PROJECT IMPLEMENTATION PLAN
INTEGRATED DISEASE
SURVEILLANCE PROJECT
(IDSP)
14th May 2004
Government of India
Ministry of Health and Family Welfare
Department of Health
Nirman Bhawan, New Delhi
Table of Contents
PART 1 : RATIONALE FOR AN INTEGRATED DISEASE SURVEILLANCE PROJECT
IN INDIA ................................................................................................................... 2
1
2
3
4
5
6
7
Background .................................................................................................................... 3
1.1
Burden of disease due to communicable diseases ............................................. 3
1.2
Increased risk of diseases and epidemics ........................................................... 4
1.3
Human and economic burden of epidemics ....................................................... 5
1.4
Relative burden of communicable & non communicable diseases & their risk
factors ................................................................................................................. 5
1.5
Disease control efforts and role of surveillance ................................................. 6
National commitment to improve disease surveillance ................................................. 6
2.1
Central Council of Health and Family Welfare ................................................. 6
2.2
Technical Advisory Committee on plague ........................................................ 7
2.3
Committee on National Mission on Environmental Health and Sanitation ....... 7
2.4
Expert committee on Revamping of Public Health System............................... 7
2.5
National Apical Advisory Committee (NAAC) ............................................... 7
2.6
Technical Advisory Group on diseases of international public health
importance.......................................................................................................... 7
2.7
Pilot project for surveillance of communicable diseases ................................... 8
2.8
Existing components for disease surveillance in disease control programs ...... 8
Current status of surveillance in the country ................................................................. 8
3.1
Conclusions from FGDs with health workers and women ................................ 9
3.1.1
Perceptions of health workers about surveillance ........................................... 9
3.1.2
Constraints perceived by health workers in performing high quality disease
surveillance activities .................................................................................... 11
3.1.3
Gender issues in disease surveillance ........................................................... 12
3.2
Conclusions from state level workshops.......................................................... 13
3.2.1
Primary level ................................................................................................. 13
3.2.2
District........................................................................................................... 13
3.2.3
State............................................................................................................... 13
3.2.4
Poor integration and duplication of surveillance activities ........................... 14
3.3
Recommendations based on the above reports ................................................ 14
3.3.1
Process of Disease Surveillance.................................................................... 14
3.3.2
Involvement of Private Sector ...................................................................... 16
3.3.3
Community involvement .............................................................................. 16
3.3.4
Social Mobilization ....................................................................................... 17
Evolution of IDSP In India .......................................................................................... 17
4.1
Development of project implementation plan.................................................. 17
4.2
Developing consensus on IDSP in participating states .................................... 18
4.3
National workshop ........................................................................................... 19
Implementation Strategy .............................................................................................. 19
Special assessment carried out for IDSP ..................................................................... 20
Program sustainability ................................................................................................. 20
PART – II : OBJECTIVES AND COMPONENTS ..................................................................... 21
8 Objectives of integrated disease surveillance .............................................................. 22
9 Components of proposed IDSP .................................................................................... 22
10 Diseases to be included in the surveillance Project ..................................................... 27
10.1
List of Core Diseases: ...................................................................................... 27
10.2
Additional State Priorities ................................................................................ 28
11 Methods of surveillance ............................................................................................... 29
12 Surveillance of Risk Factors for Non communicable disease and their risk factor ..... 31
12.1
Aims ................................................................................................................. 31
12.2
Method ............................................................................................................. 32
12.3
Logistics ........................................................................................................... 33
PART – III : SURVEILLANCE MECHANISMS ........................................................................ 34
13 Reporting units ............................................................................................................. 35
13.1
Rural ................................................................................................................. 35
13.2
Urban................................................................................................................ 35
13.3
Special Units .................................................................................................... 35
14 Structural Framework of IDSP .................................................................................... 37
14.1
Urban surveillance ........................................................................................... 37
15 Integrating private practitioners in surveillance .......................................................... 39
15.1
Identification and selection of sentinel private practitioners (SSPPS) ............ 39
15.2
Recruitment of Private Practitioners to be Sentinel Sites in IDSP .................. 39
15.3
Sentinel private laboratory sites ....................................................................... 40
15.4
Number of private sentinel reporting sites ....................................................... 40
15.5
Phased Induction .............................................................................................. 41
15.6
Facilitating reporting by private sentinel sites ................................................. 41
15.6.1 Simplified Formats........................................................................................ 41
15.6.2 Frequency of Reporting ................................................................................ 41
16 Medical colleges .......................................................................................................... 42
16.1
Responsibility of Integrating Medical Colleges: ............................................. 43
17 Development of operations manuals ............................................................................ 43
18 Analysis........................................................................................................................ 45
18.1
Types of analysis.............................................................................................. 45
18.2
GIS Software .................................................................................................... 45
19 Surveillance actions ..................................................................................................... 46
19.1
Feedback and sharing information ................................................................... 46
19.1.1 Periphery ....................................................................................................... 46
19.1.2 District........................................................................................................... 46
19.1.3 State............................................................................................................... 46
19.1.4 Center ............................................................................................................ 47
19.3
Levels of response............................................................................................ 50
19.4
Response to surveillance challenges ................................................................ 51
19.5
Response at local level ..................................................................................... 51
19.6
Outbreak investigations and response .............................................................. 51
19.6.1 Definition of outbreak ................................................................................... 52
19.6.2 Threshold levels ............................................................................................ 52
19.6.3 Sources of information .................................................................................. 52
19.6.4 Verification of the outbreak .......................................................................... 52
19.6.5 Investigating an outbreak .............................................................................. 53
19.6.6 The District Outbreak Investigation Team (DO IT) ..................................... 53
19.6.7 Outbreak Response ....................................................................................... 54
19.6.8 Daily situation updates .................................................................................. 55
19.6.9 Interim report of DEIT .................................................................................. 55
19.6.10 Final Report of DEIT .................................................................................... 55
19.7
Epidemic investigation and response at state level .......................................... 56
19.8
Disaster management ....................................................................................... 56
20 Administrative structure of IDSP................................................................................. 58
20.1
Administrative structure at the national level .................................................. 58
20.2
The functions of the central surveillance unit .................................................. 60
20.3
Administrative structure at state level.............................................................. 61
20.3.1 State Surveillance Committee ....................................................................... 62
20.4
Administrative structure at district level .......................................................... 63
20.4.1 District Surveillance Committee ................................................................... 63
20.5 Mechanisms for vertical coordination between various levels ................................ 64
20.5
List of partners and key stakeholders............................................................... 65
20.6
National Institute of Communicable Diseases (NICD) .................................. 65
20.7
Indian Council of Medical Research (ICMR) ................................................. 66
20.8
Central Bureau of HeaIth Intelligence ............................................................. 66
20.9
National Institute of Biologicals ...................................................................... 66
20.10
Other agencies in the country doing surveillance ............................................ 67
20.10.1 Pollution control boards ................................................................................ 67
20.10.2 Water boards ................................................................................................. 67
20.10.3 Police administration at the states ................................................................. 67
20.10.4 Medical colleges ........................................................................................... 67
20.10.5 Private practitioners ...................................................................................... 67
20.10.6 Other NGOs doing surveillance .................................................................... 68
20.11
International partners ...................................................................................... 68
20.12
Technical partners ........................................................................................... 68
20.12.1 Centers for Disease Control – USA (CDC) .................................................. 68
20.12.2 IndiaCLEN Network ..................................................................................... 69
PART – IV : SPECIFIC INPUTS TO IMPROVE DISEASE SURVEILLANCE ..................... 70
21 Laboratory network for IDSP ..................................................................................... 71
21.1
Peripheral laboratories (L1 Laboratories) ....................................................... 71
21.2
Private laboratories .......................................................................................... 72
21.3
Additional needs for peripheral laboratories.................................................... 72
21.4
District public health laboratory (L2 Laboratories) ........................................ 73
21.4.1 Administrative structure and personnel in District PH Lab .......................... 74
21.4.2 Needs at district laboratories ......................................................................... 75
21.4.3 Other laboratories which may function as District PH Laboratories ............ 76
21.5
State public health laboratories ........................................................................ 76
21.6
Administrative Re-organization for Laboratory Work under IDSP ................ 78
21.7
Quality Assurance: ........................................................................................... 78
21.8
Reference laboratories ..................................................................................... 78
21.8.1 Strengthening National Institute of Communicable Diseases ...................... 79
21.8.2 National Institute of Cholera and Enteric Diseases, Calcutta as regional
IDSP laboratory in the Eastern region .......................................................... 79
21.8.3
Microbiology PGI Chandigarh as the regional IDSP laboratory for the
Northern region ............................................................................................. 79
21.8.4 Microbiology Center at CMC Vellore regional Reference Center for the
Southern Region............................................................................................ 80
21.8.5 National institute of Virology, Pune regional IDSP reference laboratory for
the Western Region ....................................................................................... 80
21.9
Role of ICMR centers in coordinating Disease Specific Reference
Laboratories in the country .............................................................................. 80
21.10
Additional Reference Laboratories for quality control and accreditation ...... 82
21.10.1 National Institute of Biologicals with AIIMS Delhi and CMC Vellore ....... 82
21.10.2 National Accreditation Board for Testing and Calibration of Laboratories . 82
22 Biosafety and bio-medical waste management ............................................................ 82
22.1
Bio-safety issues in the proposed IDSP ........................................................... 83
22.2
Improving health practices especially handling of sharps ............................... 83
22.3
Improving infrastructure .................................................................................. 83
23 Information technology in IDSP .................................................................................. 84
23.1
Proposed IDSP information technology infrastructure and networking .......... 85
23.2
IT Infrastructure for IDSP ................................................................................ 88
23.2.1 System Software and Packages:- .................................................................. 88
23.2.2 Hardware and Networking: ........................................................................... 89
23.3
Software licenses ............................................................................................. 91
23.4
Administration ................................................................................................. 91
23.4.1 Security administration ................................................................................. 91
23.4.2 Network administration ................................................................................ 91
23.4.3 Database administration ................................................................................ 91
23.4.4 Server administration .................................................................................... 91
23.5
Failure and disaster recovery ........................................................................... 92
23.5.1 Server failure ................................................................................................. 92
23.5.2 Network failure ............................................................................................. 92
23.5.3 Inter-state network failure ............................................................................. 92
23.6
Computer virus attack ...................................................................................... 92
23.7
Management of total computer failure ............................................................. 92
24 Training needs in IDSP ................................................................................................ 92
24.1
Training Needs Assessment: ............................................................................ 93
24.2
Training Strategy: ............................................................................................ 95
24.2.1 The Sensitization Workshops ....................................................................... 95
24.2.2 Types of Induction Training Programs: ........................................................ 96
24.3
Who will provide the training .......................................................................... 96
24.3.1 National Network of training Institutions – Level 1: .................................... 96
24.3.2 Level -2 Trainers: .......................................................................................... 97
24.3.3 Level 3 Trainers: ........................................................................................... 98
24.4
Quality Assurance: ........................................................................................... 98
24.5
Site of Training: ............................................................................................... 99
24.6
The Training Curricula .................................................................................. 100
24.7
Training Plan .................................................................................................. 102
24.8
Integrating existing public health training programs for training .................. 103
24.9
24.10
25.2
25.3
25.4
25.4.1
25.4.2
25.5
Institutional capacity to undertake training in different states ....................... 103
Conclusion: .................................................................................................... 104
Socio-cultural issues to be taken up for social mobilization campaign ......... 105
Gender Issues in Surveillance ........................................................................ 105
Stakeholder who can be involved .................................................................. 105
Rural areas .................................................................................................. 105
Urban areas ................................................................................................. 105
Social mobilization strategies ........................................................................ 106
PART – V
108 : QUALITY ASSURANCE ............................................................................. 108
26 Quality assurance in IDSP ......................................................................................... 109
26.1
Supervision .................................................................................................... 112
26.2
Monitoring and evaluation ............................................................................. 112
26.2.1 Surveillance Reports ................................................................................... 113
26.3
Indicators for monitoring the program ........................................................... 114
26.4
Independent external evaluation of the surveillance and response ................ 117
26.5
Quality assurance of laboratory services in IDSP.......................................... 117
26.5.1 Role of National Centers for Quality Control ............................................. 118
26.6
Accreditation .................................................................................................. 119
26.7
Role of National Institute of Biologicals ....................................................... 119
PART – VI : ENVIRONMENT MANAGEMENT PLAN &TRIBAL DEVELOPMENT PLAN ........ 121
27 Environment Management Plan ................................................................................. 122
27.1
Project Context............................................................................................... 122
27.2
Scope of the Project ....................................................................................... 122
27.3
Environmental Issues ..................................................................................... 122
27.4
Actions to be taken under this project to address these issues. ...................... 123
27.5
Project Implementation .................................................................................. 123
27.6
Key Activities under the project: ................................................................... 124
27.7
Costs and resources ........................................................................................ 124
27.8
Monitoring ..................................................................................................... 125
27.9
Schedule of Implementation .......................................................................... 125
28 Strategy for Tribal Populations .................................................................................. 126
28.1
Tribals in IDSP .............................................................................................. 126
28.2
Integrated Disease Surveillance Project......................................................... 127
28.2.1 Project Benefits ........................................................................................... 128
28.2.2 Legal Framework ........................................................................................ 128
28.2.3 Methodology for Preparation of Tribal Strategy ........................................ 129
28.3
Study of community-based disease surveillance systems .............................. 133
28.4
Institutional Mechanisms ............................................................................... 134
28.5
Implementation and Local Participation ........................................................ 135
28.6
Cost estimate and financing plan ................................................................... 137
28.7
Monitoring and Evaluation ............................................................................ 137
PART – VII : STRATEGIES FOR INVOLVEMENT OF PRIVATE SECTOR IN DISEASE
SURVEILLANCE................................................................................................. 139
29 Strategies for Involvement of private Sector in Disease Surveillance ....................... 140
29.1
Initiate Partnership With Private Health Providers For Disease Surveillance
........................................................................................................................ 140
29.2
29.3
29.4
29.5
29.6
29.7
29.8
29.9
29.10
29.11
29.12
Selection of SSPs ........................................................................................... 140
Method of Selecting the Sentinel Surveillance Unit ...................................... 140
Number of Sentinel Surveillance Units ......................................................... 141
Data Collection and Transmission ................................................................. 141
Integrating Private Sector under IDSP ........................................................... 143
Increasing Sensitivity of Reporting Units ...................................................... 143
Maintaining quality of Reporting................................................................... 143
Sustainability of Partnership .......................................................................... 144
Continuing Medical Education Session: ....................................................... 145
Other Determinants of Sustainability: ........................................................... 145
Evaluation ..................................................................................................... 146
PART – VIII 147
Procurement of goods & services ................................................................................................. 147
30 Procurement of goods and services............................................................................ 148
30.1
Civil Works: Renovation and Repair [Annexure 1] ...................................... 148
30.2
Goods & Equipment ...................................................................................... 150
30.3
Services .......................................................................................................... 154
30.4
Incremental Operational Cost [Annexure 13 & 13/I] .................................. 159
30.5
Prior Review Thresholds................................................................................ 160
PART – IX : FINANCIAL MANAGEMENT ............................................................................. 161
31 Financial Management ............................................................................................... 162
31.1
Summary Project Description ........................................................................ 162
31.2
Implementing Agency:................................................................................... 163
31.2.1 Central level ................................................................................................ 164
31.2.2 State level .................................................................................................... 164
31.2.3 District level ................................................................................................ 164
31.3
Finance Staffing and Training: ...................................................................... 164
32 Budgeting ................................................................................................................... 165
32.1
Funds Flow: ................................................................................................... 165
32.1.1 Central level: ............................................................................................... 165
32.1.2 State level .................................................................................................... 165
32.1.3 District level ................................................................................................ 166
32.2
Books of account, accounting policies and procedure: .................................. 166
32.3
Information and Reporting System: ............................................................... 167
32.4
Audit (External ) ............................................................................................ 167
32.5
Internal Audit: ................................................................................................ 168
32.6
Retroactive Financing: ................................................................................... 168
32.7
Disbursement and Payment Arrangements:- ................................................. 168
ANNEXURES .............................................................................................................................. 170
ACKNOWLEDGEMENT
The Project Implementation Report (PIP) was written with contributions from grassroots level
health workers from three states of Tamil Nadu, Maharashtra and Uttar Pradesh. We gratefully
acknowledge their contribution during the state level workshops and focus group discussions
conducted for developing the DPR. We also acknowledge the inputs of Directors of Public
Health and the State Surveillance Officers from the above three states, without which this would
not have been possible. We particularly want to thank Dr. .P. Krishnamurthy, Dr. T. J. Agustine
from Tamil Nadu, Dr. S. Salunke and Dr. R. R. Katti from Maharashtra for their contributions.
Many technical assessment groups were involved in developing this document. We want to
specially thank Dr. Ashish Mathur (IT consultant), Dr. Robert Martin, Dr. Ronald Cada and Dr.
Loris Hughes (CDC team), Dr. Davadasan (WHO) and Dr. Sampat Krishnan (WHO) who have
contributed to development of this document.
United States Agency for International Development (USAID) and the World Bank (WB)
provided financial and technical support for developing state and national PIPs. Dr. Peter
Heywood, Dr. K. Sudhakar, Mrs. Rashmi Sharma, Mr. Mamchand and Mr. Mohan
Gopalakrishnan (World Bank) and Dr. Victor Barberio and Dr. Dora Warren (USAID) played
crucial supportive roles.
We are grateful to the Ministry of Health and Family Welfare, Government of India (GOI) for
giving us this opportunity to participate in an important public health activity. We particularly
thank Mr. JVR Prasada Rao (Secretary, Health), Dr. S.P.Agarwal, DGHS, Mrs. P. Jyoti Rao,
Additional Secretary, Dr. Shivlal, Director NICD, Mrs. Bhavani Thyagarajan and Shri.
B.P.Sharma, Joint Secretary, Department of Health, who have interacted with us actively in the
preparation of the PIP.
We acknowledge Ms. Jyoti Bahri and Ms. Vaishali Chaturvedi for their contribution in editing
and giving final touch to the document.
A great deal of work was done by the PIP team of the INCLEN network particularly Dr. Kurien
Thomas, Dr. N. K. Arora, Dr. Srinath Reddy, Dr. Ramesh Ahuja, Dr. P. P. Joshi, Dr. Sunitha
Shanbagh, Dr. Saradha Suresh, and Dr. Nalini Ramamurthy. This has indeed been a team effort.
i
ABBREVIATIONS
AIDS
AFP
AMR
ANM
API
ASI
CAG
CBHI
CCHFW
CDC
CFR
CMC
CSU
CVD
DALY
DCP
DEA
DEIT
DFID
DGHS
DHS
DME
DOTS
DSO
DSU
EMP
EQA
EPI
FGDs
AFMC
GASP
GOI
GIS
HBV
HCV
HIV
IAP
IBRD
ICDS
ICMR
IDA
IDSP
IEC
IFEPT
-
Acquired Immuno Deficiency Syndrome
Acute Flaccid Paralysis
Anti Microbial Resistance
Auxiliary Nurse Midwife
Association of Physicians India
Association of Surgeons India
Controller and Auditor General of India.
Central Bureau of Health Intelligence
Central Council of Health and Family Welfare
Centers for Disease Control
Case Fatality Rates
Christian Medical College
Central Surveillance Unit
Cardio Vascular Disease
Disability Adjusted Life Years
Diploma in Clinical Pathology
Department of Economic Affairs
District Epidemic Investigation Team
Department for International Development
Director General of Health Services
Director of Health services
Director of Medical Education
Direct Observed Treatment, Shortcourse
District Surveillance Officer
District Surveillance Unit
Environment Management Plan
External Quality Assurance
Expanded Program on Immunization
Focus Group Discussions
Armed Forces Medical College
Gonococcal Antimicrobial Susceptibility Testing Program
Government of India
Geographical Information System
Hepatitis B Virus
Hepatitis C Virus
Human Immuno Deficiency Virus
Indian Association of Pediatrics
International Bank for Reconstruction and Development
Integrated Child Development Services
Indian Council of Medical Research
International Development Association
Integrated Disease Surveillance Project
Information Education and Communication
Internal Federation of Enteric Phage Typing
ii
IMA
INCLEN
IndiaCLEN
IT
ISM
M&E
MOHFW
MOU
JE
FETP
FMR
IEQUAS
MOU
NACP
NAAC
NABL
-
NAMP
NARI
NADI
NCD
NCDS
NGO
NIB
NICD
NICED
NIE
NIH
NIV
NLEP
NPV
NPSCD
PHC
PIP
PRI
RCH
RMP
RRT
RTI
RTA
SC/ST
SHSP
SPH
SPPs
SSO
SSPPS
-
Indian Medical Association
International Clinical Epidemiology Network
Indian Clinical Epidemiology Network
Information Technology
Indian System of Medicine
Monitoring and Evaluation
Ministry of Health and Family Welfare
Memorandum of Understanding
Japanese Encephalitis
Field Epidemiology Training Program
Financial Monitoring Report
Internal and External Quality Assurance system
Memoranda of Understanding
National AIDS Control Program
National Apical Advisory Committee
National Accreditation Board for Testing and Calibration
Laboratories
National Anti-Malarial Program
National Aids Research Institute
North Arcot District Information
Non-Communicable Diseases
Non Communicable Disease Surveillance
Non Governmental Organization
National Institute of Biologicals
National Institute of Communicable Diseases
National Institute of Cholera and Enteric Diseases
National Institute of Epidemiology
National Institute of Health
National Institute of virology
National Leprosy Elimination Program
Net Present Value
National Program for Surveillance of Communicable Diseases
Primary Health Center
Project Implementation Plan
Panchayati Raj Institutions
Reproductive and Child Health
Registered Medical Practitioner
Rapid Response Team
Reproductive Tract Infection
Road Traffic Accidents
Schedule Caste / Schedule Tribe
State Health Systems Project
Sentinel Private Hospital
Sentinel Private Practitioners
State Surveillance Officer
Selected Sentinel Private Practitioners
iii
STD
TB
TOTs
UNICEF
USAID
VCRC
VHAI
WAN
WHO
WB
WMP
-
Sexually Transmitted Disease
Tuberculosis
Training of Trainers
United Nations Children’s Fund
United States Agency for International Development
Vector Control Research Center
Voluntary Health Association of India
Wide Area Network
World Health Organization
World Bank
Waste Management Plan
iv
EXECUTIVE SUMMARY
INTEGRATED DISEASE SURVEILLANCE PROJECT
Background
The Government of India is initiating a decentralized, state based Integrated Disease
Surveillance Project (IDSP) in the country in response to a long felt need expressed by various
expert committees. The project would be able to detect early warning signals of impending
outbreaks and help initiate an effective response in a timely manner. It is also expected to
provide essential data to monitor progress of on going disease control programs and help allocate
health resources more optimally.
Objectives
The project development objective is to improve the information available to the government
health services and private health care providers on a set of high-priority diseases and risk
factors, with a view to improving the on-the-ground responses to such diseases and risk factors.
Specifically, the projects aims:

