Effectiveness of multisectoral collaboration in implementation of One Health Approach for control of zoonoses in Kisumu, Kenya

Study area

Kisumu County is approximately 2,576.5 sq. km, with 567 km² covered by water. The county’s population was 1,155,574, with a density of 554 per sq. Km. Livestock population for cattle, sheep, goats, donkeys, and poultry was 249360, 247,652, 745,500, 3,490, and 3,378,493, respectively^[17]. The area has a city with informal and rural settlements and international air and sea ports. It hosts wildlife reserves and a sanctuary near the Congo Basin, a major zoonotic hotspot. However, there needed to be a functional county-level One Health Unit.

Target population

The study targeted physicians, public health professionals (PHOs), veterinarians, veterinary paraprofessionals (VPPs), and wildlife professionals (ecologists and wildlife VPPs) within Kisumu County, as proposed in the One Health Strategic Plan for the Prevention and Control of Zoonotic Diseases in Kenya^[18].

Study design

The study adopted a descriptive cross-sectional approach involving both quantitative and qualitative data.

Sample size determination

The minimum sample required was estimated using the Cochran formula^[19].

n = Z²pq/e²

Where: n = minimum sample required; e = margin of error (5%), P = proportion of one health collaborators (OHC) with knowledge of zoonoses (unknown; set at 50%), q is 1 – P, Z = standard normal deviate at 95%CI (1.96). The population of OHCs in Kisumu was established to be 193; therefore, using the finite population correction factor^[19], the adjusted sample size was (n₀) = n × N/n + (N – 1) was 129, but the researcher increased it to 142 participants to accommodate non-responses.

Sampling procedure

The 193 OHCs from the county directorates of health and veterinary services and Kenya wildlife service Lake Region constituted the primary unit for sampling purposes. They were stratified in terms of profession and sub-county. The diverse nature of the target population necessitated the use of a stratified sampling technique to proportionately recruit 142 OHC from a sampling frame established from the primary unit. Participants were, after that, conveniently selected depending on their availability at their workstations and willingness to participate.

Inclusion criteria

Only physicians, public health professionals, veterinarians, veterinary paraprofessionals employed by the County government of Kisumu, and wildlife officers (veterinarians and ecologists) working in the national government but stationed within Kisumu County, present at their workstations and willing to participate were included.

Data collection and analysis

A pretested, semi-structured, self-administered questionnaire was provided to the respondents at their workplaces. The Interviewer remained nearby for any clarification. Data were cleaned, validated manually, and analyzed using Statistical Package for Social Sciences (SPSS IBM) version 26. Nature, extent, and factors that affected collaboration were determined and assessed using descriptive statistics (frequencies, percentages, averages, mean and standard deviation). Chi-Square was used to test the association between categorical variables with the P-value set at a 0.05 significant level. Collaboration was considered adequate at 70%.

Study variables

The independent variables were the extent of multisectoral collaboration among the One Health partners, with particular emphasis on which sector initiates the collaboration, the nature of multisectoral collaboration, and the factors that affect multisectoral collaboration. The intervening variables were government policies related to staff employment, deployment and retention in the various sectors, and the occurrence of natural disasters such as extremes of weather, epidemics, and pandemics. The dependent variable was the control of zoonoses.

Characteristics of the study participants

A total of 142 respondents participated in the study, of which (70.4%, n = 100) were below 45 years, with the majority from the human health sector and most having bachelor-level education [Table 1]. A majority needed to be made aware of the existence of the ZDU [Table 2]. Other than their primary pre-service course, most respondents did not attend any one health-related course [Table 3]. None of the physicians sampled benefitted from any one-health-related seminar [Table 4]. Most physicians needed to be made aware of the objectives of the ZDU [Table 5].

The proportion of OH practitioners collaborating to control zoonoses in Kisumu County was 51.4%. Most instances of collaboration were initiated by the human health sector [Table 6].

Nature of collaboration among OH practitioners

Most (86.3%) of the OH partners participating in the collaboration notified their counterparts whenever a zoonosis was encountered, with public health professionals initiating most instances of the partnership [Table 7]. Sharing of surveillance information, conducting joint sensitizations/advocacy, joint surveillance, sharing of vehicles during vaccinations, and collaboration through professional associations were also frequently reported (53.4%, 30.1%, 27.4%, and 20.5%, respectively). Veterinarians, veterinary paraprofessionals, wildlife paraprofessionals, and ecologists did not share refrigerators or vehicles during vaccination campaigns. Joint surveillance was only conducted by physicians, public health officers, and ecologists [Table 7].

Factors that prompted the collaboration

Medical officers, veterinary paraprofessionals, and wildlife paraprofessionals were prompted to collaborate by the need for particular expertise outside their sector. Veterinary officers and public health officers were prompted to collaborate by the desire to promote One Health [Table 8].

Factors that affect collaboration among OH practitioners in the control of zoonoses

Most health workers and veterinarians cited insufficient funding (P = 0.000), lack of communication (P = 0.000), lack of transport facilities (P = 0.000), lack of interest in zoonoses at work and during training (P = 0.000), and difference in emphasis on zoonoses (P = 0.002) as the significant factors affecting OH collaboration [Table 9].

When requested to comment on the factors affecting multisectoral collaboration, more specifically, respondents indicated that communication enhances cooperation and facilitates engagement at departmental levels and that lack of it may frustrate collaborators’ efforts. Transport was needed to strengthen responses where collaboration was required. While funding was necessary to support One Health operations such as training, sensitization meetings, and advocacy for OH approaches [Table 10].

