Public Health Surveillance in India – Vision 2035

Recently, the NITI Aayog has released a white paper called ‘Vision 2035: Public Health Surveillance in India’.

  • The paper is a joint effort of Health Vertical, NITI Aayog, and Institute for Global Public Health, University of Manitoba, Canada with contributions from technical experts from the Government of India, States, and International agencies.
  • The Vision 2035 document proposes to use the definition ‘Surveillance is information for action’, drafted by an expert group in 2012 by the Department of Health i.e. Public Health Surveillance in the vision document entitled, “Towards a Public Health Surveillance for England”.
  • The 1988 Cholera outbreak in Delhi and 1994 plague outbreak in Surat prompted the Government of India (GoI) to constitute a National Apical Advisory Committee (NAAC) in 1995.
  • The Indian Council of Medical Research (ICMR) has played a key role in strengthening surveillance and research related to surveillance.
  • The network of ICMR continues to expand and at present have 106 Viral Research and Diagnostic Laboratories (VRDL), 35 diagnostic centres and a number of apex institutions.
  • In 2019, the World Health Organisation (WHO) in partnership with the Government of India launched the Integrated Health Information Platform (IHIP) within the IDSP program.
  • The IHIP is a digital web-based open platform that captures individualised data in almost real-time, generates weekly and monthly reports of epidemic outbreaks and early warning signs.

Need for Public Health Surveillance

  • The public health surveillance is the ongoing systematic collection, analysis, and interpretation of data, closely integrated with the timely dissemination of these data to those responsible for preventing and controlling disease and injury.
  • The public health surveillance is a tool to estimate the health status and behavior of the populations served by ministries of health, ministries of finance, and donors.
  • The purpose of surveillance is to empower decision makers to lead and manage more effectively by providing timely, useful evidence.
  • The public health objectives and actions needed to make successful interventions determine the design and implementation of surveillance systems.
  • The public health surveillance provides the scientific and factual database essential to informed decision making and appropriate public health action.

Challenges in India’ Public Health Surveillance

  • Re-emerging and new Communicable Diseases: A number of new infections have emerged and pathogens and diseases have re-emerged with resistant or mutant strains.
    • 75% of emerging/re-emerging diseases are zoonotic and therefore a system of active animal surveillance and integration with agriculture and other sectors is critical.
  • Increasing rates of non-communicable diseases and acute and chronic conditions: The Ministry of Health in its document “India-Health of Nation’s states” (2019) states that 61% of mortality and 55% of the disability adjusted life years were caused by NCD in 2016.
  • Growing threat of Anti-microbial resistance: The factors which contribute to AMR include overuse and misuse of antibiotics through self-medication, indiscriminate access to antibiotics without prescription.
    • The use of pharmacies and informal healthcare providers as basic sources for healthcare seeking, and the lack of knowledge about when to use antibiotics.
  • Implementation challenges-patchy surveillance, not comprehensive: One of the important system design issues is that data on the citizen utilization of services for treatment of disease is separate from notification mechanisms for disease outbreaks.
    • There is a lack of uniformity in outbreak investigation and reporting and there are limitations in geographic coverage within states.
  • Surveillance functions in vertical siloes of programs and institutions: The vertical programs such as the National AIDS Control Program and the National TB Elimination Program have achieved significant success in reducing disease transmission, increasing the proportion of people who know their HIV or TB status.
  • Private sector involvement in surveillance is limited: The private sector is not a homogenous entity as it includes unregistered practitioners, stand-alone clinics, pharmacies and laboratories, smaller nursing homes, medium to large hospitals, medical colleges, corporate institutions and apex institutions.
  • Inadequate linkage of morbidity with mortality data: The RCH program has recently begun focusing on enhancing maternal and neonatal death review to enable the identification of contributing factors and potential solutions to inform health care service deliveries and prevent future deaths.
  • Human resource challenges: The recruitment of human resources for State and District Level Surveillance Units has been devolved to states.
    • The reasons for the lack of importance attributed to Public Health Surveillance by state governments needs to be explored and addressed.
  • Training of Public Health Core-Capacity: There are many examples of training programs for public health professionals specifically in the area of surveillance.
  • Limited use of digital, social and print media in surveillance: The social and print media are increasingly being piloted for use in surveillance.
    • The media sources can also be used to promote disease prevention and containment actions at community level during new infectious disease outbreaks.
  • Limited focus on non-communicable disease surveillance: The non-communicable disease (NCD) surveillance was introduced in many developed countries almost 35-40 years ago.