To establish a decentralized state based system of surveillance for communicable and
non-communicable diseases, so that timely and effective public health actions can be
initiated in response to health challenges in the country at the state and national level.

To improve the efficiency of the existing surveillance activities of disease control
programs and facilitate sharing of relevant information with the health administration,
community and other stakeholders so as to detect disease trends over time and evaluate
control strategies.
The project will assist the Government of India and the states and territories to:

surveil a limited number of health conditions and risk factors; 

strengthen data quality, analysis and links to action; 

improve laboratory support; 

train stakeholders in disease surveillance and action; 

coordinate and decentralize surveillance activities; 

integrate disease surveillance at the state and district levels, and involve communities and 
other stakeholders, particularly the private sector.
Components
Component 1. Establish and Operate a Central-level Disease Surveillance Unit.
Under this component, Ministry of Health and Family Welfare (MOHFW) will establish a new
Disease Surveillance Unit at the central level to help coordinate and decentralize disease
surveillance activities. The new unit will support and complement the states' disease surveillance
v
efforts. The unit will be staffed by existing permanent staff reassigned from within the MOHFW.
This component will address the constraints of lack of coordination despite central control of
surveillance activities and the need for changing the diseases included in the system. Effective
coordination (as compared to control) of disease surveillance activities depends on establishing
the appropriate processes and institutional arrangements at the central level. This will be done
through the creation of a small disease surveillance unit to support the states disease surveillance
efforts.
Component 2. Integrate and strengthen disease surveillance at the state and district levels.
This component addresses the constraints imposed by lack of coordination at the sub-national
levels, the limited use of modern technology and data management techniques, the inability of
the system to act on information and the need for inclusion of other stakeholders. It will integrate
and strengthen disease surveillance at the state and district levels, and involve communities and
other stakeholders, in particular, the private sector.
Component 3. Improve laboratory support. This component will consist of:
(i)
upgrading laboratories at the state level, in order to improve laboratory support for
surveillance activities. Adequate laboratory support is essential for providing on-time
and reliable confirmation of suspected cases; monitoring drug resistance; and
monitoring changes in disease agents;
(ii)
introducing a quality assurance system for assessing and improving the quality of
laboratory data.
Component 4. Training for disease surveillance and action. The changes envisaged under the
first three components will require a large and coordinated training effort to reorient health staff
to an integrated surveillance system and provide the new skills needed. Training programs will
include representatives from the private sector, NGOs and community groups.
Project Highlights

It will monitor a limited number of conditions based on state perceptions including 13
core and 5 state priority conditions for which pubic health response is available.

District, State & Central Surveillance units will be set up so that the program is able to
respond in a timely manner to surveillance challenges in the country including emerging
epidemics.

It will integrate surveillance activities in the country under various programs and use
existing infrastructure for its function.

Private practitioners / Private hospitals / Private laboratories will be inducted into the
program as sentinel units.

Active participation of medical colleges in the surveillance activities.

The project will ensure uniform high quality surveillance activities at all levels by
vi
(i)
(ii)
(iii)
(iv)
(v)
(vi)
Limiting the total number of diseases under surveillance and reducing overload at
the periphery
Developing standard case definitions
Developing formats for reporting
Developing user friendly manuals
Providing training to all essential personnel, and
Setting a system of regular feed back to the participants on the quality of
surveillance activity.

District Public Health Laboratory will be strengthened to enhance capacity for diagnosis
and investigations of epidemics and confirmation of disease conditions.

Use of information technology for communication, data entry, analysis, reporting,
feedback and actions. A national level surveillance network will be established up to the
district level.
Diseases conditions under the surveillance program
(i)
Regular Surveillance:
Vector Borne Disease
Water Borne Disease
Respiratory Diseases
Vaccine Preventable Diseases
Diseases under eradication
Other Conditions
Other International commitments:
Unusual clinical syndromes
(Causing death / hospitalization)
(ii)
: 1.
: 2.
: 3.
: 4.
: 5.
: 6.
: 7.
: 8.
: 9.
Sentinel Surveillance
Sexually transmitted diseases/Blood borne : 10
Other Conditions
: 11
: 12
(iii)
HIV/HBV, HCV
Water Quality
Outdoor Air Quality
(Large Urban centers)
Regular periodic surveys:
NCD Risk Factors
(iv)
Malaria
Acute Diarrhoeal Disease (Cholera)
Typhoid
Tuberculosis
Measles
Polio
Road Traffic Accidents
(Linkup with police computers)
Plague
Menigoencephalitis/Respiratory
Distress Hemorragic fevers, other
undiagnosed conditions
: 13
Anthropometry, Physical activity,
Blood Pressure, Tobacco, Nutrition,
Blindness
Additional State Priorities : Each state may identify up to five additional conditions for
surveillance.
vii
Note: GOI may include in a public health emergency any other unusual health condition.
Project funds could be used for such emergencies and reimbursed by IDA subject to
agreement at the next joint project review mission.
Phasing
Phase I (commencing from FY 2004-05)
Andhra Pradesh, Himachal Pradesh, Karnataka, Madhya Pradesh, Maharashtra, Uttaranchal,
Tamil Nadu, Mizoram & Kerala
Phase II (commencing from FY 2005-06)
Chhatisgarh, Goa, Gujarat, Haryana, Rajasthan, West Bengal, Manipur, Meghalaya, Orissa,
Tripura, Chandigarh, Pondicherry, Delhi
Phase III (commencing from FY 2006-07)
Uttar Pradesh, Bihar, Jammu & Kashmir, Jharkhand, Punjab, Arunachal Pradesh, Assam,
Nagaland, Sikkim, A & N Nicobar, D & N Haveli, Daman & Diu, Lakshdweep.
Key performance indicators:
Key aspects of overall performance of the surveillance system will be assessed using the
following indicators:










