Public Health is defined as the art and science of preventing diseases which leads to the prolongation of life and also the promotion of health by the hard work of the society. Efficiency in the Public Health can be achieved by well timed, reliable and precise information which can be used to study the health pattern in the different populations. India has been experiencing a very high burden of the infectious diseases in the world accelerated by factors such as large population, poor sanitation, high poverty levels, and problems related with the access to preventive services and health care.
Traditionally it had been difficult to monitor the trends of diseases in India and even more difficulty in detection, diagnosis and controlling the outbreaks until they became very large. In the effort to ensure improvement in the response and surveillance in the country, the Integrated Disease Surveillance Project was started in November 2004 with funding from World Bank. With the surveillance problems in India, this project was meant to accomplish the goals by having a list of priority conditions, with most of them being syndrome-based at the sub center and community level and easily recognizable at the inpatients and outpatient care of facilities at the low levels of health care system.
This project also included activities which are comparatively high in technology such electronic data transmission, computerization and video conferencing for training and communication. The Integrated Disease Surveillance Project was planned to be implanted across India in a phased manner which was to stress on the 14 states with an intensive follow-up to ensure that there was a successful implementation of the project.
The objective of the project is to ensure improvement of the information available to the private health care providers and more so to the government health services on the risk factors and the high priority diseases with an aim of improving the responses on the ground to those diseases and risk factors. In detail, the project aims at:
- Establishing a decentralized system for the surveillance of non-communicable and the communicable diseases to ensure effective and timely public health actions to be initiated to respond to the health challenges in India.
- Improving the efficiency of existing surveillance in the disease and control programs and also facilitate the sharing of important information with the community, health administration and the other stakeholders in order to evaluate the control strategins and detect trends of the diseases over some time.
The objectives of the project were also directed in helping the Government of India to: improve data quality, analysis and the links to action, monitor some health conditions and the risk factors, train the stakeholder in the disease action and surveillance, decentralize and coordinate the surveillance activities, integrate the disease surveillance at the district and state levels and also involve the communities, and improve the laboratory services.
Beneficiaries and stakeholders
The World Health Organization has played a very crucial role to assure quality of the project by guiding the member states to set up the Integrated Disease Surveillance systems and also in the provision of technical and legal framework for the project. The Country Office of the WHO provided a dedicated staff that included microbiologist, epidemiologist and information technology specialists. The support from the United States Center for Disease Control and Prevention also helped in the improvement of quality by networking with national center for disease control, independent assessment and some other types of technical assistance.
The World Bank was very helpful in funding this project by its donations and lending of money to the Indian government. The World Bank has also helped in monitoring the progress of the project as they ensure that the funding they give is used in the right ways. The Indian government has been involved in ensuring that the project is working in the right way by allocating the money funded to the projects to the sectors that need it. It has also been helpful in providing data of the previous trends of diseases and determining the hot spots of disease attacks.
The beneficiaries of this project were not specified at the start even though it is very clear that the intentions of the project were to benefit general population by reducing the disease burden in the timely identification, response and reporting. However, it had some secondary beneficiaries who included the paramedics, community-level workers and the health professionals. The policy makers at the different levels also benefit from the technical assistance and training under this project. The capacity to identify and respond to the infectious diseases was improved with the response kits and the laboratory equipments being supplied by the project.
Beneficiaries of the Tribal Development Action Plan consisted of all tribal populations who were in the pilot blocks for the selected project districts and states. The integration of the disease surveillance programs was meant to provide complete and coherent health information, improve response by the health system and provide proper monitoring of the disease burden in the tribal areas. Information from the community would also be a major input to the District Surveillance Unit in the coordination of analysis, response and feedback of information on the diseases. These interventions were meant to have a positive influence on the communities and their health status.
Following the Cholera epidemic in Delhi and the Plague epidemic in Surat, the Indian Government through the National Surveillance Programme for Communicable Diseases initiated a pilot project for the surveillance of diseases. The program was implanted a hundred and one districts of India with an aim of providing surveillance of the communicable diseases to enable early reporting of the diseases outbreak and enhance the response to those outbreaks.
Only the communicable diseases had been targeted by this program, however the success of the pilot project in the reporting of disease outbreak caused the Government to begin a program that is comprehensive and aimed at surveillance of diseases on a wider range. Consequently, the Indian Government in partnership with the World Health Organization, the Indian Council of Medical Research, the National Institute of Communicable Diseases and the World Bank. The program was initially started in phases implemented in some of the Indian states and later extended to the other states.
