Sustainability of a field epidemiology and laboratory training programme: the Ghanaian story

Introduction Field Epidemiology Training Programmes (FETPs) are functional ways of strengthening epidemiology, surveillance and outbreak response capacity in countries. However, sustainability of FETPs is a major challenge facing most countries especially in Africa. The Ghana Field Epidemiology and Laboratory Training Program (GFELTP) started in 2007 in the University of Ghana School of Public Health as a solution to gaps in the public health workforce. This paper assessed the sustainability strategies embedded in the Ghana Field Epidemiology and Laboratory Training Programme. Methods We assessed the sustainability of GFELTP by document reviews and interviews with programme staff and stakeholders to identify sustainability structures (programme, financial and institutional) that were in place. We grouped information into the following headings: programme structure, institutional, financial and political structures. Results As of July 2017, a total of 350 public health experts have been trained in both frontline and advanced courses since the programme's inception. For funding structures, the programme is funded mainly by its partners and stakeholders who are local government organisations. They provide resources for running of programme activities. Under institutional and political structures, the programme was established as a Ministry of Health/Ghana Health Service programme based in the University of Ghana. The programme steering committee which is currently chaired by the Director Public Health of Ghana Health Service, jointly ensures its implementation. Other structures of sustainability observed were involvement of stakeholders and alumni in human resource of the programme; use of stakeholders as faculty for the programme. These stakeholders include staff from University of Ghana School of Public Health, Ghana Health Service and Veterinary Service Department, World Health Organization and Centers for Disease Control and Prevention. The programme showed evidence of stable sustainability strategies in all four structures evaluated. Conclusion The assessment found the GFELTP to be sustainable. The main factors that contributed to rendering it sustainable were funding, programme, institutional and political structures embedded in the programme. One remarkable sustainability element observed was the strong collaboration that existed between stakeholders of the programme who worked hand in hand to ensure the programme runs smoothly. However, more sources of funding and other essential resources need to be considered to help the programme obtain a pool of resources for carrying out its activities.


Introduction
Sustainability of public health programmes is of much importance since it helps in maintaining and improving existing health system structures. Field Epidemiology Training Programmes (FETPs) are described by Schneider and colleagues as functional ways of strengthening epidemiology, surveillance and outbreak response capacity in countries [1]. The main aim of FETPs is to build a public health system which can rapidly respond to health threats as they assist in developing scientific evidence-based policies [2]. As an essential public health strategy, existence and functionality of FETPs are key to solving the dynamic public health challenges that keep arising. Thus, there is the need to sustain FETPs to enable them meet their goals. FETPs in Africa were established to strengthen the public health workforce to implement and lead multi-disease surveillance and response in Africa [3]. Sustaining these programmes in Africa in the face of dwindling donor support is therefore of much essence to FETPs in Africa and countries at large [4,5]. AFENET has since developed into a robust network of FE(L)TPs in over 33 countries in Africa. As the first FETP to be formed in West Africa [6], GFELTP has a vision of improving the health of the people in Ghana and beyond. The programme has a mission of contributing to addressing Ghana's public health needs and priorities through training and service provision in applied Epidemiology and Public Health Laboratory Management [7]. The GFELTP uses the One Health approach, ensuring teams of professionals from diverse backgrounds at the national and sub-national levels develop the capacity to early detect, investigate and respond to outbreaks in their districts. Guided by the World Health Organization International Health Regulations (WHO/IHR) core capacity requirements, the program strives towards building and strengthening national and local capacity to effectively respond to public health emergencies and mitigating their impact.
GFELTP began with initial funding from the US CDC. The impact of the programme during its initial years proved that it was a great idea and could indeed strengthen the nation's public health systems. However, after five years, the funding from US CDC could not be continued. The programme had to identify other ways of running considering its contribution to solving public health issues in Ghana after its few years of existence. Sustainability has been one of the major challenges FETPs face [8]. One key aspect of sustainability is ensuring that programme services are maintained through the continuous provision of these services to the nation [8]. This can only be possible if sustainability strategies are in place. Sustainability of programmes has been found to go beyond just finances. Areas such as human resource, political support, operating environment and infrastructure have been considered as key determinants of sustainability [9]. A number of strategies in these major areas seem to have been adopted by GFELTP over time through the changing phases of the programme to enable its continuity. This paper assessed the sustainability strategies embedded in the Ghana Field Epidemiology and Laboratory Training Programme.