Number and percentage of districts providing monthly surveillance reports on time - by
state and overall;
Number and percentage of responses to disease-specific triggers on time - by state and
overall; 
Number and percentage of responses to disease-specific triggers assessed to be adequate by state and overall;
Number and percentage of laboratories providing adequate quality of information - by
state and center;
Number of districts in which private providers are contributing to disease information; 
Number of reports derived from private health care providers; 
Number of reports derived from private laboratories; 
# and % of states in which surveillance information relating to various vertical disease
control programs have been integrated 
# and % of project districts and states publishing annual surveillance reports within three
months of the end of the fiscal year;
Publication by CSU of consolidated annual surveillance report (print, electronic,
including posting on the websites) within three months of the end of fiscal year.
Expectations
Surveillance is the essence of a disease control program. By setting up a decentralized, action
oriented, integrated and responsive program, it is expected that IDSP will avert a sufficient
number of disease outbreaks and epidemics and reduce human suffering and improve the
efficiency of all existing health programs. Such a program will also allow monitoring of resource
allocation and form a tool to enhance equity in health delivery.
viii
YEAR WISE PROJECT COSTS
(Rs. in millions)
Year
2004-05
2005-06
2006-07
Sub Total (Xth Plan)
2007-08
2008-09
Sub Total (XIth Plan)
Grand Total
Total
700.0
880.0
1020.0
2600.0
840.0
643.6
1483.6
4083.6
Components-wise Project Costs
Non-Recurring :
Rs. in Millions
Renovation & Furnishing
Laboratory Equipments
Computer Hardware & Accessories
Office Equipments
Application Software
Furniture & Fixtures
IEC Activities
Training of Personnel
Consultancy (Procurement, Software,
Evaluation Studies etc)
Sub-total Non Recurring Costs
243.6
641.9
432.6
102.5
220.0
142.5
360.1
204.3
158.6
2506.2
Recurring (for 5 years):
Laboratory consumables
Personnel Costs
Networking Costs
Operational & Maintenance Costs
Sub-total Recurring Costs
310.5
561.2
125.2
580.6
1577.5
GRAND TOTAL
4083.6
1
PART – I
RATIONALE FOR AN INTEGRATED DISEASE
SURVEILLANCE PROJECT IN INDIA
2
1
BACKGROUND
Integrated Disease Surveillance Program (IDSP) is intended to be the backbone of public
health delivery system in the country. It is expected to provide essential data to monitor
progress of on going disease control programs and help in optimizing the allocation of
resources. It will be able to detect early warning signals of impending outbreaks and help
initiate an effective response in a timely manner. IDSP will also facilitate the study of disease
patterns in the country and identify new emerging diseases. It will play a crucial role in
obtaining political and public support for the health programs in the country.
India is currently passing through an epidemiological transition. Many states in India have
good health delivery systems while other states are lagging far behind. Health problems of
some states are predominantly due to communicable diseases, while in others it is due to noncommunicable diseases. Any system that intends to be futuristic will need to take into
account the variability and cater to differential needs in the country. It will need to be
decentralized and state specific. The program will need to cater to the wide geo-political and
socio-economic differences in the country and tailor its implementation to levels suitable for
the given region in the country. Equity in health delivery is one of the primary concerns of
the government. Through an effective disease surveillance program, health of vulnerable
populations in underdeveloped regions and tribal populations in India will be better
understood and corrective steps will be taken to improve their conditions.
Surveillance is essential for the early detection of emerging (new) or re-emerging (resurgent)
infectious diseases. In the absence of surveillance, disease may spread unrecognized by those
responsible for health care or public health agencies, because sick people would be seen in
small numbers by many individual health care workers. By the time the outbreak is
recognized, it may be too late for intervention measures. Continuous monitoring is essential
for detecting the ‘early signals’ of outbreak of any epidemic of a new or resurgent disease.
For disease surveillance to prevent emerging epidemics, the time taken for effective action
should be short.
Empowering the public to be responsible is an important function. Surveillance data can be
effectively used for the purpose of social mobilization to help the public participate actively
in controlling important diseases. This is an important step in reducing the burden of disease
in the community.
1.1
Burden of disease due to communicable diseases
The disease burden due to infectious diseases in India is among the highest in the world.
Infectious diseases are major causes of admissions in the hospitals and visits to health
facilities. Tuberculosis and malaria are the leading causes of deaths in the country.
In recent years, India faced the plague outbreak and dengue hemorrhagic fever outbreaks.
National lack of preparedness was evident. Various health bodies have issued warnings
regarding the importation and spread of yellow fever. Our state of preparedness requires
immediate strengthening and surveillance is the key pillar of our state of preparedness.
3
The communicable disease burden as seen through Disability Adjusted Life Years (DALY)
loss carried out by World Bank and WHO has shown that there has been some decline in
communicable diseases during the last one decade. The table below gives distribution of
DALY loss by cause for the world and India for the years 1990 and 1999.
TABLE : DISTRIBUTION OF DAILY LOSS BY CAUSE AND DEMOGRAPHIC
REGION, 1990 AND 1999
Cause
World
1990
India
1990
World
1999
India
1999
Population (Millions)
5,267
850
5,961
995
+
Total DALY (Millions)
1,362
292
1438
250
-
Communicable diseases (%)
45.8
50.5
39.1
41.2
-
Tuberculosis
3.4
3.7
2.3
6.9
+
STDs and HIV
3.8
2.7
9.0
4.8
+
Diarrhea
7.3
9.6
5.0
6.7
-
childhood 5.0
6.7
7.6
4.1
-
Malaria
2.6
0.3
3.1
2.4
+
Worm infections
1.8
0.9
0.12
1.8
+
Respiratory infections
9.0
10.9
7.0
7.9
-
Others
12.9
15.7
5.5
6.7
-
Vaccine-preventable
infections
Trend
Source:- World Bank Report 1993
World Health Report 2000
1.2
Increased risk of diseases and epidemics
Rapid urbanization, industrial and other development activities, encroachment by man on
areas so far uninhabited leading to ecological changes, deforestation and rapid means of
transportation within the country as well as international travel have increased the risk of
diseases and epidemics. Improvement in the living standards and changes in life styles are
accompanied by increased health hazards. The receptivity of an area to outbreaks is related
to inadequate drinking water facilities, poor sanitary conditions and a weak public health
system. Unfortunately, conditions are conducive for outbreaks in most parts of the country.
While, not all outbreaks can be predicted or prevented, epidemic preparedness and
precautionary measures can reduce the risk of outbreaks, minimize their scale and lessen their
impact on human suffering.
4
1.3
Human and economic burden of epidemics
The outbreaks of diseases in the past have highlighted the urgency for a disease surveillance
system so that early warning signals are recognized and appropriate control measures
initiated in a timely manner. Epidemics are public health emergencies that disrupt routine
health services and are a major drain on resources. Besides direct costs involved in outbreak
control measures and treatment of patients, the indirect costs due to negative impact on
domestic and international tourism and trade can be astronomical. The avoidable human
misery and loss in productivity resulting from illness and death cannot be quantified in mere
economic terms.
1.4
Relative burden of communicable & non communicable diseases & their risk
factors
Socio-cultural, economic and political diversities in India also reflect on the disease burden.
India is going through an epidemiological transition and in many states non-communicable
diseases contribute significantly to overall burden of the disease in the community.
The table below shows that in the first ten disease conditions related to burden of disease,
communicable diseases and non-communicable diseases are more or less equally distributed.
Any disease surveillance program capable of responding to the future needs of the people will
need to integrate both communicable and non-communicable diseases in its preview.
TABLE 1.4 RELATIVE IMPORTANCE OF NON-COMMUNICABLE DISEASE IN
INDIA
INDIA
INDIA/WORLD
(000) % of total
% of World
Total Population
982223 % of total
16.7
Deaths
9337
100
17.3
1
Ischemic Heart Disease
1471
15.8
19.9
2
Lower Respiratory Infections
969
10.4
28.1
3
Diarrheal Disease
711
7.6
32.1
4
Cerebrovascular Diseases
557
6.0
10.9
5
Tuberculosis
421
4.5
28.1
6
Road Traffic Injury
217
2.3
18.5
7
Measles
190
2.0
21.4
8
HIV/AIDS
179
1.9
7.8
9
Tetanus
165
1.8
40.3
5
10
Chronic Obstructive Pulmonary 153
Disease
Communicable diseases
Non Communicable diseases
1.6
6.8
28.2
25.7
Source World Health Organization 1999
Unlike communicable diseases, most non-communicable diseases are more latent and they
occur after a prolonged exposure to life style risk factors like smoking, blood sugar, blood
pressure and hyper-cholestremia. Public health action will be primarily directed against
preventive strategies for the disease and hence the priority is to monitor risk factors rather
than NCD diseases itself. A similar policy has been adopted by WHO on NCD surveillance.
1.5
Disease control efforts and role of surveillance
From the preceding introduction it is clear that there is an urgent need for effective control of
diseases. There are different approaches for achieving control of diseases. Prophylactic
immunization is one such highly cost-effective and powerful method. By the strategic
application of immunization, smallpox was eradicated. It is worth pointing out that diseasesurveillance was also an integral part of the strategy of smallpox eradication. The universal
application of selected vaccines in infancy and preschool age has resulted in the dramatic
decline of childhood tuberculosis, meningitis, diphtheria, whooping cough, poliomyelitis and
measles. The selective application of tetanus prophylaxis in pregnancy has resulted in a
similar reduction of neonatal tetanus. Diseases can be brought under effective control through
early diagnosis and prompt treatment, reducing the number of patients actively transmitting
the infection to others. This strategy is being adopted for the tuberculosis control program. A
Febrile Flaccid Paralysis (AFP) surveillance under National Polio Eradication Initiative is a
robust example of surveillance and its contribution to disease eradication / control efforts.
The other examples of targeted disease control programs which are under implementation
are: National Anti-malarial Program (NAMP), National AIDS Control Program (NACP)
Revised National Tuberculosis Control Programme and National Leprosy Elimination
Program (NLEP). In all these programs, surveillance is an important component to facilitate
disease control efforts not only through early detection of outbreaks but also by providing
valuable data about the impact of the interventions and time trend analysis of disease. This
information has helped in midcourse corrections in program strategy wherever necessary.
2
NATIONAL COMMITMENT TO IMPROVE DISEASE SURVEILLANCE
The concept of improving disease surveillance has been under active consideration of
Government of India. Various political and technical committees have provided considerable
support to the concept.
2.1
Central Council of Health and Family Welfare
The Central Council of Health and Family Welfare (CCHFW) is the apex political and policy
formulating body comprising of Union Minister of Health and Family Welfare (chairperson)
6
and health ministers from all the States / Union Territories of the country as members. The
council has recommended the establishment of state and district level epidemiological units
and revitalization of procedures of identification and reporting of outbreaks through the
primary health care system. The Fourth Conference of the Central Council of Health and
Family Welfare took cognizance of the existing inadequate disease surveillance system and
recommended that a nation wide disease surveillance program should be launched with the
National Institute of Communicable Diseases (NICD) as the national coordinating agency.
2.2
Technical Advisory Committee on plague
After the outbreak of plague in 1994, Government of India constituted a technical committee
to suggest measures to prevent recurrence of such outbreaks. Initiation of a nation wide
effective disease surveillance program was strongly recommended by the Committee. It also
suggested the strengthening of disease surveillance activities at all the tiers of health care
delivery system.
2.3
Committee on National Mission on Environmental Health and Sanitation
An inter-ministerial committee under the chairpersonship of the Union Health Secretary was
constituted in 1995 by the Government of India to suggest ways and means to mitigate
diseases due to environmental degradation and insanitation. The Committee recommended
launching of a Health Surveillance and Support Services.
2.4
Expert committee on Revamping of Public Health System
The expert committee constituted in 1995 under the chairpersonship of Member, Planning
Commission on Revamping of Public Health System also stressed the need to strengthen the
public health system for effective implementation and evaluation of national health programs
and prevention of large outbreaks, which had adverse implications at national and
international levels. The Committee also identified the surveillance and control of diseases as
an important function of public health system.
2.5
National Apical Advisory Committee (NAAC)
The Government of India constituted a National Apical Advisory Committee for National
Disease Surveillance and Response System (NAAC) vide GO T 21011/8/94-PH (Pt.1), April
1996. The NAAC assigned the task of preparing a Concept Plan to a Sub-Group. This
Concept Plan was prepared after extensive deliberations in two sittings of the NAAC and
three meetings of the Sub-group. The concept plan prepared by NAAC was circulated to all
state governments as well as WHO for their comments. A meeting was convened by the
Government of India to formulate the concept plan. State health secretaries and delegates
from WHO (Geneva) participated in the meeting.
2.6
Technical Advisory Group on diseases of international public health importance
The Government of India constituted a technical advisory group on diseases of international
public health importance in 1999. The report submitted by this group highlights the
importance of effective surveillance and need for strengthening of infrastructure to meet the
7
growing challenge posed by various microorganisms, which have tremendous international
public health importance.
2.7
Pilot project for surveillance of communicable diseases
A pilot project called the National Surveillance Program for Communicable Diseases was
launched in 1997-98 to strengthen the disease surveillance system so that early warning
signals of outbreaks are recognized and appropriate timely follow-up action is initiated. The
main objective of the program were capacity building at district and state levels. The program
is being implemented through the existing health infrastructure and surveillance system
strengthened through training of medical and para-medical personnel, up gradation of
laboratories, communication and data processing systems. The program is being implemented
through the state health systems. The program at the central level is coordinated by the
National Institute of Communicable Diseases, Delhi. It presently covers 100 districts and a
budgetary allocation of Rs. 25 crores was made for the program during the Ninth plan.
2.8
Existing components for disease surveillance in disease control programs
Most of the existing disease control programs have surveillance components that exist
independently, but many do not function in a coordinated manner. The programs with
major surveillance components include:
 The National Anti-Malaria Control Program
 National Leprosy Elimination Program
 Revised National Tuberculosis Control Program
 Nutritional Surveillance
 National AIDS Control Program
 National Polio Surveillance Program as part of the Polio eradication initiative
 National Programme for Control of Blindness (Sentinel Surveillance)
Surveillance components have been built into the ‘State Health Systems Projects’ to improve
health care infrastructure in various states under World Bank funding. The Family Welfare
department carries out surveillance activities for family planning, child and maternal
morbidity and mortality. Department of Women and Child conducts surveillance of nutrition
through the National Institute of Nutrition. The Integrated Child Development (ICDS)
program monitors the nutritional status of children at the village level. For the surveillance
system to be efficient and cost effective, all such activities need to be coordinated and
information and resources shared.
3
CURRENT STATUS OF SURVEILLANCE IN THE COUNTRY
Three state level workshops and ten focus group discussions (FGDs) were conducted with
male (five) and female (five) health workers in three states, namely Tamil Nadu, Maharastra
and Uttar Pradesh to understand the present status of surveillance activities. In addition, five
FGDs were conducted with tribal (two), rural (two) and urban (one) women in Bilaspur
district of Chattisgarh.
In the following sections the summary findings from FGDs and state level workshops are
presented.
8
3.1
Conclusions from FGDs with health workers and women
3.1.1 Perceptions of health workers about surveillance
Discussions held with health workers in FGDs revealed that they generally understood
disease surveillance related to collecting data regarding occurrence and spread of different
disease conditions with relation to time. They felt that the purpose of surveillance was to
identify epidemics, study root causes, investigate epidemiological causes and take action to
contain the outbreaks. In fact, some of the health workers perceived epidemic investigations
as synonymous with surveillance of diseases.
House to house visits were perceived as active surveillance and the most important
component of the process. Some also mentioned that the data collection at the health
facilities constituted passive surveillance, although this data was used rarely. Surveys are also
undertaken, as part of surveillance activities.
Several health workers thought that whatever information they collected including the
demography were part of the surveillance activity. Imparting health education, identifying
beneficiaries and delivery of different services to the people under various national health
programs were other activities mentioned as part of surveillance. The workers felt that
surveillance was useful to forecast epidemics, detect disease outbreaks, evaluate usefulness of
the actions taken, treatment given. Surveillance data was useful for taking decisions about
new health care policies and programs.
Usually data is collected through house visits. It is also obtained from out patient clinics,
during various health camps or when patients are admitted to a hospital. In such cases,
they also make house visits to collect more information. Many health workers enjoy good
relationships with their communities. In their area, people come forward on their own and
give them the desired information During the field visits, they have regular contact with the
village elders, particularly ladies and the Pradhan, chauwkidar or other community persons
who give them information. At times people come forward and tell them about the disease
outbreaks in the community and health workers later go to the community to verify the
reports. The health workers also get disease information from the ICDS workers during their
interactions for other activities.
Attempts are made to get surveillance information from local private practitioners but most
health workers are not satisfied with the response. Allopathic doctors, RMPs and practitioners
of ISM are generally busy with their clinical practice and maintain few records. They pass
on the information only if the health workers approach them to get information about specific
type of patients or refer those who cannot afford private treatment.
Data is recorded in pre-designed formats. These formats are designed according to the needs
of various programs. In addition, for other diseases, which come under routine reporting,
formats for entering data are available at some places, while at other places, health workers
have evolved their own data recording formats. Reporting is done weekly or monthly, but
during epidemics reporting is on a daily basis and a nil report is also sent.
9
During epidemics all other activities become secondary to the epidemic work. Health workers
often receive the first information about epidemics from the community leaders, local
Panchayat members or NGOs working in the area. Some times, they come to know about it
through the newspapers. There are rumor registers that are kept in health facilities. In all such
situations, the health worker first verifies the information for type of disease outbreak and its
location before passing it on to the higher authorities.
Health workers are aware of the timings and locations of the potential outbreaks of diarrhoeal
diseases, cholera, and malaria. They are more vigilant for such information during the
epidemic and a more active search for the cases is done. During the non-epidemic period,
only random search for these cases is done. At times local people send telegrams to the
collector directly and then the health worker gets the information which is confirmed and
reported.
Two copies are made and one is sent to the concerned officer and the other is kept for
records. At some of the places the data is compiled from three sections: field, health facility
based and information from the private practitioners, all reported separately. The data is
mostly in form of frequency tables and no further analysis is done at the PHC level. Although
most health workers claimed that data was reliable as well as valid, they did agree that it did
not represent the whole picture. Many patients seek care from the private sector and are hence
left out of the reporting system. There are also areas which are left out during surveillance
activities because of being scattered over a large geographical area. Duplication of data is
also a possibility due to the same patients being contacted during field visits and subsequently
attending the health facilities. In the field, some community members give incomplete or
invalid information. The senior officers and health supervisors do not regularly supervise data
collection and data recording processes and no feedback is received from them.
Reports are either sent directly to the PHC medical officer or to the health inspectors or to the
staff nurses at some places. At times the Panchayat members, press and village health
committees or local leaders provide information to health authorities in an informal manner,
bypassing the health worker. This is particularly true during disease outbreaks.
Health workers understand the imperatives of an epidemic and often use the fastest mode of
communication as well as break the transmission chain to hasten appropriate action. The
district authorities may be informed before the PHC doctors.
Occasionally, delays of several days occur in providing information about the epidemic,
especially if the health worker is not able to verify the existence of the outbreak or does not
give credence to the information received. Some health workers are vary of informing about
sudden increases in the number of cases with diseases that have the potential to develop into
an epidemic; or report occurrence of unusual cases because of the fear that it would increase
their work load.
Feedback mechanism for surveillance data is considered less than optimal at present. After
the surveillance data is submitted, it travels up through various levels from the PHC to district
to state head quarters but no feedback is given to the ground staff about the interpretation and
proposed actions. Many times the health workers come to know about the response to data
10
through other channels. Thus most health workers are not sure about the current use of the
surveillance data for response, planning and improving health systems.
In case of small outbreaks at the local level, health workers along with medical officers at
PHC level initiate action without waiting for formal instructions from the district and higher
levels. However, if the number of cases is large, outside help in the form of logistic supplies,
and additional manpower support is sought.
3.1.2 Constraints perceived by health workers in performing high quality disease
surveillance activities
Health workers perceived the training to carry out tasks pertaining to disease surveillance as
being insufficient. Manuals for some diseases are available in English and most of the health
workers are not able to comprehend them. Case definitions are often not clear. When new
programs are launched, or modified, case definitions are some times changed, creating
confusion among the health staff and also affecting the quality of data collected.
The health workers uniformly complained of being asked to collect too much data in the
field. This had influenced both the quality of work and ability to complete the task assigned.
At places, they were required to fill up 24 registers with every new program adding an
additional one.
Furthermore, stationary was often not available or adequate thus forcing the workers to use
loose sheets, and occasionally purchase the stationery on their own. Health workers make a
lot of effort to draw data collection formats on the loose sheets themselves, thus increasing
the possibility of filling incomplete as well as inconsistent information particularly when predesigned formats are not available. They often carry loose sheets in the field to avoid carrying
all the registers.
Priorities of the health authorities are perceived as changing, creating confusion in the minds
of the health workers, resulting in poor as well as inconsistent reporting of data. Several
patients go directly to the doctors', particularly private practitioners, and thus they are not
included in the reporting system.
There is inadequate data collection because the population under each worker is too large and
several posts are lying vacant. Commuting to the work area is an additional constraint in
obtaining complete data. Some times the same information is required to be filled in several
places so there is duplication of efforts. Surveillance activities are also hampered during
epidemic conditions and when camps were organized.
Supervision is not perceived as being supportive and many health workers perceived the
supervisory visits as occasions for reprimand leading to loss of confidence. In some places,
male and female health workers, voluntary health nurses, and other categories of health
personnel complained of being subjected to discriminatory treatment by the department
which was demoralizing for their overall performance.
It was stated that some people were too shy and embarrassed to talk about diseases related to
sex and reproductive organs, particularly if they did not have a good rapport with the health
11
workers. Thus, information related to HIV-AIDS, RTI, and STD were difficult to elicit.
Similarly, tuberculosis and leprosy were considered diseases with social stigma. In some
places, people consider exanthemata as a curse of GOD and do not let outsiders enter their
houses or share the information with health workers. Occasionally mothers would not speak
about the illness of their children to health workers because they feared further wrath of evil
spirits on their offspring.
Religious minority groups in some areas are suspicious of the government health systems and
hence withhold information. Urban subjects of higher socio-economic status did not wish to
utilize public health services and therefore are not included in reporting of surveillance
activities. Due to poor credibility of health systems, many people consider the surveillance
activity is meant for the health department with no benefit to common people.
Women do not speak freely particularly when the head of the family is not at home or if male
health workers approach them for any information.
3.1.3 Gender issues in disease surveillance
In FGDs it was found that family elders, in-laws, husbands, sons or the earning members of
the family take decisions regarding the place, type and timing of seeking health care. Tribal
women and women residing in urban as well as rural areas perceived their education and
financial status as important factors in taking independent decisions in matters of health for
themselves and their children.
Women in both rural and urban areas do not talk about their symptoms either with their
family members or with health workers during early the phase of the diseases. They usually
first talk to their husbands about their illnesses.
Tribal and rural women felt that doctors in public sector health facilities do not provide good
care because they are poor. Due to poverty and poor accessibility to health facilities, women
first try home remedies. When the symptoms do not ameliorate, help is sought from
traditional healers or the local drug store. Thus, it is often quite late when they reach out to
existing health facilities for their illnesses. However, for diseases that are perceived as serious
in the community, patients are taken to hospital early.
If someone inquires about the symptoms and illness, women do not hesitate to share the
information, particularly in the tribal areas. Focus group discussions with women in tribal,
rural and urban areas consistently brought out the gender disparity to seek health care. When
men fall sick, the family gets worried, and treatment is promptly sought. In contrast, attention
is not given to the initial symptoms in women. If the symptoms do not subside on their own
or with home remedies, then they are taken to health care providers. Women perceived that
boys are more delicate and emotional as compared to girls. It was felt by women that girls
could withstand the illness better and recover faster, as compared to boys. Interestingly, such
perceptions were more prevalent among urban women than among rural or tribal women.
12
3.2
Conclusions from state level workshops
The state level workshops in Tamil Nadu, Maharashtra and Uttar Pradesh brought out the
following issues on current disease surveillance activities.
3.2.1 Primary level











Active or passive data collection is going on for more than 60-90 different conditions
in some of the states
The peripheral data collection system is over burdened with a substantial percentage
of the time of the ANM spent on surveillance related activities
Quality of reporting is hampered by absence of clear case definitions
Data transmission is affected by poor communication facilities available
Absence of formats for reporting diseases adversely affect quality of the data collect.
There is no horizontal integration of surveillance activities of existing disease control
programs
Data is not collected from private practitioners, private laboratories and private
hospitals both in rural and urban setting.
Infrastructure for urban surveillance is very weak in view of the rapid growth in urban
populations
There is no system of feedback to the lower levels of the health system.
Data collection during emergencies and epidemics is of better quality
There is no system of quality control for the data collected and there is very little
analysis and action based on the data
3.2.2 District








Quality of data collected is poor
Analysis of data is inadequate for meaningful interpretation
The laid down protocols were not being followed and needed to be activated
District level response system is activated only in times of outbreak
NCDs not included in surveillance even though the burden due to them is high
The information is not shared across disease control programs
There is lack of coordination between departments
District administrative system not able to make use of the health data
3.2.3 State





There is need to improve the quality of data in terms of reliability and validity
There is problem of timeliness as data is transmitted to state head quarters irregularly
and often late.
Most of the data received at the state level is not analysed
Data is not used for routine program planning
There is need to improve human resources
13
3.2.4 Poor integration and duplication of surveillance activities
A number of distinct and independent surveillance activities exist in the states with
significant duplication of resources and poor information sharing across stakeholders.
Surveillance activities of vertical programs of Malaria, Tuberculosis, Polio, HIV are
functioning independently. There is also a pilot project in 100 districts for surveillance of
communicable diseases (NPSCD). Few non-governmental agencies are also involved in
surveillance. But the overall experience is that the disease surveillance system is not working
effectively. It is not able to detect and respond to epidemics, nor is it providing information
on important health conditions. There is considerable scope for improvement in many areas
and there are certain areas, which are not covered by the present surveillance activities.
The main reason why disease surveillance activity in the country perhaps is not as effective
as it could be, is because of the following factors:








There are a number of parallel systems existing under various programs which are not
integrated.
The existing programs do not cover non-communicable diseases.
There is need to bring the medical colleges and large tertiary hospitals in the private
sector into the reporting system as well as for utilization of laboratory facilities.
The laboratory network needs to be improved and there is a need to prescribe clear cut
thresholds for response at each level.
Surveillance is necessary not only for detection of epidemics, but for rapid response to
arrest spread of disease and to generate essential data for decision making on a regular
basis. Presently, surveillance is sometimes reduced to routine data gathering with
sporadic response systems.
There is a need for increased use of information technology in order to ensure that
information is gathered rapidly and responses made immediately. IT can also be used
to analyze and sort data so as to predict epidemics based on trends of the reported of
disease so that preventive action can be taken.
The consensus is to evolve a system that functions within the existing healthcare system by
improving the existing infrastructure and facilities rather than by creating new monoliths; to
concentrate on improving human capacity and to focus on utilizing existing facilities for
surveillance to the fullest.
3.3
Recommendations based on the above reports
3.3.1 Process of Disease Surveillance

Health providers at all levels ought to understand the scope and benefits of disease
surveillance and be able to delineate surveillance related activities from other health
services.

Strategies to improve the validity of surveillance data

Increasing the specificity of data
14

There is need to develop operational manuals in the local language for
different levels of health functionaries. The health staff should be formally
oriented to the contents of the operational manual on surveillance with
periodic reinforcement of key issues.

The case definitions of the diseases that are under surveillance should be
clearly understood by the health workers and other staff. Changes in case
definitions should be avoided unless absolutely necessary.

Surveillance formats should be simple, requiring minimum necessary
information to be obtained and readily available as printed forms. The
health workers must complete these during their contact with patients at
home, field or health facilities.

Increasing the sensitivity of data

Complete coverage of population under every health worker by
i. Targeting hard to reach and migratory populations
ii. Improving efficiency of fieldwork through micro planning and
categorizing surveillance data that needs to be collected during
house visits or from health facilities.



Involving all stakeholders in the entire process (private sector, community,
leaders, influences, etc.) by various strategies like social mobilization,
sensitization, training and ownership activities.
Improvement in the overall quality of data.

Surveillance should be restricted to 10-15 health conditions that are of public
health significance in the area.

Training of health workers and other health personnel in basic principles of
epidemiology, data collection, surveillance of health conditions that are now
proposed to be included in the list e.g. non - communicable diseases and
preliminary data analysis and interpretation.
Early identification of outbreaks / epidemics

The health workers and field staff should have a pre-defined list of epidemic
prone diseases in their area. They must be aware of the epidemiology of these
health conditions and risk factors that facilitate disease outbreaks, and
maintain a high level of suspicion.

Health workers should be able to recognize unknown disease conditions
occurring / reported in their area.
15

Awareness levels of traditional sources of first information about epidemics
(i.e. community members, local leaders, press, NGOs) should be increased to
facilitate early reporting.

Interval between first information and confirmation of outbreak needs to be
minimized to avoid delays in response.

Health staff should be encouraged to report occurrences of unusual cases or
observed increase in the number of cases with epidemic potential.

Trigger levels and standard operating procedures need to be pre defined for all
health conditions with epidemic potential.

Disease Surveillance has to be associated with feedback to field staff and community
and appropriate responses.

There is a need for an inbuilt mechanism of regular monitoring of the program with a
checklist of tasks that ought to be supervised. Supervision has to be supportive. PHC
doctors should perform their role as leaders of the primary health care team by
providing appropriate training, motivation and encouragement, to health workers.
3.3.2 Involvement of Private Sector

The objective of incorporating the private sector in health will be to improve the
sensitivity of surveillance data. The private health facilities / practitioners including
traditional healers can function as sentinel sites to regularly collect and send
information on a very restricted number of health conditions. Such information will at
least be able to demonstrate the trends in disease occurrence.

The process of involving private sector requires some experimentation. Some of the
strategies suggested by health workers during FGDs are:
-
to create awareness about disease surveillance and its benefits.
to provide them training for carrying out surveillance related activities.
legislation may also prove to be effective in their involvement.
3.3.3 Community involvement

An institutional mechanism to be put in place where field staff makes proactive
efforts to develop personal rapport with the community and solicit their support and
cooperation in various health programs including disease surveillance.

Community must be regularly given feedback about surveillance data and the
consequent responses to sustain their participation and interest. Community leaders,
influencers and NGOs should also be made part of the process that makes health
related decisions at the community level.
16
3.3.4 Social Mobilization

Different IEC and social mobilization campaign strategy for
-
4
health personnel and private practitioners; and
community, community leaders and NGOs

IEC messages have to be prepared within the local context and in a locally
comprehensible language.

All channels of communication to be used for creating awareness.

