Vision 2035: Public Health Surveillance in India

Surveillance is defined as ‚Äúa core public health function that ensures that the right information is available at the right time and in the right place in order to inform public health decisions and actions‚ÄĚ1 . In short, surveillance should be ‚ÄúInformation for Action‚ÄĚ

 

Vision

In 2035, India’s Public Health Surveillance will:

Be a predictive*, responsiveŌÄ , integrated# and tiered@ system of disease and health surveillance that is inclusive of Prioritised$ , emerging and re-emerging communicable and non-communicable diseases and conditions. Readiness for actions at community, facility and health and governance systems are key aspects of the response.

Be a system that is primarily based on de-identified individual level patient information which includes health care facility and laboratory data as key sources, amongst others.

Be governed by an effective administrative and technical structure that is adequately resourced.

Serve public good through the provision of meaningful ‚ÄėInformation for Action‚Äô to relevant stakeholders^, with due attention to privacy and confidentiality of the individual, and enabled with a client feedback mechanism.

Provide regional/global leadership in compliance with International Health Regulations and management of events that constitute a Public Health Emergency of International Concern

 

Vision 2035: Public Health Surveillance in India

NITI Aayog‚Äôs mandate is to provide strategic directions to the various sectors of the Indian economy. In line with this mandate, the Health Vertical released a set of four working papers compiled in a volume entitled ‚ÄėHealth Systems for New India: Building Blocks ‚Äď Potential Pathways to Reform‚Äô during November 2019.

‚ÄúIndia‚Äôs Public Health Surveillance by 2035‚ÄĚ is a continuation of the work on Health Systems Strengthening. It contributes by suggesting mainstreaming of surveillance by making individual electronic health records the basis for surveillance.

Public Health Surveillance (PHS) cuts across primary, secondary, and tertiary levels of care. Surveillance is an important Public Health function. It is an essential action for disease detection, prevention, and control. Surveillance is ‚ÄėInformation for Action‚Äô.

This paper is a joint effort of the Health vertical, 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.

 

 In 2035,

 India’s Public Health Surveillance will be a predictive, responsive, integrated, and tiered system of disease and health surveillance that is inclusive of Prioritised, emerging, and re-emerging communicable and non-communicable diseases and conditions.

 Surveillance will be primarily based on de-identified (anonymised) individual-level patient information that emanates from health care facilities, laboratories, and other sources.

 Public Health Surveillance will be governed by an adequately resourced effective administrative and technical structure and will ensure that it serves the public good.

 India will provide regional and global leadership in managing events that constitute a Public Health Emergency of International Concern.

 

Multiple disease outbreaks have prompted India to proactively respond with prevention and control measures. These actions are based on information from public health surveillance. India was able to achieve many successes in the past. Smallpox was eradicated and polio was eliminated. India has been able to reduce HIV incidence and deaths and advance and accelerate TB elimination efforts. Many outbreaks of vector-borne diseases, acute encephalitis syndromes, acute febrile illnesses, diarrhoeal and respiratory diseases have been promptly detected, identified and managed. These successes are a result of effective community-based, facility-based, and health system-based surveillance. The program response involved multiple sectors, including public and private health care systems and civil society.

The COVID-19 pandemic has further challenged the country. India rapidly ramped up its diagnostic capabilities and aligned its digital technology expertise. This ensured that there was a comprehensive tracking of the pandemic. As well, relevant information was widely shared with the public. India rapidly instituted both case-based (Trace, Test, Treat) and population-based measures (wear masks, wash hands, maintain distance, avoid crowding and closed spaces) for COVID-19 prevention, management, containment, and control. This vision document describes what India’s Public Health Surveillance can be in 2035. This vision document on India’s Public Health Surveillance by 2035 builds on opportunities that include the Ayushman Bharat scheme that establishes health and wellness centers at the community level- to strengthen non-communicable disease prevention, detection, and control and assures government payment for hospitalisation- to reduce out-of-pocket expenses of individuals and families at the bottom of the pyramid.