The total cost of the project had been estimated to be about $88.64 million where the World was to contribute a sum of $ 68 million and the Indian Government was to fund the rest. The Ministry of Health and Family of India was mandated to meet the costs of implementing the project with other non-bank sources contributing to the project.
In the beginning, the project experienced a very smooth start but after some time, it entered into prolonged periods of slow implementation. It encountered several key bottlenecks that included: difficulty in the hiring quality project management staff and technical staff, delays in the procurement of good and in consultations because the Bank and the Indian Government could not reach agreements in the appropriate methods of procurement in a timely manner. Due to these bottlenecks, the restructuring that took place in the year 2010 shifted and narrowed down the project support to a few geographic and technical priorities. Reducing the project foci and size turned out to be more practical and realistic than the original planned objectives and activities.
In order to address the crisis in the human resources the project was facing, the National Health Mission went on to sanction all the contractual positions of microbiologists, entomologists and epidemiologists needed for the functioning of the system. Consequently, the Indian Government assumed a bigger responsibility in funding the project after the Government and the Bank decided to cancel some of the credit from the Bank and also funding the Disease Surveillance Project in the states that had been dropped from that project so as to make sure it had a full coverage in all territories and states of India.
The advancement of ICT infrastructure tremendously helped to increase quality and coverage of the Disease Surveillance Project even in the remote areas. Creation of Project’s portal made report generation, query, data entry and analysis using graphs at the district level possible. This portal served as a storage area for the on-line IT training modules and also made other information resources associated to disease surveillance accessible to all the units of the Disease Surveillance Project. Broadband access enabled video conferencing and training. The enhanced coverage and quality of the landline and mobile phone service in India made the operation of toll free call centers become a reality.
During the early times of the project implementation, there was very little technical assistance and supervision for the understaffed Central Surveillance Unit. Inadequacies in the arrangements for technical and troubleshooting support to the states were usually documented in supervision Aide Memoire due to lack of required manpower at the Central Surveillance Unit. Incredible strengthening of the central surveillance unit was observed after restructuring took place in the year 2010 which correlated very well with the accelerated progress towards attaining the set objectives of the project.
At the state and central levels, a huge number of refreshment and orientation training activities were implemented by the network on state and national institutes and universities that were contracted under the project. Improvements in the staff training have resulted to a steady improvement in the technical performance of the surveillance coverage, consistency, timelessness and in the number of outbreaks investigated and detected were observed. In the component of animal health, 95% of para-veterinary and veterinary staff went through training under the projects and also an overseas postgraduate training organized for 26 veterinary staff. This significantly upgraded the capacity of regional centers for the veterinary services.
The project has flexibility in adapting to the changing circumstances. It responded positively and swiftly to changed requirements for disease control and prevention in the country. With the outbreaks of HPAV (H5N1) that were reported in India, the Government of India and the Bank quickly reached an agreement to restructure the project so as to respond to the perceived threat that came from HPAI H5N1 for both animal and human health sectors in the year 2007. After the year 2010, when the investment from the Indian Government increased for the Disease Surveillance Program, the proceeds of the project were strategically shifted and focus on aspects which could result to greater added values through focusing on the improvement of technical oversight from the Central Surveillance Unit as well as the selected geographic and technical priorities.
Revised components between 2010 and the time of project completion
Component 1: Central Surveillance Monitoring and Oversight
Good progress was made on training programs for trainers as well as the two-week Field Epidemiology Training Program for the state epidemiologists. In the life of the disease surveillance project, about 1033 trainers went through training against a load of 920 and a total of 221 epidemiologists availed the training against the initial planned 218. A total of 188,031 health professionals including hospital doctors and medical officers, nurses/pharmacists, health workers and lab technicians were trained in disease surveillance and the appropriate responses. Supervision and monitoring role of the Central Surveillance Unit improved as was reflected in the number of visits to states and the interactions with the states via meetings and the videoconferences that took place.
Component 2: Improving District/State Surveillance and Response Capacity.
About 97% of districts of the nine priority states had reported on both the ‘P’ and the ‘L’ forms. The quality of reporting by hospitals and the private health care providers was considerably improved. Improvement in the quality of the laboratory investigations was confirmed by EQAS. The pilot projects on community based surveillance began in the selected area states of Karnataka, Maharashtra and Gujarat. The number of outbreaks reported and the number of confirmed outbreaks by the laboratory evidence increased tremendously. Information gathered from the surveillance project systems were disseminated to the public and the policy makers and was used to inform the design of the public health programs.
