In a move that is expected to bring in significant reforms in the detection, prevention, control, and treatment of disease, the government has laid down its vision to strengthen public health surveillance and make individual health records the basis for surveillance of various communicable and non-communicable diseases in India by 2035. The policy direction comes at the time of the Covid-19 pandemic when the country had to quickly scale up its diagnostic and treatment capabilities and align its expertise in digital technology for effective surveillance.
Public health surveillance is undertaken to inform disease prevention and control measures. The World Health Organization defines surveillance as “An ongoing, systematic collection, analysis and interpretation of health-related data essential to the planning, implementation, and evaluation of public health practice.”
Titled, “Public Health Surveillance in India by 2035”, the vision document developed and proposed by the NITI Aayog promotes surveillance as an important public health function. It builds on India’s past experience in handling diseases. It also draws on lessons learned from global best practice from Thailand, Taiwan, Germany, United Kingdom, USA, and Canada.
It proposes mainstreaming of public health surveillance by 2035. Surveillance in this context is ‘information for action’. It cuts across primary, secondary, and tertiary levels of health care. It includes the detection of disease and early warning signs of impending outbreaks or epidemics, both those endemic to the country as well as public health emergencies of international concern. Tracking disease trends and responding with timely and effective actions are critical functions of surveillance.
According to the white paper, India’s Public Health Surveillance should build on opportunities presented by the Ayushman Bharat scheme and the Integrated Health Information Platform of the Integrated Disease Surveillance Program while aligning with the idea of citizen-centricity promoted in the National Health Policy 2017 and the National Digital Health Mission.
The white paper lays out India’s vision 2035 for public health surveillance through the integration of the three-tiered public health system. It also stresses on the need for expanded referral networks and strengthening laboratory capacity.
In line with the recently launched National Digital Health Mission, the white paper proposes a unitised and unified real-time surveillance system that allows interoperability and data sharing and is not based on traditional systems of data entry and upload. It lauds citizen-centric and community-based surveillance and the use of point of care devices
and self-care diagnostics. Surveillance is to be primarily based on anonymised individual-level patient information that emanates from health care facilities, laboratories, and other sources.
Well-functioning information systems that include a robust digital health infrastructure are, therefore, the basis of effective public health surveillance. The vision document proposes drastic improvements to the existing data systems operating in silos. It recommends an integrated solution encompassing a ‘One-Health’ approach that merges health information from different sources.
It is expected that suggestions made by the white paper will help enhance the capacities and expand the scope of the existing Integrated Disease Surveillance Program of the Ministry of Health and Family Welfare to include noncommunicable diseases, occupational health, injury and environmental health surveillance, in addition to the existing communicable diseases covered under the program.
Why is Public Health Surveillance needed?
Surveillance systems can guide public health policy and strategies in a number of ways. They serve as early warning systems that can identify public health emergencies. A surveillance system also documents the impact of an intervention and the progress towards specific public health goals. It monitors the epidemiology of a condition to guide public health policy and strategies in priority setting.
As per WHO, a surveillance system has the following functions:
- collection and consolidation of pertinent data
- investigation and confirmation (epidemiological, clinical and/or laboratory) of cases or outbreaks
- routine analysis and creation of reports
- feedback of information to those providing the data
- feed-forward (i.e. the forwarding of data to more central levels)
- reporting data to the next administrative level
As is evident, the above mentioned functions cannot be achieved unless digital health systems are well in place. The lessons learned from COVID-19 and similar past experiences in identifying and controlling outbreaks, reducing, and eradicating diseases must be utilized to be able to strengthen public health surveillance in India.
What does the white paper propose?
The vision document was developed by the NITI Aayog, and the Institute for Global Public Health, University of Manitoba, Canada with contributions from technical experts from the Government of India, states, and international agencies.
It suggests “the utilization of new situation-aware real-time signals from social media, mobile/sensor networks and citizens’ participatory surveillance systems for event based epidemic intelligence in addition to the existing systems and electronic health records for case-based surveillance linked through the optimal use of unique health identifier.” It highlights the effective support coordination of multidisciplinary teams, risk communication with citizens as the primary stakeholders and the implementation of prevention measures at all levels for a timely and effective public health response.
It proposes four building blocks as below:
- A federated governance architecture between the centre and states,
- Improved use of data for surveillance based on unitized, citizen-centric comprehensive electronic health records with a unique health identifier (UHID). Existing disease surveillance data and information from periodic surveys is expected to complement this information
- Enhanced use of new data analytics, data science, artificial intelligence, and machine learning.
- Advanced health informatics.
The Next Steps
Drawing on proven best practices, the document suggests seven areas of action for India. These steps align with the principle of using surveillance as a tool for the public good. These are:
- Create a governance framework that is inclusive of political, policy, technical, and managerial leadership at the national and state level.
- Identify disease categories to be included under surveillance.
- Improve surveillance of non-communicable diseases in a phased manner.
- Regularly prioritize diseases, posing as a public health concern, for elimination.
- Improve core support functions and system attributes for surveillance at all levels; national, state, district, and block.
- Establish mechanisms to streamline data sharing, capture, analysis, and dissemination for action.
- Encourage innovations in surveillance activity.
The Covid-19 pandemic has made us take another, closer look at emerging diseases. Some of these are due to increased interaction between humans, animals, and the environment. Early identification is essential to break the chain of transmissions and to create a resilient surveillance system. The white paper lays down the roadmap towards achieving this vision and highlights the building blocks required to get there effectively. It talks about a citizen-friendly public health systeminvolving diverse stakeholders such as individuals, community, healthcare facilities and laboratories, while protecting the individual’s privacy.
The vision behind the white paper is that by 2035, India’s public health surveillance will be a predictive, responsive, integrated, and tiered system of disease and health surveillance that is inclusive of prioritized, emerging, and re-emerging communicable and non-communicable diseases. Public Health Surveillance will be governed by an adequately resourced administrative and technical infrastructure and will ensure that it serves the public good. India will provide regional and global leadership in managing events such as global public health emergencies. Implementation of this vision can propel India to be a global and regional leader in effective public health surveillance.