News Excerpt
NITI Aayog released a white paper on more responsive and citizen-friendly public health surveillance system which would have a better data-sharing mechanism between the Centre and states while ensuring individual privacy and confidentiality.

Pre-Connect
NITI Aayog’s 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 ‘Health Systems for New India: Building blocks – Potential Pathways to Reforms’ during November 2019.

What was the need?
•    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 COVID19 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 COVID19 prevention, management, containment, and control.

About India’s Public Health Surveillance by 2035
    This 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, state governments, and the International agencies.
    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 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.
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 hospitalization- to reduce out of pocket expenses of individuals and families at the bottom of the pyramid.
    It builds on initiatives such as the Integrated Health Information Platform 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.

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.

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.

Challenges in India’s existing Public Health Surveillance
Implementation challenges – patchy surveillance, not comprehensive: The IHIP is not yet fully operational across the country. There are a number of notable implementation challenges.
Surveillance functions in vertical siloes of programs and institutions: 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, enhancing the coverage of treatment among those infected or confirmed with disease and reducing mortality from the disease.
Private sector involvement in surveillance is limited: The private sector is not a homogenous entity; 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 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, however, the response of states to address these human resource gaps is varied. Health is a state subject, while Health Surveillance is a national prerogative. Human resource vacancies and staff capacity continue to plaque the system.
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: Social and print media are increasingly being piloted for use in surveillance. Few states do have operational media scanning cells or media-advocacy initiatives that help highlight disease outbreaks, or help identify a sudden increase in hospitalisation or death due to an unusual event.
Limited focus on non-communicable disease surveillance: Non-communicable disease (NCD) surveillance was introduced in many developed countries almost 35- 40 years ago. India faces the dual burden of non-communicable and communicable diseases. The WHO predicted that by 2020, NCD would account for 73% deaths and 60% of morbidity globally. (WHO 2003).
Fragmented and minimalistic approach in Occupational Health Surveillance: Occupational Health Surveillance in India falls into two broad categories: Hazard surveillance and health surveillance. The NCDC has a division of Occupational and Environmental Health.

Conclusion
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. The EHR becomes the main basis of surveillance and is complemented by periodic national/state/district level surveys, special studies and research in order to reconcile the threshold and redefine standard definitions of cases, as disease patterns evolve. 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. Surveillance uses new analytics, health informatics and data science and innovative ways of disseminating ‘information for action’. This will further thrust India to be a global/regional leader in Public Health Surveillance.