The extent of collaboration among OH practitioners

In this study, most collaboration was between the sectors responsible for health and livestock and primarily driven by the efforts of PHOs, unlike in Tanzania, where the animal health sector was instrumental^[20]. Collaboration between the wildlife and health sectors needed improvement due to the low staffing level that restricted their focus on ecosystem conservation. The better performance of the human health sector over the animal health sector was attributed to the low staffing levels in the latter due to increased workload while concentrating on the perceived core mandates, which left little opportunity for interactions with their OH partners. Understaffing was common in the veterinary and wildlife sectors. Indeed, only three wildlife experts were deployed across the study area, with one wildlife veterinarian serving Kisumu County from the Nairobi office.

Although public and veterinary services are devolved functions in Kenya, the national government retained policy formulation. However, since a county-level OH coordinating unit was not in place, the OH policy needed to be revised regarding practical guidance, promotion, and sustenance of multisectoral collaboration. This observation compares well with a Tanzanian study where a lack of policy statements contributed to the insufficient collaboration between physicians and veterinarians^[20]. This inadequate collaboration should concern disease control experts since most zoonotic disease pathogens originate from the wildlife sector^[21]. Medical officers （MOs） make critical decisions regarding disease control in hospitals and populations. For that reason, the low awareness of the existence of the ZDU and its objectives is a source of concern but explains the low level of cross-sector collaboration.

The level of post-basic training for the OHC could have been higher, as shown by the slow uptake of courses and seminars. The few staff who benefited from the Kenya Field and Epidemiology Training program needed to be adequately deployed to drive the OH agenda. Indeed, only some of the MOs sampled attended any OH course, and fewer participated in an OH-related seminar. However, much focus on curative services, though necessitated by staffing regime and the increasing number of patients, in addition to specialization, significantly reduced opportunities for collaboration.

Nature of collaboration among OH practitioners

Whereas a policy on OH existed at the national government level, there appeared to be some lethargy in its implementation, indicating either inadequacy of the document or lack of motivation. Partners were prompted to collaborate by the need for expertise outside their work sector. However, as noted elsewhere, the need for knowledge in disease detection and response, targeted surveillance and notification systems, joint meetings, and activities provided cues for partners to collaborate^[22]. Due to their role as extension agents of the human health sector and appreciable staffing inventory, PHOs undertook most of the daily One Health activities^[20].

Sharing surveillance information and other forms of notification on suspected zoonosis was common in collaboration among partners. Even though the wildlife sector is widely regarded as a source of zoonotic infections, human and animal health engagement was limited. However, with its smaller workforce, the wildlife sector shared information across all sectors. Collaboration through joint activities should have provided an opportunity for partnership but needed to be improved due to resource constraints and low staff levels in the animal and wildlife sectors.

Factors affecting OH collaboration

As observed elsewhere, some factors influencing OH collaboration are sector-specific^[23]. Insufficient funding had the most influence on the practice of OH since funds are required to support one health operations, such as training practitioners through seminars or short courses, and acquisition of critical infrastructures such as vehicles, offices, communication systems, and other materials^[20,24,25]. OH collaboration would ideally succeed with an adequately trained, appropriately deployed, motivated, and properly equipped workforce. A multisectoral collaboration, as part and parcel of the health system, requires clearly defined unifying OH effort, champions and partners, clear policy direction, and allocation of adequate resources to expand its capacity for better preparedness and resilience^[25,26]. Such kind of infrastructure was lacking.

A communication system is fundamental to the success of any OH approach since it drives peer engagement and enhances rapid community education about disease outbreaks and management^[27]. Communication across the collaborating sectors allows sharing of surveillance data and planning. According to this study, communication among collaborating partners can enhance knowledge integration and cooperation through engagement at different departmental levels, as observed elsewhere^[25,28]. Communication failure was mainly due to inadequate policy, as in Tanzania, where such a policy needed to be improved^[20].

Placing much focus on perceived critical departmental objectives could have improved collaboration, such that some veterinarians should have considered veterinary services as part of human health. Human health experts concentrated on curative services, ignoring the potential of a preventive approach to zoonoses^[24]. Where curative health services are prioritized, the need to consult with collaborating partners remains the same. Preventive and control measures need to start in the wildlife phase, followed by the livestock sector, which is a buffer between the wildlife sector, which is regarded as the source of most zoonotic pathogens, and the human hosts^[24,29]. In this study, some human health experts wrongly assumed that zoonotic diseases were the domain of veterinarians. Some OH partners did not appreciate the full impact of zoonoses, while for some, it was only an issue outside the urban settings. This observation is attributed to continued specialization and inadequate post-basic course training, including a need for opportunities for acquiring new knowledge on zoonoses^[27,30].

In conclusion, multisectoral collaboration for OH needed to be improved due to a deficient OH policy at the Kisumu County level. The proportion of human health experts collaborating for OH was higher than their animal health and wildlife counterparts. Conducting joint sensitizations and notification of partners whenever a zoonosis was encountered were the preferred collaboration methods. The main barriers to multisectoral collaboration were the need for more funding, inadequate communication, lack of transport facilities, and low interest in zoonoses at work and during training. The need for particular expertise, the desire to promote OH, and the requirement to mainstream OH as a departmental policy prompted partners to collaborate.

The study recommends reviewing the OH policy under the leadership of the Zoonotic Disease Unit to enhance guidance and sustainability at the county level. The formation of a well-resourced county-level coordination unit by Kisumu County public service is critical to driving the OH agenda. To enhance interest in the OH approach, there is a need to entrench it in the syllabus of all health-related courses by training institutions. Setting up an automated real-time alert system that enhances data collection, processing, and dissemination can address the lack of communication. The study recommends further study on the low interest in one health among physicians despite their critical role in the approach’s success.