Opportunities of Public Health Surveillance System

  • Introduction of Ayushman Bharat Scheme: Pradhan Mantri Jan Arogya Yojana (PMJAY) is the largest health assurance scheme in the world which aims to provide a health cover of Rupees five lakhs per family per year for secondary and tertiary care hospitalization for poor and vulnerable families.
    • The health and wellness centres (HWC) present an opportunity to conduct surveillance for infectious disease, non-communicable disease, occupational health and injury related conditions at the individual, family and primary care level.
  • Integrated Health Information Platform (IHIP): It provides an opportunity to be rapidly scaled up across the country, to expand on the number and type of disease conditions captured and to include data from the private sector.
  • National Digital Health Blueprint: The two key recommendations from the National Digital Health Blueprint document are the use of a unique health identity number (UHID) and the strengthening of electronic health records in the public and private health care sectors.
  • Opportunity for India’s mobile sector: The growth of smart phones and penetration of mobile telephones also presents a huge opportunity for the paperless capture of almost real-time information, inclusive of geo-coordinates.
  • Digitisation of Health Management Information System: The Clinical Establishments Act has been passed and a number of states have been able to create directories of clinical establishments and use this information to build upon and enhance notification for disease, death and births, especially within the private sector.

Building blocks for India’ Public Health Surveillance

  • Governance Principle-Develop an eco-system for surveillance: A federated governance system that is based on ensuring ‘public good’ and that pools public health surveillance resources and information both for the ‘Centre’ and ‘States/Union Territories’, is the foundation for Surveillance.
  • Information Systems linked with robust lab networks as data sources for Surveillance: New data sharing mechanisms ensure that Surveillance does not replace existing vertical and integrated programs, but amalgamates the data on a ‘Surveillance Information Platform’ in near real-time using data-sharing mechanisms, rather than traditional data entry systems.
  • Data Analytics: The definitions of disease are standardized for surveillance that is agreed upon by clinician, researcher and epidemiologist, and between veterinary, plant and human sciences, in alignment with the ‘One-Health’ principle are universally utilised.
  • Information for Action Principle-For Public good: The Public Health Surveillance undergoes a paradigm shift from being visualized as a core Government function, to one that is ultimately aimed at making relevant information available to the common citizen for public good.

Measures to be adopted for India’ Public Health Surveillance

  • Forecasting and Preparedness for Epidemic Outbreaks: The prediction for communicable and emerging epidemics of non-communicable disease, both re-emergences of known illnesses in different forms.
  • Guiding Prevention and Health Promotion Strategies: Identify new/hidden reservoirs and sources of infection, block chains of rapid transmission and limit the resulting morbidity, disability or death.
  • Responding to Outbreaks and Guiding Future Programs of Disease control: Institute standard protocols of:
    • Characterising results beginning with molecular tests,
    • Digitise results and ultimate action in real-time, and
    • Conduct genetic mapping to explore variations in the pathogen or the susceptible host.
  • Setting surveillance priorities: The priorities should include chronic and acute conditions, especially in the context of occupational, environmental and nutritional health.
  • Identifying and preparing the human resource capacity: The government should ensure to have a dedicated Public Health Cadre at block, district, state and national levels, in adequate numbers and with composite competencies that are regularly updated.

Road ahead

  • India’s Vision 2035 for Public Health Surveillance envisions integration within the three-tiered health system, strengthened community based surveillance, expanded referral networks and enhanced laboratory capacity.
  • Surveillance is not solely dependent on individual disease driven active or passive surveillance systems, though these may remain important contributors to surveillance information.
  • The building blocks for this vision are an interdependent federated system of Governance between Centre and States, new data sharing that is not dependent on traditional systems of data entry, but one that is positioned over and above existing disease surveillance programs.
  • The surveillance uses new analytics, health informatics and data science and innovative ways of disseminating ‘information for action’ which will further thrust India to be a global/regional leader in Public Health Surveillance.
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