Social mobilization campaigns must address the prevalent socio-cultural beliefs and
issues relating to gender disparities.
EVOLUTION OF IDSP IN INDIA
In 1998 the Government of India requested the World Bank to support preparation of a
disease surveillance project. During subsequent discussions, the Bank and the GOI agreed to
collaborate on preparing a disease surveillance project, which will have the following
characteristics:









4.1
The program will cover a limited number of disease conditions of public health
importance, in which public health response is needed.
It will cover both communicable and non-communicable diseases.
The system will use different methods of surveillance (e.g. sentinel sites, periodic
surveys etc. in addition to the regular surveillance).
The program will be action oriented with the ability of timely response at the local
and regional level, in addition to national level responses.
It will integrate all existing surveillance activities of the disease control programs.
The program will envisage the use of modern Information Technology to facilitate
transfer of information.
The program will be decentralized and state based in its administrative structure.
The center will be responsible for co-ordination, quality control, policy formulation,
financial and technical assistance.
There will be an overall emphasis on monitoring system performance, evolution and
change, and on building capacity at all levels.
Development of project implementation plan
The project preparation commenced with a meeting at Hyderabad in September 2000, in
which four states and the GOI were present together with representatives of WHO, CDC,
NIH, USAID, DFID and other national agencies like NICD and ICMR. In this meeting a
consensus on the above project plans was reached. Following this meeting the MOHFW set
up a steering committee chaired by the Special Secretary, (Health) and six members from
NICD, ICMR, WB were selected to oversee the progress of this project.
17
MOHFW, GOI requested Tamil Nadu, Maharashtra and Uttar Pradesh and later Andhra
Pradesh, Karnataka, Himachal Pradesh to prepare the state Project Implementation Plan for
the project. INDIACLEN consultants were contracted to help the state governments in the
preparation of the PIPs in the three states.
4.2
Developing consensus on IDSP in participating states
Health is a state subject in the federal constitution and is administered by the state
governments with guidance from MOHFW, Government of India. The states have initiated a
number of health programs to improve the health of the people. The vertical disease control
programs administered by the central government are also mediated through the state health
systems. Most of these programs have been only partially successful in their delivery because
of the wide variation in socio-cultural differences and health infrastructure. In this setting it is
not possible to adopt a common surveillance system for the whole country and there is need
to understand and adapt to differences in the region. Therefore, it was considered important to
have a grass root level approach to the development of IDSP in India.
Three state level workshops were conducted in Tamil Nadu, Maharashtra and Uttar Pradesh
to facilitate state PIP development. The objective of the workshops was to understand the
current surveillance activities of the state with a view 1) to improving the quality of disease
surveillance activities and 2). To identify priority diseases which require surveillance, based
on the burden of disease and availability of public health action.
These meetings were organized primarily by the Director of public health in the three states
with collaboration from MOHFW GOI, USAID, WB and INDIACLEN. A bottoms up
approach was used and state level meetings included grass root level workers from PHCs,
Block and District level administrative officers, representatives of Indian Medical
Associations and other NGOs doing surveillance, in addition to state level program officers,
state health secretary, Director of public health.
Currently State PIPs have been obtained from two states, Tamil Nadu, Andhra Pradesh,
Karnataka, and Maharashtra. In addition, state level workshops and situational analysis and
assessment of current needs were additionally performed in Uttar Pradesh. The government
has corresponded with state administrations on the concept plan of IDSP and obtained feed
back from six states and three union territories: 1) Haryana, 2) Arunachal Pradesh, 3)
Karnataka, 4) Goa 5) Gujarat 6) Uttaranchal, 7) Union territories of Lakshadeep, Dadra and
Nagar Haveli, Pondichery. They have committed to implement IDSP.
A national level PIP draft was prepared, based on the above information. This was circulated
to at least eight other states (West Bengal, Manipur, Madhya Pradesh, Uttaranchal, Andra
Pradesh, Karnataka, Goa, and Pondichery) to further understand the basic differences,
particularly on infrastructural differences in quality and types of laboratory networks.
Available human resources, capacity for undertaking training for the program and differences
in administrative structures in the states were taken into account in the preparation of the final
document.
18
4.3
National workshop
In June 2001, a National level workshop was conducted in New Delhi to reach a consensus
on the role of central agencies. This meeting was organized by the MOHFW, GOI in which
the conceptual framework for the Integrated Disease Surveillance (IDS) Program was
discussed with partner agencies. Responsibilities of partners were discussed to develop a
surveillance system in the country without delay, which is:




5
Integrated
Decentralized
Action oriented
Responsive
IMPLEMENTATION STRATEGY
TABLE : RESPONSIBILITIES AND ACTIVITIES OF STAKE HOLDERS:
ANM
Serial No: Activity Disease/Risk factors
1
Data Collection
1) Malaria
2) TB
3) ADD
4) Typhoid
5) EPI - Fever with Rash
6) Jaundice
7) AFP
8) Other Rare disease
a) Meningitis
b) Tetanus
c) Whooping Caugh
d) Plague
e) Anthrax
f) Death unknown cause
g) Suicides
9) Water Quality
10) Road Traffic Accidents
11)
12)
13)
14)
15)
16)
MHW
MO_PHC
Community/ Village
SSPs Pradhan/Media
District
***
***
***
***
***
***
***
***
***
***
Medical Colleges
State
*
7
8
9
10
Training
Monitoring & Evaluation
Policy & Guidelines
Consultancy
TOTAL
***
**
***
***
**
*
***
*
***
**
***
***
***
*
*
*
*
*
*
***
**
*
***
***
***
***
***
***
***
***
***
Urban Data
Lab confirmation of diagnosis
Internal Quality control
Epidemic Investigations
Analysis, Dissemination & Reporting
External Quality control
Partners
**
**
**
**
**
**
**
CVD Risk Factors
HIV/AIDS
STDS/RTI
Other Risk behaviour
Air Pollution
AMR
2
3
4
5
6
Center
*
*
***
*
*
***
*
***
***
***
***
***
***
**
*
**
**
***
**
**
6
5
4
9
***
8
**
**
9
7
14
***
**
**
***
8
5
The variations in health infrastructure in the participating states require that the IDSP
program be implemented, using a modular strategy in a phased manner. The four main
components of IDSP in terms of resource allocation are:
1) Information Technology and Networking
2) Laboratory Upgradation
3) Human Resource Development
4) Disease surveillance and response mechanisms.
19
It is envisaged that the states will be utilizing funds differentially on different key
components of the program to achieve IDSP objectives. External evaluation of the program
will be undertaken at the end of the second year and fourth year, to assess the progress in the
process of implementation and the result of this evaluation will determine the type of support
provided for the next phase of implementation of IDSP in a given state. By the end of the
first year it is expected to bring at least 10 states with ‘Political Will’ into the program. The
states will be included in the program as and when the state PIPs are completed during year
two and by the end of the second year, it is expected that all the states in India will be
inducted into the program at a basic level. The detailed time line is given in section 32.
The ability of Medical colleges to perform the functions specified under IDSP will be ensured
by the Government by initiating appropriate consultations with the state health administration
and Medical Council of India. The participation of private practitioners is crucial in detecting
trends of disease and for early detection of emerging diseases since, more than 70% of the
health care is being carried out by non-governmental agencies. Sentinel Private Practitioners
and Hospitals will be integrated in the program. The recruitment of sentinel private
practitioners will be undertaken in a phased manner with doubling of the number of private
practitioners in the second year of the program. This will be facilitated by establishing formal
linkages with Indian Medical Associations and other relevant national professional bodies of
medical practitioners. The state and district surveillance officers will be primarily responsible
for this activity. The participation of all private laboratories will be mandated with legislation
and accreditation. Registration of these entities with the authorized State / National
accreditation bodies will occur after the legislation is passed.
6
SPECIAL ASSESSMENT CARRIED OUT FOR IDSP
1.
2.
3.
4.
5.
6.
7.
8.
7
Assessments
Laboratory Needs for IDSP
Information Technology assessment
Determinants of Quality in Data collection
Institutional Assessment
Economic Assessment
Training Assessment
Environmental Assessment
Social Assessment
Agencies
- CDC / WB / INDIACLEN
- World Bank/Deptt. of IT
- INDIACLEN / WB
- World Bank
- World Bank
- WHO / INDIACLEN / WB
- World Bank
- World Bank
PROGRAM SUSTAINABILITY
The IDSP will be completely funded in the first five years. Thereafter, the important heads
under which costs are likely to be incurred on a recurring basis are: Information technology
and communications, laboratory and training. It is estimated that approximately 10% of the
project costs are required to sustain these components. No additional expenditure on
personnel and infrastructure are envisaged for the proposed IDSP. Furthermore, the current
expenditure on surveillance components of several vertical programs will also be available
for IDSP.
20
PART – II
OBJECTIVES AND COMPONENTS
21
8
OBJECTIVES OF INTEGRATED DISEASE SURVEILLANCE
The project development objective is to improve the information available to the government
health services and private health care providers on a set of high-priority diseases and risk
factors, with a view to improving the on-the-ground responses to such diseases and risk
factors.
Specifically, the projects aims:

To establish a decentralized state based system of surveillance for communicable and
non-communicable diseases, so that timely and effective public health actions can be
initiated in response to health challenges in the country at the state and national level.

To improve the efficiency of the existing surveillance activities of disease control
programs and facilitate sharing of relevant information with the health administration,
community and other stakeholders so as to detect disease trends over time and
evaluate control strategies.
The project will assist the Government of India and the states and territories to:

surveil a limited number of health conditions and risk factors; 

strengthen data quality, analysis and links to action; 

improve laboratory support; 

train stakeholders in disease surveillance and action; 

coordinate and decentralize surveillance activities; 

integrate disease surveillance at the state and district levels, and involve communities
and other stakeholders, particularly the private sector.
9
COMPONENTS OF PROPOSED IDSP
Project Component 1
Establish and Operate a Central-level Disease Surveillance Unit
Under this component, MOHFW will establish a disease surveillance unit at the central level.
The new unit will support and complement the states' disease surveillance efforts. The unit
will be staffed by 7 permanent staff reassigned from within the MOHFW. In addition, 15
contract staff (5 technical and 10 support staff) will be hired. Government orders for
establishing the unit have already been issued and the positions for contract staff have been
advertised. Suitable office space has been identified and communications and information
technology equipment and furniture are included in the budget. The permanent and contract
staff will be responsible for the activities of the unit which will include:


preparation of national guidelines for disease surveillance based on agreement with
the states and other stakeholders on the priority diseases and conditions to be included
in the surveillance system, standardized case definitions and the methods to be used
for their surveillance.
promoting compliance by the states with central policies and technical guidelines. 
22




providing overall support to states and coordinating national surveillance activities,
including the preparation of a national plan of action.
coordination and timely transport of specimens to the regional, national and
international reference laboratories.
data analysis to identify epidemiological trends and preparation of national reports on
the epidemiological situation.
coordination of Quality Assurance surveys (in conjunction with the states). 

The project will finance consultants, equipment and furniture and incremental operating
costs.
Project Component 2
Integrate and strengthen disease surveillance at the state and district levels
This component includes involvement of communities and other stakeholders, in particular
the private sector. This component addresses the constraints imposed by lack of coordination
at the sub-national levels, the limited use of modern technology and data management
techniques, the inability of the system to act on information and the need for inclusion of
other stakeholders. It will consist of 4 sub-components:
(a) State-level. A disease surveillance unit will be established at the state level under the
project. The State Surveillance Unit (SSU) will be headed by a technical officer from the
state cadre. The state office will also hire 3 technical consultants and 4 support staff.
Emphasis will be on strengthening integration of the activities of existing health staff,
laboratory information, the private sector and the community into the overall system through
implementation of procedures and activities spelt out in the district-level and state-level
disease surveillance manuals.
Activities at the state level will include:







preparing and sending monthly summaries of the disease situation to the central level; 
training state and district level staff; 
implementing periodic surveys for non-communicable diseases and/or their risk
factors; 
implementing Quality Assurance surveys (in conjunction with GOI); 
integration of disease control efforts based on the surveillance data; 
supporting districts in data analysis, transport of laboratory specimens, and outbreak 
investigations;
analyzing surveillance data across districts. 

(b) District level. The District Surveillance Unit (DSU), established under the project, will be
headed by a medical graduate with a background in public health and/or epidemiology. Other
contract staff will include a microbiologist and 4 support staff, including data entry operators.
Activities will include:



analyzing surveillance data from the peripheral level; 
providing support for collection and transport of specimens to laboratory networks; 
initiating investigation of suspected cases; 
23


providing feedback to the health facility; 
responding promptly to information provided by communities. 

(c) Community level: Activities will include:

notifying the nearest health facility of a disease or health condition selected for
community-based surveillance

supporting health workers during case or outbreak investigations 

using feedback from health workers to take action, including health education and
coordination of community participation.
(d) Strengthen data quality, analysis and links to action: Activities will include:

'real-time' on-line entry, management and analysis of surveillance data through use of
computers, the Internet and the WWW;

reporting surveillance data using standard software, including GIS, while allowing
flexibility to add new systems as needed;

email services between central sections and departments, within and between states,
laboratories 

and other persons and institutions involved in public health;

rapid dissemination of 'health alerts' and other textual information; and electronic
distribution of reports both to the public health staff and civil society;

Quality Assurance surveys of laboratory information. 

The Information Technology aspects of the project will involve setting up a network to
transfer data between various levels of the system, provision of stand alone computers at the
district level and links to district, state and national units. Software for the system will be
developed to facilitate simplified data entry with multilingual formats, analysis and
consolidation of data at each level, generation of alerts on the basis of disease-specific
thresholds, documentation of the system and development of manuals, phased deployment of
software, skills assessment of staff and provision of appropriate training.
Further details of the Information Technology element of the project are given in Annex 11.
The project will support incremental operating costs, purchase of services from NGOs,
consultants, computers, development and purchase of software, technical assistance,
strengthening of electronic communication between the districts, states and center, IEC
materials and media space.
Project Component 3
Improve Laboratory Support.
This component would consist of:
(i) The upgrading of laboratories at the state level, in order to improve laboratory support for
surveillance activities. Adequate laboratory support is essential for providing on-time and
reliable confirmation of suspected cases; monitoring drug resistance; and monitoring changes
in disease agents; and
24
(ii) The introduction of a quality assurance system for assessing and improving the quality of
laboratory data.
The laboratory network for the IDSP will have 4 levels: L1 - peripheral laboratories and
microscopy centers; L2 - district public health laboratories; L3 - disease-based state
laboratories; and L4 – reference laboratories and quality control laboratories.
L1 laboratories will provide information for the diagnosis of malaria, TB, typhoid,
chlorination levels in water and fecal contamination of water. Whilst these laboratories
already handle examination of sputum and blood smears, some need minor internal
modification as well as the provision of kits for typhoid diagnosis and assessment of fecal
contamination of water.
L2 laboratories will need to carry out tests for TB, malaria, typhoid, cholera and water
quality, primarily to confirm results from the peripheral levels and for quality control. Some
will require minor internal modification and additional equipment, reagents and kits. These
laboratories will also be connected to the computer network. Staff will be as already assigned,
reassigned from other laboratories or, in the case of microbiologists, hired on contract.
L3 laboratories will carry out tests to confirm L1 and L2 results, for some state-specific
diseases (e.g. leptospirosis), as part of the internal quality control mechanism, and assays
required for the non-communicable disease surveys. The project provides for some minor
internal modification of laboratories, equipment required for additional tests, reagents and
kits, and a computer, software and telephone connectivity.
L4 laboratories - IDSP will have one central and four reference laboratories to support routine
work and specific outbreak investigations. These are high quality laboratories which already
have the capacity to carry out the laboratory tests required. The project will fund incremental
operating costs and, if required, a computer, software and telephone connectivity.
External Quality Assurance surveys (EQAS) of laboratory data are an important tool in
improving the quality of laboratory information. This will be carried out under contract to a
third partner with external accreditation for medical laboratory quality assurance. Standard
material will be supplied or the assay and assessment to a sample of IDSP laboratories in
each state each year. These results will then form the basis for specific interventions in the
IDSP system to improve laboratory quality. The Terms of Reference for these surveys are set
out in Annex.13.
The component would finance renovation of existing buildings, purchase of equipment,
technical assistance, incremental operating costs and surveys.
Project Component 4
Training for Disease Surveillance and Action
The changes envisaged under the first three components will require a large and coordinated
training effort to reorient health staff to an integrated surveillance system and provide the
new skills needed. This component will support

general training for orientation of staff in both the public and private sectors to disease 
25



surveillance;
specific training for disease control staff; 
specialized training in epidemiology; 
specialized training in data management and communications. 