Methods
Study design: the study was conducted in the GFELTP secretariat from March to June, 2017. A record review of database of residents and all programmatic documents was done. Interviews (key informant interviews (KII) were also carried out. We grouped the information collected under four main categories; programmatic, financial institutional and political structures. All components of the programme which contributed to ensuring continuous provision of the programme and its services were considered.
Data collection: data collection was done with a data extraction tool which covered information on residents' demographic characteristics, and available data on the indicators of sustainability we sought to assess. An interview guide based on the indicators of sustainability we sought to assess was used for the qualitative interviews.
Questions on; how the programme has been funded since its inception, who the programme stakeholders were and the roles they played, how the programme runs and political structures governing the programme and the achievements of the programme since its inception were asked. We retrieved and extracted data from a database of residents enrolled onto the program from 2007 to 2017 and examined data on resident demographic information such as gender, nationality, and place of work before enrollment into the programme and their current places of work. All programme documents including the FELTP curricula, reports on residents, programme activities, and programme support files and administrative documents of the GFELTP from its inception were organisations which provide funds to solve specific health related challenges, in this case, those which provided funding to support the programme mainly with funds for a specific period [11,12].
Stakeholder: institutions which have a stake in the impact the program makes and partner to ensure the day-to-day smooth running of programme activities such as the Ministry of Health, Ghana Health Service, University of Ghana and AFENET [13,14]. Sustainability: the availability of human, financial, programmatic infrastructure and organizational resources to plan and provide services to meet needs and attain results on an ongoing basis to carry out core functions of the programme independent of individuals or one-time opportunities [2,15].

Results
Programme structure how the programme is run and its performance from 2007-2017: GFELTP runs a two-tier training programme; frontline which is a three-month course and advanced which is a two-year training course which offers an MPhil degree. As of July 2017, the frontline course had trained seven cohorts and the advanced ten cohorts.
Residents trained by GFELTP: the programme has trained 350 people mainly from the Health Services with 94% (329) being Ghanaians.
Residents of the programme were from all ten regions of Ghana (Table 1) (Table 3).
Evaluation: the GFELTP secretariat conducts monthly faculty meetings to evaluate the progress of the program. There were records of bi-annual evaluation of the programme, faculty and residents. These evaluations were conducted by residents. Likewise, the programme also evaluates residents enrolled in the programme.
Though the programme is still in its preparatory phase of finalising a strategic plan, the AFENET strategic plan had been modified and adopted for their use. The programme was preparing to take up the TEPHINET accreditation when this review was done. WAHO also conducted a quality assurance evaluation of its partnership with the programme following a two-year collaboration. This process included review of documentation by the programme, interviewing of residents and faculty of the programme. After support from the initial donors ceased, the programme reached out to other organisations to build partnerships to supplement stakeholder efforts in training residents. Survival of the programme during this time was of critical concern since sustaining grant-funded programmes after funding ceases has been known as a major public health challenge [16]. Should funds for the programme run out, the overhead cost of the programme are absorbed by the university through funds from other projects it runs. This has been one of the greatest sustainability strategies which has kept the programme running over the past years.
Over the years, GFELTP has weathered the storm of financial challenges using this strategy and was saved from this major setback in its early years. This innovative idea adopted at the inception of the programme is in line with the principle that implementation and sustainability go hand in hand. Therefore, ways of ensuring the longevity of a programme need to be in place during the initial stages of implementation [19]. Resources and administrative support the programme needed were mainly provided by stakeholders who work        (