 

It builds on initiatives such as the IHIP of the Integrated Disease Surveillance Program.

 It aligns with the citizen-centricity highlighted in the National Health Policy 2017 and the National Digital Health Blueprint. It encourages the use of mobile and digital platforms and Point-of-Care devices and diagnostics for amalgamation of data capture and analyses.

 It highlights the importance of capitalizing on initiatives such as the Clinical Establishments Act to enhance private sector involvement in surveillance.

 It points out the importance of a cohesive and coordinated effort of apex institutions including the National Centre for Disease Control, the Indian Council of Medical Research, and others. As well, there may be a need to create an independent Institute of Health Informatics. The document identifies gap areas in India’s Public Health Surveillance that could be addressed.

 India can create a skilled and strong health workforce dedicated to surveillance activities.

Non-communicable disease, reproductive and child health, occupational and environmental health and injury could be integrated into public health surveillance.

 Morbidity data from health information systems could be merged with mortality data from vital statistics registration.

 An amalgamation of plant, animal, and environmental surveillance in a One-Health approach that also includes surveillance for anti-microbial resistance and predictive capability for pandemics is an element suggested within this vision document.

 Public Health Surveillance could be integrated within India’s three-tiered health system.

 Citizen-centric and community-based surveillance, and use of Point-of-Care devices and self-care diagnostics could be enhanced.

Laboratory capacity could be strengthened with new diagnostic technologies including molecular diagnostics, genotyping and phenotyping. To establish linkages across the three-tiered health system, referral networks could be expanded for diagnoses and care.

 

Four building blocks are envisaged for this vision:

1. An interdependent federated system of Governance Architecture between the Centre and States

2. Enhanced use of new data collection and sharing mechanisms for surveillance based on unitized, citizen-centric comprehensive Electronic Health Records (EHR) with a unique health identifier (UHID). As well, existing disease surveillance data and information from periodic surveys will complement this information

3. Enhanced use of new data analytics, data science, artificial intelligence, and machine learning, and

 4. Advanced health informatics.

 

Vision

The next Mega Science Vision (MSV)-2035 Exercise has been undertaken by the Office of the Principal Scientific Adviser to the GOI.  The support to projects has now become necessary in fields of research due to the need for experimentation, collection, and analysis of data on large scale. The Year 2035 has been chosen keeping in view the timelines of similar exercises undertaken elsewhere in the world and the expected lifetime of the utilization of major global facilities in which India is involved at the present time. The MSV-2035 Exercise has begun in the right earnest and will result in Road-Map Documents in the said areas after widespread national stakeholder consultations.

 

Opportunities

There are important and timely opportunities within the Indian and global context that can be leveraged to expand a Public Health Surveillance system in India.

India recently rolled out the Ayushman Bharat scheme. One of the two interrelated key features of this scheme is the expansion of primary health care initiatives through the creation of 150000 Health and Wellness Centres (HWCs), staffed by front-line workers and a new cadre of Community Health Officers. The second is the Pradhan Mantri Jan Arogya Yojana (PMJAY). 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 hospitalisation for poor and vulnerable families that form the bottom 40% of the Indian population. The HWCs 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. The PMJAY could be a useful source of information to estimate out-of-pocket expenditure on hospitalisation expenses, as well as for surveillance of diseases managed within in-patient facilities.

The Integrated Health Information Platform (IHIP) under the IDSP is already partially functional across several states. The experience in few states has demonstrated its potential to detect epidemics, issue early warning signals, capture outbreak investigation and respond appropriately. There is potential for this platform 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. However, surveillance cannot be seen as a separate activity from patient care. This document emphasizes that surveillance can ride on top of a unitized, citizen centric electronic health record (EHR).

There has been an explosion of digital technologies in health. NITI Aayog launched the National Digital Health Blueprint in July 2019. 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. These two recommendations are central to the basis for the future of surveillance in India, as outlined in this vision document.