The training strategy and plan for the project is based on training needs assessment carried
out in 6 states. Eight separate short-term training programs for various categories of staff are
to be covered in the training program. The material to be covered for each group and the
numbers to be trained are shown in the table below:
Trainees
I
Training of
central, district
and state
surveillance
teams
II
Medical Officers
ofthePHCs,
CHCs and Urban
Health sector.
MOs of local
Medical colleges.
Mos of NGOs/
Mission
Hospitals
III
Medical Officers
of the Hospitals,
Sub-district
Hospitals,
Medical College
Hospitals
IV
MPWs (Male /
Female), Health
Supervisors,
NGO volunteers,
unregistered
Medical
practitioners
Content of Training
Number to be trained
• Overview and introduction to surveillance with
special reference to IDSP.
• Basic epidemiology pertaining to surveillance
including definitions like rates, ratios, Incidence
Rate, Prevalence Rate, spot maps, graphs etc.
• Details of case detection, including case
definitions, reporting units and filling up forms,
compilation and transmission of data
• Collection and transmission of laboratory
specimens and bio-safety issues
• Details of analysis and interpretation of data
• Details on response to outbreaks
• Supervision Monitoring and Evaluation .
• Feedback
• Training methodology
• Inter-sectoral coordination
• Cluster survey sampling and analysis methods
(state team only)
• Overview and introduction to surveillance with
special reference to IDSP.
• Details of case detection, including case
definitions, reporting units and filling up forms,
compilation and transmission of data
• Collection and transmission of laboratory
specimens and bio-safety issues
• Basics of analysis and interpretation of data
• Details on response to outbreaks
• Supervision Monitoring and Evaluation.
• Overview and introduction to surveillance with
special reference to IDSP.
• Details of case detection, including case
definitions, reporting units and filling up forms,
compilation and transmission of data
• Basics of lab confirmation - what specimens to be
sent to which lab, and in what manner for
confirmation
• Overview and introduction to surveillance
• Syndrome description
• Filling up of forms
• Transmission of data
• Collection of specimens
• Biosafety issues
• Basic response to outbreaks
2523
19298
6900
160153
26
• Overview and introduction to surveillance with
special reference to IDSP
• Hands on training on diagnosis of specific
diseases. Especially culture and sensitivity of stool
and blood, serology etc.
• Quality assurance mechanisms
• Biosafety issues
V
State and District
level
microbiologists /
lab technicians.
Also of the urban
health sector.
Also
Microbiologists
from local
Medical Colleges
VI
Training for lab • Introduction to IDSP
assistants at CHC • Testing for sputum AFB, Malarial smear, Typhoid
/PHC
test
 Collection, Storage and transportation of
specimens
 Biosafety issues
Training for data  Introduction to IDSP
management at
 Extracting of data from the computers
district and states
 Analysis of data
level
VII
2368
3356
592
10 DISEASES TO BE INCLUDED IN THE SURVEILLANCE PROJECT
The diseases to be included in the surveillance program will be based on the following
criteria:
1)
Burden of disease in the community,
2)
Availability of public health response and
3)
Special considerations and international commitments. Based on the information
obtained from the state level workshops the following core conditions will be
included in the IDS program.
The disease conditions that are included in the core list and state specific list of the
surveillance program will be reviewed once in two years based on disease burden and
availability of public health action and suitably modified.
10.1 List of Core Diseases:
Regular Surveillance:
Vector Borne Disease
Water Borne Disease
Respiratory Diseases
Vaccine Preventable Diseases
Diseases under eradication
Other Conditions
: 1.
: 2.
: 3.
: 4.
: 5.
: 6.
: 7.
Malaria
Acute Diarrhoeal Disease (Cholera)
Typhoid
Tuberculosis
Measles
Polio
Road Traffic Accidents
(Linkup with police computers)
27
Other International commitments:
Unusual clinical syndromes
(Causing death / hospitalization)
: 8.
: 9.
Plague
Menigoencephalitis / Respiratory Distress
Hemorragic fevers, other undiagnosed
conditions
Sentinel Surveillance
Sexually transmitted diseases/Blood borne : 10
Other Conditions
: 11
12
HIV/HBV, HCV
Water Quality
Outdoor Air Quality
(Large Urban centers)
Regular periodic surveys:
NCD Risk Factors
: 13
Anthropometry,
Physical
Activity,
Blood pressure, Tobacco, Nutrition,
Blindness and any other unusual health
condition GOI may include in a public
health emergency - subject to agreement
at the next joint project review mission,
project funds could be used for these
surveillance activities).
10.2 Additional State Priorities
In addition to the core diseases which will be under surveillance for all the states, each state
will be able to identify up to five additional conditions for which surveillance will be
initiated. State Specific Diseases for States covered in Phase I are given below :
Andhra Pradesh
Karnataka
Kerala
Tamilnadu
Maharashtra
M.P.
Uttaranchal
Mizoram
H.P.
Filariasis
Filariasis, KFD & HGS, Leptospirosis
Leptospirosis
Leprosy,Leptospirosis
Diphtheria, NN Tetanus, Leptospirosis
Leprosy, Diphtheria, NN Tetanus
Leprosy, Diphtheria, Tetanus
Cancer, Substance Abuse, Acid Peptic Disease, Pneumonia
Thyroid Diseases, Leishmaniasis, Acid Peptic Diseases, Rheumatic
Heart Diseases, Cancer
Note: In the event of a public health emergency, this list may be expanded to provide the
necessary surveillance and rapid response by MOHFW and States. The inclusion of such
disease and its surveillance and rapid response activities under the Project would be
reviewed by the subsequent Joint Review Mission (JRM). Such activities would be
eligible for IDA financing until the subsequent JRM. The financing of such activities by
IDA beyond the Joint Review would depend on the recommendations of the JRM.
28
11 METHODS OF SURVEILLANCE
Quality of data collection is of crucial importance. Hence, overloading the peripheral health
worker will be avoided. The following three main sources of data will be tapped within the
system for collection of surveillance data.
Routine reporting will be conducted at the PHC by the ANMs and HWs. State specific
diseases will be added to this, to a total of not more than 15 disease conditions including the
state list. Information related to geographical changes in prevalence can be obtained by the
system by sentinel surveillance. This form of surveillance will be used for HIV, HBV, HCV,
Water Quality, Air Quality etc.
Special teams will be developed to assess NCD risk factor surveillance.
The below specifies the details and type of surveillance for various diseases identified in the
above list
TABLE : FREQUENCY, RESPONSIBILITY AND TYPE OF REPORTING
Disease
Conditions
1
2.
3.
Tuberculosis
Malaria
Cholera
Unit
Surveillance Method Recording
PHC
SPPs/PH
DH
Regular
Micro C
P-Lab
DPHLab
PHC
SPPs/PH
DH
Micro C
Regular
Passive
Active
and
Passive
Daily
Weekly
Daily
Daily
Weekly
Daily
Daily by
HW
Weekly
Daily
Daily
P-Lab
DPHLab
Other
Weekly
Daily
Weekly
PHC
Daily by
HW
Weekly
Weekly
Daily
Daily
PHC
Regular
SPPs/PH
DH
DPHLab
Passive
Confirming/
Reporting
Weekly MO
Weekly
Weekly DTO
Weekly DTO
Weekly
Weekly LD
Weekly MO
Weekly
Weekly DMO
Weekly
(ADPH)
Weekly
Weekly LD
Weekly
MO/DMO
Weekly MO
Weekly MO
Weekly
Weekly DMO
Weekly LD
Lab
Confirmation
Peripheral Lab
Peripheral Lab
Peripheral Lab
29
Other
Disease
Conditions
4.
5.
Typhoid
Measles
Unit
Weekly
Surveillance Method Recording
PHC
SPPs/PH
P-Lab
Regular
DH
DPH
Lab
Passive
PHC
Active
PHC
Regular
SPPs/PH
DH
Other
Passive
PHC
Active
Passive
DH
6.
Polio
Regular
Passive
SPPs/PH
Other
7.
Unusual
clinical
syndromes /
Diseases
with
international
commitments
PHC
PHC
DH
Other
Active
Regular
Passive
Weekly
MO/DMO
Confirming/
Reporting
Weekly
Weekly
Weekly
Daily
Daily
Weekly MO
Weekly
Weekly
Weekly DMO
Weekly LD
Daily by
HW
Weekly
Weekly
Daily
Weekly
Weekly by MO
Daily
Follow
current
system)
Follow
current
system
Follow
current
system
Weekly
Weekly MO
Weekly MO
Daily
Weekly
Daily
Weekly
Weekly DMO
Weekly DMO
Weekly DMO
Weekly
Weekly by MO
Weekly
Weekly DMO
Weekly
MO/DMO
Weekly DMO
Lab
Confirmation
Peripheral Lab
and District
Lab
District
Laboratory
State and
Reference
Labs
Weekly DMO
Weekly
Peripheral,
District and
State Labs
30
8
State
Specific
Diseases
(Refer
Section 10.2
for Details)
Disease
Conditions
9
Road Traffic
Accident
10 HIV – ANC
data
Water
11.
Quality
12. Out door Air
pollution
13. NCD Risk
Factors
PHC
Unit
S.Police
SACS
PHC
WB
PCB
DSO
Regular
Passive
Daily
HW
by
Surveillance Method Recording
Regular
Sentinel
Confirming/
Reporting
-
Weekly
Active
Once in a Once
in
3
month
months
Monthly
Monthly MO
Monthly
Monthly DSO
Twice
Twice weekly
weekly
Once in 1 1 Years DSO
year
Sentinel
Active
Active
Active
Sentinel
Active
Sentinel
Weekly by MO
District and
State Labs
Lab
Confirmation
Weekly
NA
District Lab
Peripheral and
District Labs
State Lab
State Lab
12 SURVEILLANCE OF RISK FACTORS FOR NON COMMUNICABLE DISEASE
AND THEIR RISK FACTOR
12.1 Aims•
 Assessing prevalence of CVD risk factors, among various populations so as to
monitor trends in population health behaviors and risk factors for chronic disease over
time.
 Determine the need for chronic disease prevention and control programs in the
community.
 Determine financial allocation for programs in controlling NCDs in the community.
It is proposed to measure the following, as the first stage of NCD surveillance in the IDSP
program:
 Demography
 Tobacco and Alcohol use
 Pulse rate
 Blood pressure
 Height and weight
 Waist measurement
 Physical activity index
 Pattern of nutrition.
31
As the second stage, the measurement of Hb, Cholesterol and HDL / LDL ratios, Blood
glucose may be taken up on a random sample of subjects in coordination with the state
surveillance laboratory.
FIG. STEP WISE METHOD IN NCD RISK FACTOR SURVEILLANCE IN IDSP:
Step-wide Approach to Risk Factor Surveillance
Biochemical
es
Tr
ig
ex
ici
ty
lyc
er
id
measures
Co
m
pl
Fasting blood glucose
m
Ti
ed
k,
w
Blood Pressure
sk
al
s
es
ai
BMI
iv
ity
W
s t/
H
ip
BP
KA g
n
pi
co
str
d
Physical
measures
Reported
Comprehensive
l
ica
ed
M
,
t
e
Di ry
sto Expanded
hi
Demography
P
BM hys
i
I cal
Ac
t
Tobacco Alcohol
l
fo
in
Cost
Cholesterol
Core
12.2 Method
A Proportionate to Population Cluster Survey will be conducted in 20% of the districts every
year on a regular basis. This would ensure full coverage in five years time and provide
information on a yearly basis. Health delivery clusters will be selected on a stratified random
basis in urban and rural sectors, so that information is available on high-risk populations in
the urban areas and targeted interventions can be initiated as necessary.
Regular surveys will be carried out under the directions of the state Director of Public Health.
The design of the survey will be made in collaboration with ICMR. Manual of procedures
will be made available to the investigating team. The NCD surveillance team will be
contracted to an organization who has previous experience in conducting public health
surveys. Training will be provided to the NCD survey team in collaboration with ICMR and
State Medical Colleges.
External quality assurance for the program will be the responsibility of ICMR. Since the
same team will be doing surveillance for 20% of the district each year, the learning curve and
feed back from monitoring and evaluation will provide necessary inputs to improve their
quality of work as the program evolves.
32
12.3 Logistics
It is proposed that on a yearly basis the survey will be contracted out to the best bidders for
this program who will be able to deliver the results in the stipulated time of 1-2 months to
cover 20% of the geographical area. Money will be allocated for this under IDSP.
The NCD Risk factor surveillance manual will be developed by ICMR and the State NCD
team will be trained within six months of the IDSP, so that NCD surveillance can start by the
first half of 2003. Retrospective financing may need to be arranged for NCD team training.
33
PART – III
SURVEILLANCE MECHANISMS
34
13 REPORTING UNITS
13.1 Rural
a. Medical Officer Block PHC (BPHC / CHC –100,000)
i
Sub-centers
ii
PHC (30,000)
iii
CHC (100,000)
b. Sentinel Private Practitioners
c. Informers at community level (Rumor registry)
i.
Village Pradhan
ii.
Teachers
iii.
Anganwadi members
iv.
Self help group
v.
News papers
13.2 Urban
a. Hospital
b. Medical Colleges
c. Sentinel Private Practitioners/ Sentinel Private Hospitals/Private Lab
d. Specialty Hospitals:
i.
Infectious disease
ii.
Tuberculosis
iii.
Children
e. Municipal Corporation
i.
Hospitals
ii.
Dispensaries / Health Posts
f. Employees State Insurance Scheme (ESI)
i.
Hospitals
ii .
Dispensaries
g. Central Government Health Scheme
i.
Hospitals
ii.
Dispensaries
h. Railways
i.
Hospitals
ii.
Dispensaries
i. Informers at the community level (Rumor registry)
i.
Ward members
ii.
Anganwadi workers
iii.
Youth groups
iv.
News papers
13.3 Special Units
a. Other NGOs doing surveillance activities
b. State Water Pollution Control Board
c. Regional/ State Air Pollution Control Board
d. District Police Information System
35
STRUCTURAL FRAMEWORK OF INTEGRATED DISEASE SURVEILLANCE PROJECT
RURAL SURVEILLANCE
CSU- Central Surveillance Unit
SSU- State Surveillance Unit
DSU- District Surveillance Unit
CSU
UUu
UUS
UUU
UU
URBAN SURVEILLANCE
SSPS - Selected Sentinel Private Sites
SSU
District/HIV/AIDS
Rural SSPS - 15
District TB Lab
District Hospital
PHC , Sub-centres
Informers
ID Hospitals
Dispensaries
Informers
DSU
UU
ESI
Railway Hosp
Water Dept.
CGHS
Corporation Hosp
Pollution Control
ICMR Labs
Rural Medical Colleges
Police
District Malaria
Unit
36
Medical Colleges
Urban SSPS-15
14 STRUCTURAL FRAMEWORK OF IDSP
Consistent with the philosophy of IDSP and to meet its objectives, the focal point of all
surveillance related activities at the periphery will be the District Surveillance Unit (DSU). DSU
will receive surveillance data from both rural and urban reporting units. To increase the
sensitivity of data, additional reporting will be identified in both urban and rural areas. It will be
particularly critical for urban areas where current surveillance efforts are grossly inadequate.
For the first time private sentinel sites from both urban and rural areas will be identified as
partners. Further, in urban regions ESI, Railway Hospitals and Dispensaries, Medical Colleges,
Private Hospitals, Army Hospitals will also contribute to urban surveillance. Information on
Road Traffic Accidents will be obtained from the police department. Analysis, response and
feedback from these sources will be coordinated by the DSU.
DSU will be in communication with the state and central surveillance units through the district
surveillance network in vertical integration.
At the periphery, public sector reporting units especially, the CHCs will be directly entering data
through the computer network supplied as part of the program. If facilities are available the
sentinel private practitioners and other reporting units will directly transfer data to these units.
Alternatively, data entry operators will need to input approximately 40 reports per week from
rural and urban sentinel sites at the DSU.
14.1 Urban surveillance
Census 2001 shows that there are 31 cities with more than 10 lacks population in the country. Of
these 3 are Mega Cities (Metros) with more than 8 million population and 3 Large cities with 4-8
million population. The distribution of these cities is given in the Map attached. The urban
disease surveillance system is weak with poor infrastructural support and over load of existing
staff in most urban setting. There is also wide variability in the administrative structure of these
corporations. Currently surveillance is weak and the program involves only the government
sector. The IDSP envisages integrating all available resources with emphasis on private
practitioners, Private hospitals and laboratories and medical colleges wherever available as
described under sections 15 and 16. Thus the thrust of the IDSP in urban surveillance will be
through Sentinel hospitals, Medical colleges and Sentinel Private Practitioners.
It is proposed that for every 20 lacks-40 lacks (2-4 million) population infrastructure will be
provided to undertake district level surveillance activities. Thus metro cities of Delhi, Mumbai &
Culcutta will have 3 district level infrastructure while large cities like Chennai, Bangalore and
Hyderabad will have 2 district level infrastructure each. Smaller corporations 1-4 million will be
considered as one health district. Corporations having smaller than 1 million population will
37
report to the district surveillance unit of the district head quarters along with rural sites of that
district.
Each urban district will have 15 sentinel surveillance units / 10 lack population. including
government and private sector reporting to the urban district surveillance officer (DSO). The
number of sites may be doubled over the next 1 year. This will be further linked to the state level
surveillance unit as with other district surveillance units.
Number of Mega Cities with more than 8 million Population
Number of Very Large Cities with 4-8 million Population
Number of Large Cities with 2-4 million Population
Number of Moderately large Cities 1-2 million Population
= 3 Sentinel sites = 3 x 8 x 15
= 3
“
= 3 x 4 x 15
= 4
“
= 4 x 2 x 15
= 21
“
= 21x1 x 15
= 360
= 180
= 120
= 315
Details of the flow of information will vary with the administrative structure of the urban health system in
38
each situation. The overall framework has been specified above. Thus for urban surveillance in the country
there will be approximately 1000 sentinel units of which 500 will be from the government sector (District
hospital, ESI, Railway, Medical colleges etc) and 500 will be private sentinel sites (Private hospitals,
Private laboratories, Private practitioners, Private medical colleges etc).
The sentinel sites under government sector will undertake outbreak investigations and other preventive
action in response to surveillance information. The private sentinel sites will be largely data gathering sites
to increase the sensitiveness of the system to changing trends.
15 INTEGRATING PRIVATE PRACTITIONERS IN SURVEILLANCE
More than 70% of primary health delivery in our country is by private health providers (Private
Practitioners - PPs) of traditional or modern medicine. Valid and timely information on disease
patterns can be collected only if they are integrated into the Disease Surveillance Program. It is
logistically difficult to include all PPs and maintain the quality of data collection. Therefore it is
proposed to have selected Sentinel Private Practitioners (SPPs) to be part of the program so as to
detect trends of disease and identify the occurrence of outbreaks, early.
Objectives:


To identify disease outbreaks early
To find out trends of disease over a period of time
15.1 Identification and selection of sentinel private practitioners (SSPPS)
The district surveillance officer will be responsible for integrating SSPs in each district. The
selection criteria will be:
 Willingness to participate in the program.
 SPPs who are likely to come across a large number of cases of the disease of
interest.
 Previous experience with collaboration on health programs with the Public
Health System.
The private sector has been effectively involved with AFP surveillance by the NPSP, as
reporting units. Involving ~20,000 private sites across the country, and ensuring their sustained
interest as well as participation will be very challenging. A partnership of this magnitude
between the public and private sector has not been experimented with before in the health sector.
15.2 Recruitment of Private Practitioners to be Sentinel Sites in IDSP
Specific steps required to be taken by the district surveillance officer to facilitate private
participation include:
39
a. Approaching the private practitioner through professional bodies like IMA, IAP,
API, ASI etc.
b. Organizing surveillance workshops at state and district levels to disseminate
objectives, methods and outcome of proposed IDSP.
c. Establishing direct dialogue with potential private sentinel sites.
d. Motivating participation through incentives such as:





Inclusion of name in the network directory.
Certificate of recognition and participation under IDSP.
Access to IDSP computer web reports.
Quarterly bulletins on health status of the region from District
Surveillance Officer.
Feedback from health workers during regular visits to collect data.
Membership in village health committee meetings on rotatory basis.
The most important incentive will be the regular feedback offered to them. Those who have
access to computers may access the Web database of the IDSP and hence get regular reports on
disease patterns. This will also allow them to see who has reported what diseases in the last
quarter. The name included in the data base will act as an incentive.
Printed quarterly reports will be sent to all participating SPPs from the district surveillance unit.
This bulletin will list all the SPPs who are contributing to the program in the district and the
number of cases reported by them in each quarter. A written memorandum of understanding will
be made with participating SSPs in each district.
15.3 Sentinel private laboratory sites
These will serve as another category of urban reporting units. At least 10 urban private
laboratories per district including the district hospital will be included. If and when the
accreditation process becomes operational, then all accredited laboratories will be included. Till
then, the process of selection would be similar to the one under SSPs.
15.4 Number of private sentinel reporting sites
It is proposed that each surveillance unit at the block level have at least one sentinel private
practitioner / Sentinel Private Hospital site reporting regularly on specified diseases under IDSP.
There are approximately 15 blocks per district. Thus there will be ~9000 rural sentinel sites.
Similarly, in the urban area of each district there will another 15 SSPs / SPH sites per district
total of about ~9000 urban sites. In large metros there will be at least 20 sentinel sites selected
and distributed throughout the urban surveillance unit in the city / municipal limits. Large cities
in the country with a population of more than 2 million which will be considered metros. These
cities will contribute another 500 additional sentinel sites bringing the total of SSPs / SPHs to ~
20,000 in the country with 650 districts. This would also ensure that at the district level we will
be entering data from 10 CHCs and 30 SSPs, a total of 40 per district.
40
15.5 Phased Induction
There will be a phased increase in the induction of SSPs in the program. In the second year, the
total number of SSPs will be increased from 15 to 30 per rural and urban region of the blocks
and 40 SSPs from large metropolis cities. This will bring ~20,000 urban and ~20,000 rural SSPs
contributing to the IDSP by year three.
15.6 Facilitating reporting by private sentinel sites
15.6.1 Simplified Formats
As this is an attempt to see the disease pattern and not actually the disease burden, the format
would contain limited information like diagnosis, age, sex and residence only.
15.6.2 Frequency of Reporting
It is suggested that each of the SPPs report at weekly intervals. Since at each PHC there will be
10 SPPs this will mean at least one report per day from each region and three to four reports per
day at the Block PHC. In addition, if there is any untoward case or a sudden increase noted,
additional reports may be sent. Emergency telephone numbers will be made available to contact
MO PHC / Health worker.
Flexibility will be provided in the method of reporting by the SPPs. Each PHC may choose an
optimal method that is suitable in the situation. Any of the following methods may be used:
a.
b.
c.
d.
Telephone followed by mailing of IDSP format by hard copy
Fax
Electronic mailing
Courier
i. Office of the DSO / CHC
ii. Direct contact with Health Worker if necessary
iii. Private Courier can be contracted
Telephonic reports will be encouraged during epidemic situations so as to avoid delay. MO
Block PHC / computer entry person / District Surveillance Officer will be able to receive
information from the periphery. Routine reporting will be facilitated by the health worker
visiting the SPPs in the rural areas on specific days assigned for reporting. In urban areas,
telephones can be used or the health workers can collect reports from SPPs as done in the polio
program.
41
16 MEDICAL COLLEGES
Medical colleges are currently not contributing effectively to surveillance activities in the
country. Diseases presented at medical colleges are not being reported to surveillance officers
due to poor motivation and other commitments. In IDSP, a defined role for all the medical
colleges of the country is being proposed. The following departments in the colleges will be the
sites for reporting the diseases under surveillance. In this way it would become part of urban
surveillance activity, because most of these colleges are situated in urban areas.
It is proposed that one faculty member from each of the following departments will constitute an
institutional IDSP sub-committee. The chairperson of the sub-committee can be the nodal person
who will report to the district surveillance officer and ensure that relevant information is sent in
on time.







