IDSP-a critical analysis

Gnanaranjan DasBOT,MBA, PGDPHM(contd)

Integrated Disease Surveillance Project

• IDSP was launched with World Bank assistance in November 2004 to detect and respond to disease outbreaks quickly.

• The project was extended for 2 years in March 2010. From April 2010 to March 2012, World Bank funds were available for Central Surveillance Unit (CSU) at NCDC.

• The Programme continues during 12th Plan under NRHM with outlay of Rs. 640 Crore from domestic budget only.

Organizational Structure

Disease Surveillance Committee

Executive Committee

Disease Surveillance Unit

District Surveillance Committee

Chairperson* District Surveillance Committee

District Surveillance Officer (Member Secretary)

CMO(Co. Chair)

RepresentativeWater Board

Superintendent Of Police

IMA Representative

NGORepresentative

District PanchayatChairperson

Chief District PHLaboratory

Medical CollegeRepresentative

if any

RepresentativePollution Board

District Training Officer(IDSP)

District Data Manager(IDSP)

District Program ManagerPolio, Malaria, TB, HIV - AIDS

* District Collector or District Magistrate

STRUCTURAL FRAMEWORK

C.S.U.

S.S.U

D.S.U.

P.S.U

MED COL.

DIST HOS.

PVT. HOS.

OTHER HOS.

LABSSUB CENTRES

PHCs/CHCs

RURAL PPs

Need for Surveillance

The Government of India realized the importance of Disease surveillance after the Cholera outbreak in Delhi and the Plague outbreak in Surat, which not only had significant mortality and morbidity but also significant economic consequences.

Objectives of IDSP

• Establish a decentralized system of disease

surveillance for timely and effective public health action

• Improve the efficiency of disease surveillance for use in health planning, management and evaluating control strategies

IDSP

Based on case based reporting • Syndromic surveillance (suspect case reporting

at PHC and below) • Confirmed case reporting of selected priority

diseases (at district level)

• Passive reporting of Road Traffic Accidents and Air Pollution.

Syndromic surveillance

• Fever<7 days (alone, with rash, with altered sensorium/convulsions, bleeding skin/gums

• Fever>7 days• Cough>3 weeks• AFP• Diarrhea• Jaundice• Unusual events causing death/hospitalization

Target diseases

• Malaria• ADD(Cholera)• Typhoid• Tuberculosis• Measles• Polio• Plague • HIV, HBV, HCV

• Unusual Syndromes• Accidents• Water Quality• Outdoor Air Quality• NCD Risk factors• State Specific Diseases

Project components

• Integrating & decentralizing disease surveillance & response mechanisms

• Strengthening Public Health Laboratories

• Using Information Technology and Networking in disease surveillance

• Human Resource Development

Level of responses

• Level-1 : Response Health Workers

• Level-2 : Outbreak Inv. & Response (PHCs/ CHCs)

• Level-3 : Outbreak Inv. & Resp. (DSU)

• Level-4 : Epidemic Response (SSU)

• Level-5 : Disaster Response (CSU)

Project phasing

Phase – I (2004-05): Tamil Nadu, Kerala, Karnataka, Andhra Pradesh, Maharashtra, Madhya Pradesh, Uttaranchal, Himachal Pradesh & Mizoram (nine states)

Phase – II (2005-06): Chattisgarh, Goa, Gujarat, Haryana, Rajasthan, West Bengal, Manipur, Meghalaya, Tripura, Chandigarh, Pondicherry, Delhi

Phase – III (2006-07): Uttar Pradesh, Bihar, Jammu & Kashmir, Jharkhand, Punjab, Arunachal Pradesh, Assam, Nagaland, Sikkim, A & N Island, D & N Haveli, Daman & Diu, Lakshwadeep.

Formats & manuals

• Standard Case Definitions

• Standard Formats for reporting

• Operations manual for Health Workers, Medical Officers, Laboratory Technicians and District/State Surveillance Teams

• Standard user friendly training manuals

NCD risk factor surveillance• Monitor trends of important risk factors of

NCD in the community over a period of time

• Evolve strategies for interventions of these risk factors so as to reduce the burden of diseases due to NCDs

• Strengthen NCD surveillance at District level

• Integrate NCD risk factor surveillance with IDSP

Strengths of IDSP

• Functional integration of surveillance components of vertical programmes

• Reporting of suspect, probable and confirmed cases• Strong IT component for data analysis• Trigger levels for gradated response• Action component in the reporting formats• Streamlined flow of funds to the districts

Lessons learntIDSP• IDSP cell in Ministry with budget• Integration• Budget for retraining

• Adequate feedback planned• Strong IT component• Strong state ownership (all districts)• Fast financial flow• Strong M & E, supervision• Advocacy at all levels

Integration

• National programmes• NCDs• Private sector• Police, Pollution Control Board, Water supply• IEC activities• Training• Formation of committees to oversee integration

Integration ?!

• What exactly do we expect in integration• Functional integration to what degree• Vertical programmes still continue• NCD component invariably stand alone• IEC, Training, Formats- consultation with these

programmes • Fund sharing a daunting task

National Issues

• Political considerations based on Centre-state relations

• Central assistance proportionate to political affiliations

• Media attention an important consideration for response

• Time constraints-inadequate time given for outbreak investigation

National Issues cont’d

• Reduced attendance in public health system and increased in private sector almost 40:60 or more

• Wide-spread quackery in the name of alternate medicine (ayurveda, unani, homeopathy, etc)

• ‘Overworked’ clinicians so poor maintenance of medical records like case sheets/prescription slips/provisional diagnosis/etc

• Lack of ownership by states of central vertical programmes

State issues• State RRT not utilized to full potential• Regional labs strengthened but lab diagnosis not

enhanced & increasing dependence on Centre• Insufficient epidemiological analysis • No clear IEC strategy• Frequent transfer/retirements of trained staff so

programme invariably suffers• Shortage of staff so multi-tasking for state and district

level functionaries. • Fund issues and Utilization certificates

State issues cont’d

• Lack of competent staff especially Public Health Professionals and Microbiologists in majority of the states. Short trainings not likely to build the necessary capacity.

• Clear demarcation between the Directorate of Health Services and Directorate of Medical Education so difficulties in integrating Medical colleges

District issues• Programme is focused on district epidemic preparedness

and response but some districts yet to get their act together

• Reporting from periphery needs improvement. If media first reporting then SURVEILLANCE FAILURE

• Weekly reports incomplete and irregular (and under reporting)

• Monthly reports also irregular• Communication ‘failure’• CMO-CMS-DSO lack of co-ordination

District issues cont’d• Overworked peripheral staff to whom all programmes are

dependent on• Multiple formats for different programmes• Rapid Response Teams usually composed of specialists

from District hospital/ Medical college and problem in rapid mobilization as from different agencies

• Concept of Nil reporting/routine reporting difficult for the peripheral staff to understand, compounded by lack of feedback from the higher levels

District lab issues• District labs few established and functioning not

satisfactorily• Many labs in a district:– Public health lab-testing water samples– Hospital lab-testing for NCDs and clinical requirements– Medical College lab-testing for majority of the diseases– Surveillance lab-testing for few diseases– District blood bank –with ELISA reader– Peripheral labs-Microscopy only

Co-ordination between these labs is difficult so that overall district lab capacity diminished

Reference

• Indian Public Health Standard• National center for disease control• www.idsp.nic.in• IDSP Portal• Training manual for Medical officers,

Paramedical staff & other health professionals for Hospital based disease surveillance