is the reporting tool. States have a report for each event, keep a copy of their sent reports, and share the report with the non-health sector and NGOs. Sending or receiving feedback report was not identified by reviewers as a common practice. The response to an event and to an emergency, in general, is perceived as good and findings related to supporting activities for EBS and surveillance were encouraging. More than 80% of respondents stated having plans for surveillance and response, coordination committees with partners, supported telephone calls, guidelines for CBES, and have integrated EBS into broader surveillance. Respondents expressed concerns about meeting with partners, buffer stock, and guidelines for overall surveillance for response. Few reported having free access to internet, ore awareness of HEEC being established in the state based on law or decree, or of an EBS team.

Following the TOT training in 2018, states, through support from the Federal MOH and other partners, identified target areas and trained community volunteers. States keep records of the volunteers which includes telephone numbers. During the visits to five states, the assessment teams) randomly selected 5 – 7 volunteers from the list and communicated with them by phone. Surprisingly, almost all attempts succeeded. Out of 26 volunteers, 13 were female. The mean (SD) age was 37.9 (11.1) years ranging between 23 to 62 years. Fourteen have basic education and 10 have university/ above university education. Eighteen designated themselves as community volunteers and 4 as health care providers. The majority (21 respondents) were involved with CEBS for 2 years or less, and 5 of them were involved in such work for more than 5 years. Twenty-two of them were trained and knew what their role was, and almost all knew what needed to be reported. Eighteen of the respondents had reported an event before. Most of the reported events could be classified as biological (diseases) and a few were social (displacement). The events came to the attention of the volunteers during engagement in social gathering, personal contact and observation. Volunteers used phones to notify to the higher level, the locality EBS focal person. The majority of respondents at the community level identified no hindrances apart from communication network problems. Only 11 respondents reported having notification forms, and 10 had a register for events. Of those ten, only 4 registered the last event they had. One third of them received occasional feedback from the lower level. What is outstanding is that 20 were satisfied with CEBS and 22 were willing to continue. The volunteers’ suggestions to improve the project include support to phone calls, training and supplies such as notification forms and registers.