Principal / Medical superintendent (Chair)
Community Medicine
Medicine
Pediatrics
Chest and Tuberculosis
Microbiology
Cardiology
The participants of the IDSP sub-committee are selected on the basis of diseases currently under
surveillance in the program. Medicine and Cardiology are also responsible for NCD components
of the IDSP. The sub-committee is chaired by a senior administrative staff member of the
medical college so that participation in the program will be effective.
In addition to data collection Medical colleges can contribute to the IDSP as
 Reference laboratories
 Quality Assurance / Evaluation
 Training
 Epidemic Investigation / response in collaboration with DSO or SSO
(State Surveillance Officer)
 NCD Surveillance
Reference Laboratory: Many state medical colleges are functioning as reference laboratories for
specific microorganisms. They will continue to do the same under the IDSP. Members of the
IDSP sub-committee can serve as members of the rapid response team at the district and state
level if required. The evaluation and quality assurance team can include members of the medical
college staff. Since, the staff in medical colleges in the state is often not administratively under
Director of Public Health this allows for independent evaluation. IDSP plans to integrate the
surveillance of communicable and non-communicable diseases in one program. The NCD risk
factor surveillances are planned as regular surveys once in three to five years in different parts of
the state in a cyclical manner. The members of the medical college sub-committee, particularly
42
cardiology and medicine will assist the director of Public Health in planning and executing the
NCD risk factor surveillance.
The participation of medical colleges will not only help IDSP activities as outlined above but,
also help the institutions in the teaching and training of undergraduates and postgraduate students
and in operational research in surveillance related issues. This would give students an
opportunity to have hands on experience in surveillance while under training for the first time in
the country, as they are the future health care providers and managers of the various programs.
This would mean sustainability on a long-term basis for the IDSP.
Medical college faculty members are particularly good at training issues since they are primarily
teachers. IDSP plans to incorporate these faculty members in improving the training of IDSP
personnel.
Each Medical College will be encouraged to adopt an administrative block from the field
practice area used for the training of medical undergraduate and postgraduate students. The
surveillance data collected from this block will be provided to the district surveillance unit. Since
most of the medical colleges are situated in the urban and semi-urban regions where surveillance
is weak, this will provide additional inputs from the urban regions of India.
16.1 Responsibility of Integrating Medical Colleges:
The state surveillance unit will take responsibility of training and facilitating the integration of
medical colleges into the system. The director of Medical Education in the state will select one
of the medical college team members as the overall coordinator for all the medical colleges’
activities in the state. The health secretary will facilitate the activity of developing the state IDSP
unit in each medical college in the state. Medical colleges willing to take on the surveillance
function as urban district surveillance unit (urban - DSU) will be provided data entry and other
resources allocated to the district surveillance unit to facilitate this activity. The State
Surveillance Unit will enter into a written memorandum of understanding with the medical
college administration regarding performance of IDSP functions. At the central level interaction
with the IMC by the MOHFW will emphasize the need for this integration.
17 DEVELOPMENT OF OPERATIONS MANUALS
An operations manual has been developed for the IDSP. This is intended as a handbook for the
people who are going to implement the program, especially at the district level. In addition parts
of this manual with data entry, and reporting along with formats for reporting will be assembled
as a simple field manual at the periphery. Thus it is envisaged that there will be two manuals, one
for the District Surveillance Officer, which will contain all aspects of the IDSP including
technical details, and another for the field level, which will lay more emphasis on data collection
and transmission. The district operational manual will be disease specific and will deal with the
core diseases identified by the IDSP and in each state disease specific conditions will be
attached. This will be modular in structure and changes can be easily incorporated in this module
43
as disease conditions and surveillance techniques change with time.
The Technical Operations manual will inform the managers of:
 The detailed role of the staff in IDSP - who will do what.
 The details of what has to be done.
 An overview of how things have to be done.
Additional Reference manuals will be made providing details about various surveillance
activities including 1). Reporting units, 2). Reporting, 3). Analysis, 4). Surveillance Action, 5).
Feed back, 6). Monitoring and Evaluation
These reference manuals will be available at the district surveillance office (DSO).
This manual is intended for all those involved in the IDSP, especially for those at the District
level. The contents of the Operation manual are:








Introduction
Case Definitions
Role of the Functionaries - highlighting the roles of each of the staff / stakeholder
involved in the IDSP.
Recording and Reporting – deals with the details of how data has to be recorded in
prescribed formats and reported to the other levels.
Analysis - informs those involved in analysis on how to do it.
Investigation and Response - gives generic details of how to respond in the event of
an outbreak.
Specimen collection and transportation – helps the MO to decide how best to confirm
the clinical / epidemiological diagnosis.
Feed back.
The entire operations manual will be in modular fashion, so that later developments and state
specific data can be incorporated into it. It will also need to inter - phase with the laboratory
manuals and the IT manuals.
The following Reference manuals will be prepared and made available to enhance the skills
required at different levels.
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
Manual of case definitions
Manual for data collection
Manual of data entry and compilation
Manual for report generation, analysis and interpretation
Manual for containment measures
Manual of outbreak investigations
Manual of guidelines for epidemic preparedness and response
Manual of standard treatment guidelines
Manual for lab technicians
Manual of computers and software
Administrative manual
44
xii.
18
Relevant excerpts of public health act on surveillance
ANALYSIS
Analysis is necessary at all levels for the optimum utilization of information. However, at the
periphery only frequency tables are necessary and this will be automated by the use of
computers. More detailed analysis is necessary at the district, state and central levels so that
summary feed back reports and interpretations of results of surveillance data is possible without
delay. The analyzed reports need to be sent to the district / state administration and other stake
holders and will guide the surveillance actions.





Initiate response at appropriate level
Monitor disease control programs
Identify emerging epidemics
Assist in allocation of resources
Mobilization of public support for health programs
18.1 Types of analysis
Data analysis has to be made on the basis of:



Time
Place
Person
These reports need to be tabulated and percentages need to be calculated by age groups affected
and gender. If mortality is an issue, these need to be calculated from available data. Modelling
can be done based on information on both sentinel and regular data collection to calculate
disease burden in the community.
Analysis will also look into 1) Timeliness of reporting units 2) Completeness of reporting
3) Trend changes between reporting units (between private and public reporting units located in
rural and urban areas respectively).
Most of the primary analysis will be automatic background activity of the computer program at
the district and state levels. The program will produce results on trends of disease, of time and
space, and produce reports regularly, and on detecting deviations from the normal. Specific
additional analysis required for each disease will be performed by the district and state
surveillance officer.
The details of the type of analysis for individual diseases will be dealt under the IDSP manual in
greater detail.
18.2 GIS Software
Geographical Information System software (eg: Health Mapper) will be utilized to generate spot
maps and understand disease frequency and the relationship with geographic variables and other
45
variables relating to environment and population. The tool will also help to disseminate
information more optimally as a social mobilization tool and to obtain political support for the
program. Use of GIS facilitates faster and valid interpretations of changing trends of disease in
time and space.
The GIS system will function only if valid data is collected and analyzed at the district level. The
program will incorporate GIS into the system after the basic levels in performance in
surveillance activity have been established in the participating states. It is expected to be part of
the program in at least some states with advanced health delivery status, by the second year of
the program.
19 SURVEILLANCE ACTIONS
19.1 Feedback and sharing information
Sharing of information with all stake holders for effective public health action is the primary
purpose of the IDSP. Regular reports generated by the district surveillance unit will be shared
with all the stakeholders of the program at the district level and all reports generated by the state
surveillance unit will be shared by the stakeholders at the state level. The reports will be
available through internet / intranet services which can be obtained by dial up services to the
district surveillance unit and through the IDSP network at the district level. The stakeholders
include:
19.1.1 Periphery



Medical officer of PHCs
Sentinel Private Practitioners participating in IDSP
Participating laboratories
19.1.2 District







All members of the district surveillance unit
State Surveillance unit
District Public Health Laboratory
Sentinel Private Hospitals participating in IDSP
Program officers of disease control programs
Medical Colleges
Other members as decided by the district surveillance unit officer
19.1.3 State


All members of the state surveillance unit
National IDSP Officer at Delhi
46




State level Disease control program offices
State laboratories
Medical Colleges in the state
Others as decided by the state surveillance unit
In addition a monthly surveillance bulletin will be published by the state officer and dispatched
to other stakeholders in the state similar to CD Alert by NICD. The state surveillance unit may
contract private agencies to do this work.
19.1.4 Center



Dte.GHS; Ministry of Health and Family Welfare
ICMR, NICD, NIB, CBHI
Other partner agencies as identified by MOHFW
In addition a monthly summary bulletin will be issued to all other stake holders of the program.
19.2 Response to the Surveillance Information
By establishing surveillance units at the district, state and national levels the project provides, for
the first time, resources and a structure with in which a more adequate response to the
surveillance information collected can take place.
The IDSP manuals set out case definitions and trigger levels (e.g. number of suspected cases in a
specified time and location) for each of the diseases/health conditions under surveillance. The
responses to be made when each of these trigger levels is crossed for one of the communicable
diseases under surveillance are also specified in the manuals together with the reporting and
follow-up actions to be taken - a general summary of these actions is shown in the table below.
Details for each of the diseases are given in the District Operations Manuals for the project.
The software to be developed in this project will alert district level staff when the triggers have
been crossed and will also send information to the state if appropriate action by the districts is
not notified within a specific time.
For non-communicable diseases the situation is different - the frequency of collecting
information is lower, the response time is longer and the interventions of a different nature. The
surveillance information is collected through periodic surveys, on a three-year cycle and the
information will then be used to plan interventions to be carried out by the state and districts.
47
Level
Routine Activities
Trigger for Action
Action
1. Local Health
Worker
• monitoring of illnesses
(continuous) • syndromic
reporting to CHC
(weekly) • refer patients
to PHC / CHC
• suspected case count
above disease specific
action threshold specified
for the condition • unusual
syndrome causing death or
hospitalization
• inform MO PHC/CHC •
active search for similar
cases • collection and
transport of biological
samples to lab • IEC for
public • integration with
non health personnel in
the community
2. CHCMO/
PHCMO
• verification of local
health worker case reports
(weekly) • verification of
laboratory reports
(weekly) • feedback to
local health workers
(weekly)
• suspected / confirmed
case count above diseasespecific action threshold
• notification from DSU of
apparent outbreak
3. District
Surveillance
Unit/Committees
• data entry of sentinel
• confirmed case count
data from institutions not indicating local outbreak
linked directly (weekly)
• analysis including
calculation of case counts
and descriptive
epidemiology (weekly)
• monitoring and
evaluation including
assess accuracy and
completeness of submitted
reports (weekly)
• collection and trend
• verification of reports of
outbreaks from health
worker (within 24 hours).
• verification of reports of
outbreaks in the rumor
registry (within 48 hours)
• disease-specific control
activities (immediately)
• collection and transport
of biological samples to
lab
• reporting of suspected
and confirmed cases to
DSU (within 24 hours)
• IEC and integration with
village health committee
• outbreak investigation
under DSU direction
• initiate outbreak
investigation through
Rapid Response Teams
(RRT)
• provide coordination to
outbreak response
activities involving CHCs
• initiate disease control
measures and treatment
• notify SSU
• facilitate private /public
partnership in outbreak
response
48
analysis of water quality,
air quality, and road
accident data
• reporting to SSU
(weekly)
• integration and
facilitation information
flow to district program
managers.
• feedback to reporting
units (weekly)
• outreach to community
organizations
4. State Surveillance • compilation of DSU
• confirmed case count
Unit/Committees
reports (monthly)
indicating multifocal
• assess reporting
outbreak or pandemic
performance of DSUs
(monthly)
• reporting to CSU
(monthly)
• feedback to DSUs
(monthly)
• implementation of risk
factor surveys (every 3
years)
• plan and implement risk
factor control campaigns
based on survey
information
• coordination of training
activities
• implementation of
external quality assurance
program for labs
• coordinate activities
with other relevant state
agencies
• advise DSUs on disease
control measures
• monitor situation and
response (continuously)
• notify CSU
• deployment of state rapid
response team if necessary
49
5. Central
Surveillance
Unit/Committees
• development of national
guidelines for case
definitions and disease
control
• oversight and direction
ofIDSP
• compilation and analysis
of SSU reports (quarterly)
• coordination of regional
and central labs
 reporting to international
public health agencies
(for selected conditions)
• feedback to SSUs
(quarterly)
• reporting to World
Bank
• coordinate external
quality assurance
activities
• uncontrolled multifocal
outbreak or pandemic •
international health threat
potentially affecting India
• advise SSUs on disease
control measures
• monitor situation and
response (continuously)
• notify international
public health agencies
• seek and coordinate
international assistance if
necessary
Annual Surveillance Reports
Publication of annual surveillance reports by district, State and Centre Surveillance Units would
be disseminated to all Stakeholders including leading private providers. Besides specific
information on occurrence of core and state specific diseases, these reports would also include
physical progress, case studies and other relevant information. These reports would also provide
feedback to various participating units. This activity would be one of the key project deliverables
and will be closely monitored.
Integration of Surveillance under various disease control programme
One of the important objectives of IDSP is to integrate surveillance activities carried out under
various vertical disease control programmes. To facilitate integration, the project envisages
various activities like data generation using uniform and common reporting formats, integrated
training of health workers, common mode of transmission, collection compilation and analysis of
data and using common IT network for transmission to State and Centre levels. Surveillance
under National Disease Control Programmes relating to Malaria, Tuberculosis, HIV/AIDS,
Diseases under RCH (Measles, Polio, Acute Diarrhoeal Diseases) and state specific diseases
would be integrated.
19.3 Levels of response
The program will specify response levels for each of the target diseases under surveillance.
Different trigger levels will be described for the surveillance conditions, so that specific
surveillance related action can be predetermined based on the levels set for the condition. The
50
trigger levels will be modified, based on incidence of the disease in the region, by the local
health authority according to the needs of the program.
Trigger –1
Trigger –2
Trigger –3
Trigger - 4
Trigger - 5
Local response by health worker and MO.
District level response by DSO & RRT.
State Level Response to an established outbreak
State Level Response to established epidemic
Disaster response.
Details of the response in relation to specific diseases will be described in the IDSP manual.
19.4 Response to surveillance challenges
Trigger-1 Response (HWs)
Trigger-2 Outbreak investigation and response (CHC MO/ PHC MO)
Trigger-3 Outbreak investigations and response (District Surveillance Unit)
Trigger-4 Epidemic investigation and epidemic response (State Surveillance Unit)
Trigger-5 Disaster response (Center, State, District, Local)
Trigger levels will depend on the type of disease, number of evolving cases. These will be
region specific depending on incidence of disease and previous reporting trends.
E.g.: Single case of Flacid paralysis or plague - Initiate response at state / national level.
For diarrhoeal disease the number of cases will trigger a variable response.
19.5 Response at local level
The disease pattern may follow an expected time and seasonal pattern. The HW will be trained to
take local action to control predicted outbreaks under the direction of local PHC MO.
19.6 Outbreak investigations and response
Currently many states have formed epidemic investigation and response teams to tackle disease
outbreaks in the country under the pilot project of NSPCD at the state and district level. These
teams are currently not effective because there is delay in information processing and absence of
real time analysis of data. Most of the times the information comes from lay persons and the
health authorities require verification of this information causing additional delays and hence
timely and effective interventions are difficult to initiate in the current system.
Timely response therefore needs local appraisal of the developing outbreak and intervention to
be initiated without delay. In IDSP a regular analysis and trends report will be generated and
specified trigger levels for specific conditions will be identified as per the operational manual. It
will be the responsibility of the district surveillance unit under the leadership of the district
surveillance officer, to initiate the first action and to notify the state surveillance officer.
51
19.6.1 Definition of outbreak
An outbreak or epidemic is defined as the occurrence in a community of cases of an illness
clearly in excess of expected numbers. While an outbreak is usually limited to a small focal
area, an epidemic covers large geographic areas and has more than one focal point.
19.6.2 Threshold levels
The first step in investigating an outbreak is to detect it. One of the common ways of early
detection is to review the data from routine surveillance and check if it crosses threshold levels.
Details of this are provided in Section 2. The second technique is more generic, it is the detection
of unusual events.
The number of cases, needed to be termed an outbreak varies according to several factors. It
depends on past trends of the disease, case fatality rates (CFR) and potential to spread to other
places. For some diseases a single case is an epidemic e.g. Polio. States and districts should
establish criteria based on their local situations. For example, five cases of similar illness of
acute onset within an incubation period of that disease or death in a village could be considered
as an outbreak. These threshold levels will be based on previous experiences with that disease
confirmed by data of the previous years. This data maybe available as monthly reports of cases
and would need to be modified to a weekly frequency.
19.6.3 Sources of information
The nodal person for surveillance will scrutinize all the data received in the health facility from:



Routine Surveillance: Peruse the reports, laboratory results and see if the incidence of
disease has crossed the threshold levels.
Rumor register: All health facilities should maintain a rumor register and enter
information in the register whenever a suspected outbreak is reported by a layperson.
Media: Daily scanning of newspapers and other media reports of suspected outbreaks
must be carried out. Every report must be verified.
The nodal person will take immediate action if the threshold level has been crossed and report
the outbreak to the next level after verification of the outbreak. If the number of cases are very
high (exact figures could be fixed for each disease by the states), he will immediately inform the
district and state headquarters depending on the extent of the outbreak. For example, in
Maharashtra, if there are more than 25 cholera cases, then the PHC MO will inform the district,
similarly if there are more than 100 cases, then the MO will inform the state.
19.6.4 Verification of the outbreak
The preliminary step of the outbreak investigation will be to confirm the outbreak. Much time
may be wasted due to a false alarm. Even if the outbreak is suspected from the routine
52
surveillance data, it must be verified (lest it be a data entry error). The reported cases should
initially be verified by the PHC MO. If there is evidence of an outbreak, then necessary action
needs to be taken.
19.6.5 Investigating an outbreak
Efforts will be made to investigate each and every outbreak. Investigations would reveal why the
outbreak occurred, identify high-risk groups and areas, and evaluate control measures. Such
investigations, other than controlling the outbreaks, help in identifying system failures and by
taking necessary corrective action, further strengthen the health services.
19.6.6 The District Outbreak Investigation Team (DO IT)
The DEIT is a multifaceted team that looks into the various aspects of an outbreak. There will be
a DEIT team at each district. A similar team may be available at the regional and state level to
support the DEIT if and when and if necessary. Composition of this team is:
i.
Nodal officer (*) in charge of disease control in the district (Epidemiologist) – the
team leader, usually with public health training and experience.
ii.
The Clinician – either a physician or a pediatrician who is able to make a clinical
diagnosis from the cases. (Member of nearest medical college surveillance team)
iii.
The Microbiologist – (From District PH Laboratory) to collect the specimens and
to transport them appropriately. Many districts may not have a microbiologist so a
laboratory technician may be substituted. Where necessary, the state team should
also include an entomologist in the team.
iv.
District administrative nominee (not below the rank of Tahsildar).
v.
Any other person in the list of surveillance consultants with DSO.
vi.
The Health Assistant – his role is to assist the team in the community, do surveys,
make community contacts and mobilize the community when necessary. He
would also be responsible for organizing the logistics.
*The nodal officer will be selected from the program officers of disease control programs other
than the district surveillance officer. The DSO should not be the investigating officer to avoid
conflict of interest. The nodal officer will coordinate the selection of team leader for the DEIT
based on the type of disease outbreaks. For suspected Polio and Malaria, the disease control
officers for the program will head the DEIT. For unknown epidemics and for other diseases
DEIT will be selected from the available program officers. All program officers at the district
level should obtain training on a rapid response team and epidemic preparedness.
The DEIT will be allotted resources specifically for response related activities so as to be
effective. They will need:

A dedicated and functioning vehicle so that they are able to visit the site at short notice.
(This will be made available from existing vehicles at the district level by the DSO
authorized by the District Collector)
53