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. Additionally, the dissemination of meaningful information to relevant stakeholders is feasible using smart-apps, a health portal and to link to call centres that function as helplines and for other emerging purposes.

Legal frameworks for health care and surveillance already exist within the country. The Clinical Establishments Act (Registration and Regulation), 2010 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. Similarly, nationwide digitisation of the Health Management Information System can enable timely and appropriate human resource recruitment and deployment, especially of specialist services, including microbiologists and pathologists at the block/district level.

Point-of-Care (PoC) diagnostics and screening tests, including gene testing for infectious diseases and non-communicable diseases are rapidly developing. The rapid development of PoC tests and hand-held devices will enable reaching populations that are otherwise unreached by the health system and can facilitate timely diagnoses and enable self-diagnosis as well.

Finally, institutions, including the ICMR and its apex institutions, the NCDC, and the Centre and State governments, have demonstrated strong ability to rapidly respond in order to contain, control and coordinate responses to ‚ÄėPublic Health Emergencies of International Concern‚Äô.

 

KEY CONSIDERATIONS in Creating Vision 2035

Some of the key considerations in creating Vision 2035 for Public Health Surveillance in India are listed here. Concerned stakeholders including policy makers and the Government will need to address these questions in order to design and implement the vision for Public Health Surveillance in 2035.

 

What could be the goals of Public Health Surveillance?

Predicting/Forecasting and Preparedness for Epidemic Outbreaks for communicable and emerging epidemics of non-communicable disease, both re-emergence of known illnesses in different forms (influenza, MDR-TB), or new disease outbreaks (NIPA virus, Corona virus, etc.,) or new geographic foci of NCD.

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 a) characterising results beginning with molecular tests, b) digitise results and ultimate action in real-time, c) conduct genetic mapping to explore variations in the pathogen or the susceptible host.

What could immediate next steps include? Could it include:

Setting surveillance priorities: Could this include chronic and acute conditions, especially in the context of occupational, environmental and nutritional health? Could community, facility and system level components including health care seeking and social determinants of health be included within Surveillance?

  Identifying and preparing the human resource capacity: How do we ensure that we have a dedicated Public Health Cadre at block, district, state and national levels, in adequate numbers and with composite competencies that are regularly updated?

 Landscaping and strengthening laboratory capacity: How can we optimise laboratory capacity within public and private sector? How do we strengthen Point-of-Care diagnostics, self-testing protocols and referral networks to reduce time taken to produce screening or diagnostic results that are reliable, valid and useful to the patient and provider? How do we ensure that laboratory results are smoothly amalgamated with relevant clinical and socio-demographic information that contributes not only to better patient care but also to public health actions?

Developing and mobilizing technologies and methodologies: Could there be a horizon scanning for early warning signs through platforms such as WHO, PROMED and others? What is the role of social media? How do countries learn quickly on how to prevent, respond and act based on experiences of new outbreaks in a different part of the globe? How do we ensure ‚ÄėBig data‚Äô12 management and integrate Artificial Intelligence and machine learning into Surveillance platforms?

 Coordination and governance: Policy, Technical, Managerial and Digital?

How can Public Health Surveillance leverage existing talent and platforms?

Digital Health interventions

Integrated Communication Technology

Science, Technology, Social and Business platforms

How can we use routinely collect individual level patient data to create population based datasets?

Unique Health Identifier

 Unified Health/Medical record

Standard data sharing protocols

 Interoperability between systems and programs

Could Public Health Surveillance integrate different sources of data for analyses, and how do we ensure an inter-sectoral response?

Plant, animal and human disease statistics

 Environmental indicators

Economic data

What is the design of a Federal National Health Implementation Architecture?

Governance and Cooperative Federalism

 Data holding: Meta-data, data standards, case definitions, data protection, etc.,

Patient care pathways and continuum of care: Individual, Family, course of disease, etc.,

 Open mechanisms for inputs/outputs: Call centre, India Health Portal, Health Apps, Insurance