Component 3: Flu Surveillance and Response
Human Health: There was an establishment of 12 public health laboratory network for human influenza surveillance, where 11 of them were fully functional. 36% of sentinel hospital began ILI reporting. 3 of the 6 BSL level III laboratories were put up and were functioning.
Animal Health: Twenty eight BSL-II laboratories were put up at the regional level. Three BSL-III laboratories were also put up and functioning. All the materials to be used for rapid responses were stocked. AI surveillance for the commercial poultry farm, surveillance for the backyard poultry and the migratory birds along flyways and around wetlands, satellite mapping for sanctuaries of birds, wetlands and water bodies, and the development of the GIS bases animal information and disease surveillance systems included the planned projects that were cancelled in component 3.
- Surveillance units have been put up in district headquarters and states. The central surveillance unit has been established and also integrated in the National Center for Disease control.
- There has been and establishment of an IT network that connects 776 sites in all the district headquarters, states and the premier institutes in India.
- Media verification and scanning cells were established under the project and this has been utilized in detecting and sharing media alerts with the concerned areas for verification and response.
- Fifty district laboratories have been strengthened for diagnosis of diseases in the epidemic prone areas.
- 11 laboratories have been made functional and also strengthened under the project for surveillance of Avian/H1N1 influenza.
- Lack of staff that is sufficiently trained in Public health.
- The trained District Surveillance officers not being able to use their skills because of high turnover.
- Data entry operators and data managers not being outsourced centrally through the different Agencies.
- Lack of manpower/infrastructure with adequate skills to undertake confirmatory tests for some diseases at the district laboratories.
- The funds committed for the medical college laboratory which was to act as the state reference laboratory could not be provided.
- Public health only gets activated when there are disasters and crisis. There is no day to day functioning of health system.
- The high priority given to public health by the states and the strong leadership by the local Governments has been helpful in the implementation of the disease surveillance project.
- Most of the District/State surveillance officers for the project have a lot of additional responsibilities that affect the implementation of the project negatively by causing delays.
- Actions need to taken so as to increase coordination between Department of Medical Education and Department of Health Services.
- There is a short supply of the crucial human resources (entomologists, microbiologists, epidemiologists) at the district levels.
Opinion and conclusion
Disease surveillance in India has taken a new direction after the Integrated Disease Surveillance Project was introduced, with accurate data being collected and transferred to central level for storage and analysis. The monitoring of such large projects may be difficult but the decentralization in this project makes the process easy. Surveillance on a regular basis will aid to understand the trends of disease in the population. The changing trend of diseases helps in assessing effectiveness of the preventive measures hence improving the implementation.
Given the large population in India, diseases surveillance is facing a lot of challenges and thus a lot of improvements are required to get an optimum level of surveillance. The introduction of broad band networking and satellite systems will ensure the improvements required. The Integrated Disease Surveillance Project has been implemented in stages with few priorities with the decentralized approach which incorporates data instead of individual data of cases. Success can be attained with the passage of time. The major challenges can be overcome through involvement of the Private Sector, having proper infrastructure in the surveillance units and the laboratories in the borders combined with suitable quality assurance program so as to achieve effective monitoring.
Agriculture, Ministry of. "Department of Animal Husbandry, Dairying & Fisheries." Annual Report. 2011/2012.
Ashok Vikhe Pati, K. V. Somasundaram and R. C. Goyal. Current health scenario in rural India. 2002.
John TJ, Samuel, Balrj V. John R. Disease surveillance at district level: a model for developing countries. Lancet, 2009.
Monica Das Gupta, B.R. Desikachari, T. V. Somanathan, P. Padmanaban. How to Improve Public Health Systems: Lessons from Tamil Nadu. 2010.
Monica Das Gupta, Manju Rani. India's Public Health System: How Well Does It Function at the National Level? 2008.
Peter Berman, Rajeev Ahuja, Ajay Tandon, Susan Sparkes and Pablo Gottret. Government Health Financing in India: Challenges in Achieving Goals. n.d.
Salimata Ouedraogo Ki, Martin I. Meltzer. Modeling the Cost-Effectiveness of the Integrated Disease Surveillance and Response System. 2010.