Drugs so that they can start the preliminary treatment.
Diagnostic reagents and kits for doing preliminary diagnosis.
Facilities to transport the samples.
As required, state and national level teams can be brought into action as per predefined levels of
the spread of the outbreak in the region and the type of disease.
19.6.7 Outbreak Response
Even as the outbreak is detected, and is being investigated, control measures need to be
instituted. These may be general measures, till the specific source and route of transmission is
identified. For example, if one is suspecting water borne disease, then one should start a
campaign requesting people to use safe drinking water. Containment measures may be divided
into general measures and specific measures. The basic principle in control and containment is
given in the following figure.
FIG. PRINCIPLES IN CONTROL AND CONTAINMENT
Non-infected person
Infectious person / agent
Immunization
Chemoprophylaxis
Infected person
Early detection and
Good case management
Diseased person
Early detection and
Good case management
Death
54
Depending on the disease, the most effective specific measures are instituted as specified in the
manual of IDSP.
At the time of initiation of investigations into an outbreak, the district surveillance office notifies
the state surveillance officer. Based on the results of the outbreak investigation and preliminary
assessment of the team, a decision to call for state level response to control the outbreak or its
spread to other districts will be made.
The levels of occurrence of diseases for each region will be predetermined in the program
manual based on changing incidence of the disease in the region. IEC activities will be initiated
through village health committee meetings and other community leaders to control the disease in
the region in all cases.
19.6.8 Daily situation updates
During the period of the outbreak the nodal MO should continue to give daily situation updates
to the next level. This should continue even when the DEIT has started its investigation and
should include the list of new cases, laboratory results received, any new findings, any
containment measures taken etc. This daily report should continue till the end of the outbreak
(i.e. no suspect case during a period which is double the incubation period). However, it is
important that these updates are kept as simple as possible – thereby sparing the MO unnecessary
work.
19.6.9 Interim report of DEIT
The DEIT will submit an interim report within one week of starting their investigation, response
and control activities. The report should cover verification of the outbreak, total number of
affected cases deaths, time, person, place analysis, management of the patients, likely suspected
source, immediate control measures implemented, etc. The report will include reports by the
physician and microbiologist, and entomologist (where applicable), the laboratory results
received during that period, environmental factors, etc. It will also have a provisional hypothesis
of the cause of the outbreak and comments / recommendations, if any, including whether any
further outside help is necessary.
19.6.10 Final Report of DEIT
One week after the outbreak has ceased, (double the incubation period of the diseased without a
single case) a final outbreak investigation report must be submitted by the EIT. If the epidemic is
prolonged, a summary of the action taken and results obtained will be documented and submitted
to the District Collector within one month of the initiation of action through the district
surveillance officer.
This report must be comprehensive and give a complete picture of the multi-factorial causes of
the outbreak, the precipitating factors, the evolution of the epidemic, description of the persons
affected, time trends, areas affected and direction of spread of the epidemic. It should have
55
complete details of laboratory results including regional laboratory report (cross verification and
strain identification), confirmation of the provisional diagnosis and other relevant information.
Documentation of the epidemic is an important step in outbreak investigation. Useful lessons can
be learnt if the documentation is complete and data properly analyzed. The information will be
useful in drawing up long-term strategies for reducing the risk of outbreaks in the future and in
more effective handling of an outbreak, should it occur.
It is also important that feedback from the report is shared with the lower levels and also other
districts. Publication in a journal will ensure wider circulation of the lessons learnt.
19.7 Epidemic investigation and response at state level
If the outbreak investigations reveal the need for state level response or information received and
processed at the state level indicates a potential or real epidemic, the state level investigation and
response should be initiated by the state surveillance unit under guidance of the state surveillance
officer.
There will be up to three state level rapid response teams and each team will consist of the
following:
i.
State Surveillance Officer / Nominee
ii.
Microbiologist from the State Public Health Laboratory
iii.
Nodal officer in charge of disease control program in the state
iv.
Consultant Epidemiologist
v.
Representative of IDSP sub-committee of medical college
Actions: At the time of initiation of the epidemic response, the Director of Public Health,
Secretary of Public Health would be kept informed of the progress of the epidemic and results of
the investigations and interventions. The State Surveillance officer will notify the Central
Surveillance office in MOHFW, so that if needed, a national level response could be initiated by
ICMR and NICD without delay. Specific public health actions will be listed and defined in the
operations manual for each level of operations for a specified disease.
The summary of the action taken and results obtained will be documented and submitted to the
Secretary Health within one month of the initiation of action.
19.8
Disaster management
Disasters may be defined as events that are outside the control of local resources to cope with.
Out break of diseases like plague in Surat or natural disasters like earthquakes and floods could
initiate a disaster management plan in IDSP. Disasters could be epidemic induced or impact on
disease control. The disaster management plan of IDSP would take into account these situations.
Current Situation: Current disaster management plans at the nation level have the following
structure. At the national level the Prime Minister presides over the cabinet committee and the
56
policies of this committee are carried out by the Crisis Management Committee chaired by the
Central Relief Commissioner and Additional Secretary - Ministry of Agriculture. They provide
financial, technical and material assistance to the state governments who are primarily
responsible for managing the disaster.
At the state level, the crisis management group works under the chairmanship of the Chief
Secretary with senior level functionaries of various departments as members. The action plan for
disaster management is district based and formed by the district administration in consultation
with the crisis management group.
As part of integrated disease surveillance, the epidemic response teams at district and state levels
will coordinate in the event of disaster:
i.
ii.
iii.
iv.
v.
Improving preparedness for Response - computer networking, information sharing,
GIS.
Allocation of emergency stocks of medicines and equipments.
Disaster prediction and warning – Early warning of epidemics.
Improving hygiene and sanitation.
Social mobilization and public awareness of potential disasters in the country.
The operations manual for IDSP will deal with specifics in disaster management and how IDSP
will inter-phase with the crisis management group at the state and central levels.
TABLE GENERAL GUIDELINES ON TRIGGER LEVELS
Health Condition
Acute Diarrhoeal
Diseases
Cholera
Typhoid
Trigger Event
 Rising Trends
 Higher as compared to
previous years.
 Clustering of cases in time
and space.
 In endemic area, rising trends
or higher as compared to
previous years.
 In non endemic areas, even a
single case.



Malaria



Rising trends.
Higher as compared to
previous years.
Clustering of cases in time
and space.
Rising Trends.
Higher as compared to
previous years.
Clustering of cases in time
Response
Investigate and contain if
small and focal. If widespread
or of higher magnitude, then
involve the district
surveillance unit.
In endemic areas investigate
and contain.
In non-endemic areas,
investigate and contain.
Involve district/ state
authorities.
Investigate and contain if
small and focal. If wide spread
or of higher magnitude, then
involve district and state
surveillance teams.
Involve the district and state
authorities depending on the
magnitude of the problem.
57
Polio

and space.
In tribal or remote areas,
even a single case.
In other areas clustering of
cases.
One confirmed case
Water Quality


Fecal contamination.
Above permissible levels
Air Quality

If parameters above
permitted levels
Tuberculosis
HIV


Changing Trends in Disease
Changing Trends in
Disease/Infection
Measles


State Specific
Diseases
Investigate and contain if
small and focal. If widespread
or of higher magnitude, then
involve district authorities.
Involve, District, State,
National Surveillance Units.
Inform local health authorities
on changing trends and levels
of chlorination.
Develop feed back to
community on changing trends
in geographical area.
Involve the local communities.
Involve the local communities.
Will be specified in the State PIPs.
20 ADMINISTRATIVE STRUCTURE OF IDSP
There is increasing recognition of the fact that the surveillance activities involve actions at multisectoral levels, which need to be closely coordinated. In many states the activities of surveillance
and their coordination have so far been restricted to mainly the health department, despite the
fact that the control over the causes that give rise to epidemic prone diseases are in the hands of
other departments of the Government. For example, quality of water and its supply and sanitation
are under the departments of urban and rural development. In urban areas, issues related to water
supply, water quality and sanitation are dealt with by the municipal corporations, which have no
direct coordination with the health authorities in the state. Therefore, in the present project an
effort has been made to evolve an administrative structure, taking into account the peculiar
circumstances of each state, which further takes into account the multi-sectoral nature of the
activity.
It is proposed to set up Surveillance Committees at Central, State and District levels to perform
coordination functions between various stakeholders, review the surveillance activities at regular
intervals (monthly), identify trouble shooters and suggest mechanisms to rectify them, initiate
internal and external evaluations of the IDSP activities at different levels. These committees will
advise the Surveillance Officers (i. e. the nodal officer) at all the three levels to operationalize the
suggestions of the steering committees and also manage the program on a day-to-day basis.
20.1 Administrative structure at the national level
It is proposed to set up a central surveillance unit, which would be based at the Dte.GHS,
Ministry of Health and Family Welfare. The unit would be headed by the Program Officer of the
58
rank of Deputy Director General and assisted by an Assistant Director General along with
supporting staff such as technical officers and consultants as may be required for the program.
The staff for the central surveillance unit would be engaged either on deputation from NICD,
ICMR, as well as any other organizations under the Ministry of Health and Family Welfare or as
contract basis. The unit would also set up a control room with facilities for communication in the
nature of FAX machines and computers, as well as strong infrastructure for MIS. This would act
as headquarters during epidemics and disasters as well as a center for trend analysis of data
received from all over the country.
The central surveillance unit would take up technical charge of implementation of the IDSP.
Administratively, this unit would report to the Health Secretary and Secretary Family Welfare
through the DGHS. For administrative matters, a Joint Secretary in the Department of Health
Incharge would be assisted by DS / Director in the Public Health Division.
[
Proposed Structure at Central Level
National Disease Surveillance Committee
National Executive Committee
National Surveillance Unit
Technical Division
DDG (IDSP)
ADG (IDSP)
Consultant (Procurement)
Consultant (IT)
Consultant (HRD)
Administrative Division
JS (IDSP)
Director/DS (IDSP)
US (IDSP)
Accounts Officer
Consultant (Finance)
Data Manager
Data Processing Assistants
Statistical Assistant
Data Entry Operators
Steno/Office Assistants
Class IV
1
2
1
2
2
2
Proposed Structure at State Level
State Disease Surveillance Committee
State Executive Committee
State Surveillance Unit
Joint Director (SSO)
Consultant- Technical & Training
Consultant -Finance & Procurement
Data Manager
1
Data Entry Operators
2
Office Assistant
1
Class IV
1
59
Proposed Structure at District Level
District Disease Surveillance Committee
District Executive Committee
District Surveillance Unit
Deputy Chief Medical Officer as DSO
Data Entry Operator
2
Account
1
Administrative Assistant
1
ORGANOGRAM NATIONAL SURVEILLANCE COMMITTEE
Director General
ICMR
Director General
Health Services
JS
(Health)
(Co. Chair)
JS
(Family Welfare)
National Program Managers
Polio, Malaria, TB, HIV - AIDS
Chairperson*
National Surveillance Committee
IMA
Representative
JS
(FA)
NGO
Director
NICD
Consultants
(IndiaCLEN / WHO
/ Medical College / others)
Representative
Ministry of Environment
Director
NIB
Representative
Ministry of Home
National Surveillance Officer
(Member Secretary)
* Secretary Health or Secretary Family Welfare (to alternate)
20.2 The functions of the central surveillance unit



Acting as the nodal point or control room at the central level for coordinating responses
to requests received from states during epidemics and disasters.
Analysis of data received from the states and provide feedback on trends observed.
Form and supervise the movement of the rapid response team at the central level to
supplement the efforts of states during disasters or epidemics of very large magnitude.
60







These rapid response teams would be headed by an epidemiologist and would be staffed
by one microbiologist, one clinician and one laboratory expert. Entomologist,
anthropologist and related persons would also be kept in panel and called in when
required. These experts would be drawn not only from central agencies like NICD and
ICMR but also from other agencies like medical colleges and specialized institutes like
NIV, NTI and MRC. There would be at least five such teams and this surveillance unit
would form a panel of experts so that teams could be sent out to two or three places at the
same time.
Coordinate the activities of central agencies such as NICD, ICMR and referral
laboratories under the program.
Monitor the progress of implementation of all the different components under the
program.
Ensure implementation of quality guidelines and standard operating procedures evolved
under the program.
Obtain reports from states on the various activities under the programme including
expenditure and send reports and reimbursement claims as required by the World Bank
through the financial controller.
Report regularly to the central surveillance committee set up under the chairmanship of
the Health Secretary at the central level which is referred to later.
At the central level, a committee overseeing all matters relating to surveillance in the
country would be set up under the chairmanship of the Health Secretary, with the other
members being DGHS, DG(ICMR), Dir(NICD), Dir(NIB), JS(PH), representatives from
the Ministries of Agriculture and Rural and Urban Development and Department of
drinking water, as well as representatives from NGOs like Voluntary Health Association
of India as well as the Program Officer.
The committee shall meet at least once a month to consider the monthly report on
surveillance activities that would be prepared by the Program Officer and shall meet as
and when required during disasters and epidemics.
20.3 Administrative structure at state level
It is proposed to setup a state surveillance unit at the state headquarters, which would work under
the chairmanship of State Health Secretary. Director of Public Health or her / his equivalent
would be designated as the co-chair person. This unit would be responsible for:




The collation and analysis of all data being received from the districts and transmitting
the same to the central surveillance unit.
Coordinating the activities of the rapid response teams and dispatching them to the field
whenever the need arises.
Monitoring and reviewing the activities of the district surveillance units including checks
on validity of data, responsiveness of the system and functioning of the laboratories.
Coordinating the activities of the state public health laboratories and the medical college
laboratories.
61



Sending regular feedback to the district units on the trend analysis of data received from
them.
Coordinating all training activities under the project.
Coordinating meetings of the state surveillance committee, which is referred to in later
paragraphs.
20.3.1 State Surveillance Committee
A state surveillance committee is to be set up in each state under the chairmanship of the Health
Secretary to oversee all the surveillance activities in the state and will be administratively
responsible for program activities in the state. States would be free to make any variations as
long as the general structures and principles behind the structure are preserved. The
chairmanship by the Health Secretary is vital considering that the coordinating role of this
committee with other departments during large-scale epidemics is going to be very vital and it
was felt that the Health Secretary would be in a better position to do so.
A TYPICAL ORGANOGRAM AT THE STATE LEVEL
Director Health Service
Director Public Health
(Co. Chair)
Director Medical Education
State Program Managers
Polio, Malaria, TB, HIV - AIDS
Representative
Water Board
State Data Manager IDSP
Head, State Public
Health Lab
NGO
Chairperson*
State Surveillance Committee
Medical Colleges
State Coordinator
State Training Officer
Representative
Department of Home
Representative
Department of Environment
State Surveillance Officer
IMA
Representative
(Member Secretary)
* State Health Secretary
62
The members of the committee will include:
1. Health Secretary (Chair person)
2. Director of Public Health (Co-Chair)
3. Directors Health Services, Medical Educations (HODs)
4. Program managers of TB, Malaria, Polio, HIV
5. Representatives from Department of Environment and Home
6. Head of the State Public Health Laboratory
7. Representative of the state unit of the Indian Medical Association
8. Coordinating member from state Medical colleges surveillance team
9. One representative from the NGOs working for public health
10. State Surveillance Officer. (Member Secretary)
The state surveillance committee would meet at least once a month when there is no epidemic
situation and meet at more frequent intervals during times of epidemic or large outbreaks.
20.4 Administrative structure at district level
20.4.1 District Surveillance Committee
The district surveillance committee will be responsible for the regular running of the program.
The district surveillance unit will be chaired by the District collector / District -Magistrate. The
members of the DSU will include:
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
District Collector (Chair person)
Chief Medical Officer District (Co-Chair)
Program officers of PH, TB, Malaria, HIV, Polio
Representative of Medical College
Representative of SSPs in the district
Police Superintendent
Representative from the Water Board
NGO representative
Chairman District Panchayat Board
Head of the District Public Health Laboratory
The District Surveillance Officer (DDPH) (Member Secretary)
The Committee will meet once a month regularly and as often as needed during an epidemic. A
routine report of this meeting should be forwarded to the State Surveillance office once a month
to understand the progress and problems in various districts. Reports of these meeting will be
forwarded to the National Surveillance cell once in three months.
63
District Program Manager
Polio, Malaria, TB, HIV - AIDS
CMO
(Co. Chair)
Representative
Water Board
Chief District PH
Laboratory
District Data Manager
(IDSP)
Representative
Pollution Board
Superintendent
Of Police
Chairperson*
District Surveillance Committee
IMA /PvtSector
Representative
NGO
Representative
District Training Officer
(IDSP)
District Panchayat
Chairperson
Medical College
Representative
if any
District Surveillance Officer
(Member Secretary)
* District Collector or District Magistrate
20.5 Mechanisms for vertical coordination between various levels
Vertical coordination will be as critical as the horizontal coordination mechanisms outlined
above. While IDSP will be a decentralized district based program, the following issues
necessitate vertical coordination as well









Existing vertical disease control / elimination / eradication programs.
Integration and coordination of regional and national reference laboratories.
Management of national IDSP-IT network.
Special training requirements by central, regional and state institutions and organizations.
Response to surveillance data.
External quality control.
Monitoring and evaluation.
International commitments on disease control.
Planning and resource allocation.
The CSU will hold discussions with the Program Management Units of the Major Disease
Control Programs to work out modalities and time-frame for integrating Surveillance activities
carried out in these programs with IDSP. GOI and the Bank will identify indicators to measure
progress on this integration.
Regular interaction between the functionaries from different levels must take place. It is
proposed that at the state level, a meeting is convened by the State Surveillance Unit once every
quarter for all district surveillance officers of IDSP to discuss the issues outlined above.
64
Similarly, the National Surveillance Unit will convene quarterly meetings of State Surveillance
officers. During these meetings the problems faced in making progress by various states will be
discussed based on quarterly meetings from State Surveillance cell and information generated
from the IDSP database. Consultants and other stakeholders in the program will provide their
feedback during these meetings.
20.5 List of partners and key stakeholders
National Technical Institutions
NICD,ICMR,NI,NABL,CBHI
Other Agencies in the country
Air/water Pollution Control Boards
Police Administration
Medical Colleges
Indian Medical Association
Other NGOs doing surveillance
Multilaterla/Bilateral Agencies
WHO
USAID
World Bank
DFID
Technical Agencies
IndiaCLEN
CDC
20.6 National Institute of Communicable Diseases (NICD)
This institute is under the administrative control of the Director General of Health Services,
Ministry of Health and Family Welfare, Government of India. It is involved in undertaking
surveillance for major communicable diseases, and maintaining watch over newer health
problems and recommending appropriate measures to the Government to tackle these problems.
The institute has eight field stations. The NICD is expected to provide extensive support to the
integrated disease surveillance program especially at the central level. Its functions are expected
to include:




Contribution of staff to the central surveillance unit and also providing technical backup
on issues related to disease surveillance.
Functioning as the premium referral laboratory, especially in investigations of unknown
and newly emerging diseases.
Providing guidelines and training of rapid response teams at central and state levels and
equipping them to investigate outbreaks of newly emerging diseases.
Participation in evaluation of the implementation of surveillance programs in various
states.
65


Organization of training courses for various personnel as per the training needs.
Preparations of protocols for investigation of various outbreaks and also manuals and
guidelines for investigation of outbreaks and epidemics.
The National Institute of Communicable Diseases (NICD) shall monitor the epidemic prone
diseases and provide necessary technical support to the central, state and district authorities. On
request NICD will also assist the states in investigation of outbreaks of unknown etiology,
outbreaks with high case fatality rates, outbreaks with the potential of spread to other states and
other such events for which assistance maybe requested by the state authorities.
20.7 Indian Council of Medical Research (ICMR)
The Indian Council of Medical Research is an autonomous organization funded by the Union
Ministry of Health and Family Welfare, administered through its head quarters in New Delhi. It
has a network of 26 institutes located in various states in the country. The majority of them focus
on a single disease of which six address regional health issues. The outreach is further
strengthened by a large number of field stations in different geo-ecological sites in the country.
ICMR is the premier agency for medical research in the country. The roles envisaged for ICMR
are:

Providing staff for the central surveillance unit as well as rapid response teams as per
requirements.

Integration of laboratories within the ICMR system with the IDSP, especially as referral
laboratories for specific diseases.

Undertaking research on newly emerging diseases and identifying new areas for
surveillance.

Providing any other research backup that may be required by the program.

Providing training to the NIE for field epidemiologists.

NCD Risk Factor Surveillance.

Assist in monitoring and evaluation of IDSP.

Quality control in the state laboratories for performing laboratory functions.

Development and evaluation of new tools for surveillance.
20.8 Central Bureau of HeaIth Intelligence
Central Bureau of Health Intelligence will maintain the National Data Base and assist in
developing regular reports for the government.
20.9 National Institute of Biologicals
National Institute of Biologicals will be responsible for accreditation of private laboratories in
IDSP and in facilitating quality assurance of the participating laboratories, particularly in private
and sentinel laboratories in the country.
66
20.10 Other agencies in the country doing surveillance
20.10.1 Pollution control boards
The pollution control boards at different states and regional levels are responsible for monitoring
outdoor air pollution in mega cities in the country. They already have data which is collected on
a daily basis from the cities and published in a booklet. The IDSP will obtain this data on a
weekly basis through the state surveillance unit and make it available to the health policy makers
in the country. A memorandum of understanding will be made by the state pollution control
boards and the state surveillance unit for this purpose.
20.10.2 Water boards
The quality of water supplied in the urban regions of the country is controlled by the Water
Board in the states. This information is very crucial, since water borne epidemics are included in
the diseases under surveillance. A memorandum of understanding will be developed between the
water board at the state level and the state surveillance unit to provide regular information on
urban water quality at weekly intervals. This information will be collected at the district level by
the district surveillance units.
20.10.3 Police administration at the states
In many states Road Traffic Accidents (RTA) are being monitored by the police administration
in each district. In Tamil Nadu and Maharashtra RTC information is available from police
computers. Presently this is under surveillance in the North Arcot District Information system
(NADI). A memorandum of understanding will be made between the police administration and
state surveillance unit so that this information is collected at the district level each month and
entered into the district computers. An efficient link up will be established so that information
flow will be easy, and come directly from the police computers.
20.10.4Medical colleges
This has been already dealt with under Medical college Integration and Urban surveillance in
chapter 16 and 17. To facilitate this integration the state surveillance units will enter into a
Memorandum of Understanding with the participating medical colleges. At the center
interactions with the Indian Medical Council will be developed so that the importance of students
and their awareness of disease surveillance is increased in the country. Please refer to sections on
Epidemic Investigation, NCD surveillance, Training, Monitoring and evaluation, Laboratory for
further information on the role of Medical colleges.
20.10.5 Private practitioners
The informal health services provided by private practitioners both qualified and unqualified,
contribute to total health care of the country. In many states, the unqualified health practitioners
provide the bulk of the health services. The Sentinel private practitioners will include members
from both the qualified and unqualified. The method of selection and phased induction of SPPs
has been dealt with in another section. Support of Indian Medical Association and other
professional bodies will be obtained to facilitate this integration.
67
20.10.6 Other NGOs doing surveillance
Currently there are a number of NGOs who are doing community disease surveillance in the
country. NADI in Tamil Nadu, UNICEF in Rajasthan and BAIF in Maharashtra are examples of
this activity. These NGOs will be integrated in the activities of the IDSP. Memorandum of
understanding will be made by the State Surveillance Unit with the NGOs involved with disease
surveillance in the country.
20.11 International partners
IDSP program has been strengthened through the efforts of the bilateral agencies like WB,
USAID, DIFID who participated in developing the conceptual framework and funded the
different stages of the program and in writing the PIP.
USAID has on-going agreements with a number of technical partners and resources have been
allocated for surveillance related activities. USAID will continue to contribute to the GOI
surveillance initiatives by facilitating technical support from WHO, CDC and IndiaCLEN. The
bilateral agencies will support monitoring and evaluation of the program in the future and
provide valuable inputs for improving the program further.
WHO has vast experience in the field of surveillance. They have helped to establish surveillance
activities in Africa, Latin America and other developing countries. They will share their
expertise in the Integrated Disease Surveillance Program in India. Currently they are involved
with training assessment and development of the field manual for the program. WHO will
provide financing and technical support including consultants in various disciplines. WHO
representative (WR) office will act as the focal point for all WHO inputs and will work with the
GOI.
The World Bank has been in the forefront in assisting the government in developing the
Integrated Disease Surveillance Program in the country. The financial assistance from the
International Development Assistance (IDA) will facilitate the establishment of this unique
program in the country.
20.12 Technical partners
In addition to Technical Partners from National Institutes like NICD, ICMR, NIB, NABL, it is
envisaged that the following agencies / networks will have an important role to play in
strengthening the IDSP.
20.12.1 Centers for Disease Control – USA (CDC)
United States has one of most effective disease control programs in the world. This is
coordinated by CDC in USA. The CDC team of consultants will share their expertise in the
different aspects of the program, especially in laboratory standardization and establishment of
laboratory protocols and quality control. CDC will particularly assist in laboratory development,
68
bio-safety issues and training. They are also expected to play a role in training of laboratory
personnel and monitoring and evaluation of the program.
20.12.2 IndiaCLEN Network
The Indian Clinical Epidemiology Network is of medical colleges in India who have been active
in public health and disease surveillance. Initially the INDIACLEN started as a small group of
six medical colleges in India, but through its research activities it has now enlarged its activities
to include more than 40 medical colleges in the country. The members are trained in clinical
epidemiology, biostatistics and research methodology. There are also trained people in health
economics and social sciences in the network. USAID in India has supported establishment of a
good infrastructure in some of the medical colleges where the Clinical Epidemiology units were
established. The network has been involved with antimicrobial surveillance, program evaluation,
study of violence against women and children in the Indian setting. The network helped
MOHFW in developing the PIP for the IDSP.
IndiaCLEN network will assist the IDSP in the following areas:




Provide consultancy services to IDSP.
Assist the GOI in finalizing the state and national PIP.
Assist in Human Resource Development particularly in data management, analysis and
laboratory diagnosis
Participate in monitoring and evaluation of the program
69
PART – IV
SPECIFIC INPUTS TO IMPROVE DISEASE
SURVEILLANCE
70
21 LABORATORY NETWORK FOR IDSP
Laboratory support is essential to proper functioning of disease surveillance and hence
comprehensive support will be provided for surveillance related laboratory work. This includes

Incremental Infrastructure support

Equipments to perform the specific tasks where necessary

Additional reagents as required

Communication and networking

Training and human resource development to carry out high quality work
Communication and Training needs for the program are taken up in separate sections. This
section will primarily deal with Infrastructure, Equipments and Reagents.
Currently, the laboratory support in many areas appears weak and the available system is not
integrated well with the district and state surveillance program. There is a need to define the
specific roles of the various laboratories at PHCs, district and state levels and strengthen these
systems. Areas that need special attention include technology and infrastructure for performing
essential diagnostic tests at the district level, particularly microbiology cultures, bio-safety
management and quality assurance.
The laboratory network for IDS will be established at four levels of functions:





Peripheral Laboratories and Microscopic centers (L1 Labs)
District Public Health Laboratory (L2 Labs)
Disease Based State Laboratories (L3 Labs)
Regional Laboratories IDSP and Quality control Laboratories (L4)
Disease based reference Laboratories (L5)
21.1 Peripheral laboratories (L1 Laboratories)
Peripheral laboratories will function so as to assist the laboratory diagnosis of:
i.
Malaria
ii. Tuberculosis
iii. Typhoid
iv.
Chlorination level of the drinking water source in the periphery
v. Fecal contamination of water
Existing peripheral laboratories at the PHC level are capable of handling microscopic
examination of sputum and blood smears and are currently undertaking this activity under TB
and Malaria Control Programs. Typhoid can be diagnosed at the periphery using ‘Typhi Dot’
test which can be performed easily and has established validity and reliability. Kits are available
for detecting fecal contamination of water, which can be used at the periphery and these will be
made available.
71
In the urban regions the microscopic centers for TB and Malaria Program can continue to
provide inputs on these diseases, but additional selected private laboratories and established and
accredited laboratories will be brought into the network as sentinel institutions in the periphery.
Table: Peripheral laboratories can be classified as follows:
PHC Laboratory
Tuberculosis
Sputum AFB smear
Confirm 0.5%
Malaria
Blood smear for Malaria
Confirm 0.5%
Typhoid
Rapid Diagnostic test (Typhi Confirm 0.5%
Dot)
Water Quality Kit for chlorination test
Confirm 0.5%
Water Quality Rapid test Kit for fecal
Confirm 0.1%
contamination
Urban Peripheral labs
Microscopy center TB
Tuberculosis
Sputum AFB smear
Confirm 0.5%
Microscopy center
Malaria
Blood smear
Confirm 0.5%
Malaria
Accredited Private Labs Tuberculosis
Sputum AFB smear
Confirm 1%
Malaria
Blood smear for Malaria
Confirm .5%
Typhoid
Typhi Dot Test
Confirm .5%
Water Board
Water Quality Kit for Chlorination test
Confirm .5%
Rapid test for fecal
Confirm 0.1%
contamination
21.2 Private laboratories
Private laboratories will be brought under a licensing and accreditation system. Mandatory
reporting for IDSP notifiable diseases will be enforced. They will report to the District Public
Health laboratory at weekly intervals. Till accreditation is established, the private laboratories
will be included as one of the sentinel reporting units as described in section dealing with private
practitioners
21.3 Additional needs for peripheral laboratories
Peripheral laboratories need minimal structural modification of the laboratory areas in the CHC
to perform these functions well. Most of them are currently equipped with microscopes for
performing microscopy for TB and Malaria. They will also be provided rapid diagnostic tools for
diagnosing Typhoid in those presenting symptoms of prolonged fever and a rapid test kit for
fecal contamination of water. A more detailed list of needs is given in the table below.
72
1
2.
3.
4
5.
6.
7.
8.
9.
10.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
INCREMENTAL NEEDS FOR PERIPHERAL LABORATORIES
Equipments
Estimated Units
Incremental Needs
Binocular Microscope with oil Available
Nil
immersion
Lancet
Available
Nil
Ice box
Available
Nil
Stool transport carrier
Not Available
Needed
Test tube rack
Available
Nil
Table top centrifuge
Available
Nil
Refrigerator
Available
Nil
Spirit lamp
Available
Nil
Smear transporting box
Not Available
Needed
Sterile leak proof containers
Not Available
Needed
INCREMENTAL NEEDS FOR PERIPHERAL LABORATORIES
Supplies
Estimated Units
Incremental Needs
Clean slides
Available
Nil
Slide markers
Available
Nil
Gloves
Available
Nil
GBS Stain
Available
Nil
Staining rack
Available
Nil
Transport medium (Cary Blair)
Not Available
Needed
Sterile test tubes
Available
Nil
Plastic vials
Not Available
Needed
Sterile cotton wool swabs
Available
Nil
Rapid Diagnostic Kit Typhoid
Not Available
Needed
Rapid
test
kit
for
faecal Not Available
Needed
contamination
Blood culture bottles with broth
Not Available
Nil
Zeil Neelsen Acid fast stain
Available
Nil
Aluminium Foil
Not Available
Needed
Cotton
Available
Nil
Sealing material
Not Available
Needed
Extra plastic vials for transportation Not Available
Needed
of serum
21.4 District public health laboratory (L2 Laboratories)
The District Public Health Laboratory will be the backbone of the laboratory network under
IDSP. Currently, the district level laboratories are the weakest link in the program. The district
laboratories are expected to have a major role in the surveillance program and the existing
infrastructure and administrative structure will be improved to undertake the following tasks.
73
EXPECTED ROLES OF THE DISTRICT PUBLIC HEALTH LABORATORIES
Conditions
Test
Confirmation
Additional Tests
1 Tuberculosis
Sputum AFB smear Confirm 1% (both
+ves and -ves)from
Peripheral Labs
2 Malaria
Blood smear
Confirm 1% from
Periphery
3 Typhoid
Rapid Diagnostic
Confirm 1% Typhi Blood culture on
test and Blood
Dot tests Positive
1% of suspected
culture
samples
typhoid
4 Cholera
Stool Culture
ADD
Stool culture
Cholera Toxin Test
confirmation in
0.1% of suspected
cholera
5 Water Quality Chlorination tests
1% of samples
Colony count
and Colony count
from periphery
tested in 5% of
Rapid test for fecal
samples
contamination
Note: Facilities for Drug resistance tests for malaria & TB may be required at this level.
21.4.1 Administrative structure and personnel in District PH Lab
Most of the district laboratories are now situated attached to District Hospitals and primarily
perform the functions of a curative laboratory. These district laboratories will be brought under
the control of the district Public Health officer at the level of Joint Director. These laboratories
will be staffed by a qualified person who can undertake microbiological cultures. A person with
microbiology training (Diploma in Clinical Pathology -DCP) will need to be posted at this level.
Since it is unlikely that a sufficient number of MSc. microbiology level trained personnel will be
available, DCP level training is considered sufficient, since in many universities DCP curriculum
have six months of microbiology and can be provided on job training to undertake culture
activities for IDSP. This is specified in the training section.
Public Health departments will need to reallocate staff with microbiology training to district
laboratories. If adequate numbers are not available, the state surveillance unit should contract
qualified people temporarily for the job.
At the district level integration of equipment and trained staff will be improved by bringing the
DTC laboratory staff and Malaria laboratory staff within the district public health laboratory.
Integration of DTC and Malaria program at the district level is crucial for effective functioning
of the district level laboratory, since trained laboratory technicians are already available with
these programs.
74
21.4.2 Needs at district laboratories
The district public health laboratory will be included in the IDSP computer network, so that
transfer of information on identified diseases can be promptly transferred to the district
surveillance unit and to the peripheral reporting units, as soon as data becomes available. Details
are given in the IT manual
Equipment and Reagents:
These laboratories need to be upgraded with equipment and infrastructure to provide this
function. The following needs have been identified:
EQUIPMENTS NEEDED AT DISTRICT LABORATORIES
1
2
3
4
Equipments
What is needed
Binocular Microscope with
oil immersion
Test tube rack
Table top centrifuge
Incubator
5 Water bath
6 Refrigerator
7 Autoclave
8 ELISA reader and Washer
9 Hot air oven
10 Bio-safety hood
11 Inoculating loops
12 Pasteur pipettes
13 Vortex mitxer
14 - 70 Deep freezer
What is available and Where
Incremental Needs
Binocular microscopes supplied under To be supplied
TB/Malaria program/NPSCD
wherever required
Available
Nil
Available in District PH lab
Additional one needed
Available at District PH lab
Additional one needed
Not Available
2 Available at District PH lab
Small one available
Not Available
Available at District PH lab
Not Available
Not Available
Not Available
Not Available
Not Available
Needed
Nil
Needed
Needed
Nil
Needed
Needed
Needed
Needed
Needed
SUPPLIES REQUIRED AT DISTRICT LABORATORIES
1
2
3
4
Supplies
What is needed
Zeil Neelsen Acid fast stain
Blood culture bottles with
broth
Rapid Diagnostic Test kit for
Typhoid
Dehydrated media
What is available and Where
Incremental Needs
Available with District TB lab
Not Available
Nil
Needed
Not available
Needed
Not Available
Needed
75
5
6
7
HIV diagnostic kit ELISA
Diagnostic kit for water
quality
Screw capped bottles
Available with NACO
Not Available
Nil
Needed
Not Available
Needed
21.4.3 Other laboratories which may function as District PH Laboratories
The laboratories of ESI HQ and Regional Railway Hospitals and Army Command Hospitals in
some districts can take on the role of the district public health laboratory if memorandum of
understanding can be arrived at with the state surveillance unit for that function.
21.5 State public health laboratories
Most states have well developed state level laboratories capable of performing the roles of L3
laboratories. Labs in Medical colleges will be part of this level. The state level laboratories need
not be in a single laboratory but can be a group of well-networked laboratories in the state,
specific for diseases under consideration. The primary roles of the state level laboratories are to:





Provide quality control of District laboratories
Impart training of Laboratory Personnel at the district levels
Participate in the epidemic investigation in response to surveillance challenges
Link up with state and district surveillance units so that information transfer is
optimized.
Function as the Primary laboratory for NCD risk factor surveillance.
76
EXPECTED TESTS DONE AT STATE LABORATORIES
1
Conditions
Tuberculosis
2
Malaria
3
Typhoid
4
Cholera
5
Water Quality
6.
7.
8.
NCD
surveillance
Polio
Measles
9.
10
11
Leptospirae
Dengue
Hepatitis
12
13
Anthrax
Plague
Test
AFB Culture and
Sensitivity
Confirmation
Perform in 1% of
positive cultures
from district level
Confirm 1% from
districts
Sensitivity Testing in
Confirm 1% of
S.typhi isolates
bacterial isolates at
district level
Cholera culture and Typing 1% of Cholera
Cholera toxin test
isolates from
districts
Colony count
Confirm 0.5% from
district levels
Blood sugar, HDL, LDL
Follow present procedures
Kit for Measles IgM
antibodies
MAT Test for Leptospira
IgM test for Dengue
Serology for Hepatitis A,
E, B, C
Confirm 1% of
samples from
district
Identification of Anthrax
Identification of plague
Objective
Identify magnitude of
MDR TB
Pattern of AMR for
S.typhi typing
Identify pattern of
bacterial infection
Risk factor
surveillance for NCD
Confirm Polio
Confirm Measles
Confirm Leptospirae
Confirm Dengue
Quality control
Hepatitis work
Confirm Anthrax
Confirm Plague
State level laboratories will be identified by the State Health administration.
In each state the State Surveillance Unit will select the laboratories to perform the above
functions for IDSP. These laboratories will be chosen depending on the existing strength and
willingness to perform the surveillance activity and can be from both the government and private
sector.
Most state level laboratories have the infrastructure and equipment which may need to be
minimally supplemented to function effectively in the roles specified as state surveillance
laboratories. Consumables may need to be provided for some diseases for which additional load
is expected. State level laboratories are expected to do AMR testing on random samples of
isolates from districts and this needs additional inputs.
Most of the state level laboratories are already providing training for laboratory technicians at
different levels. This may need to be tailored to suit the needs of the IDSP. Currently, the biggest
77
lacuna in state level laboratories is their connectivity. Some laboratories have got computers but
there is not infrastructure for sharing the information. Development of a network is essential.
Most laboratories will be provided additional dedicated computers, softwares, and telephone
connectivity charges as part of this program.
21.6 Administrative Re-organization for Laboratory Work under IDSP
The Department of Health at the State level will identify responsibility for administrative
overseeing of the laboratory system. This individual will be designated as the state laboratory
director.
At the District Level, identify the individual who will be designated as the laboratory director
and who will be responsible for management overseeing of the peripheral health centers.
Selected Medical Colleges may be designated state laboratories and will provide services in
their area of expertise. The state IDSP unit will enter into written memorandum of
understanding (MOU) with department of medical education to assure recognition of roles and
responsibilities.
21.7 Quality Assurance:
One of the state laboratory will be designated as the organizational entity to provide training in
quality assurance and to coordinate training activities. A calendar of training offered by various
institutes and universities will be maintained and include training in laboratory methods /
techniques, quality assurance, and management.
Laboratory training will be provided to district laboratories in a central setting. In turn, district
laboratories should provide appropriate training to PHC’s.
The designated institution should be responsible for evaluation of training programs and should
include pre-and post-test evaluations as well as on-site evaluations to determine changes in
practice.
Biological safety and hazardous waste – The laboratory director in each district can oversee and
implement policy on waste management at district level.
21.8 Reference laboratories
IDSP will have one central and four regional reference laboratories catering to routine work and
outbreak investigations. The Central laboratory at NICD will function as the apex reference
laboratory for IDSP. In addition, the following laboratories will be designated as IDSP regional
reference centers in the four regions of India.
78
Along with the above designated reference laboratories, there are a number of laboratories of
high standard in the country and they could be incorporated into the IDSP as reference
laboratories for various specific disease conditions.
21.8.1 Strengthening National Institute of Communicable Diseases
The epidemiological division and various laboratories of NICD will function as the apex
laboratory for IDSP surveillance. Necessary inputs for improving the infrastructure of the central
laboratory and facilities for training will be provided under the program. Currently NICD has a
basic laboratory, this will be upgraded to a P3 laboratories. Additional funds will be provided for
reagents and civil works. NICD will take on the following responsibilities:







Participate in monitoring and evaluation of the laboratories
Participate in epidemic investigations as required
To prepare standard manuals of techniques for the constituent laboratories
To serve as a training center for laboratory personnel and coordination of training
programs for all laboratory technologists
To serve as the central referral laboratory for all laboratories in the network of the
National Surveillance program
To provide technical supervision and guidance to the laboratories in the country
To serve as a center for the preparation and distribution of certain reagents and
biological reagents for the constituent laboratories.
21.8.2 National Institute of Cholera and Enteric Diseases, Calcutta as regional IDSP
laboratory in the Eastern region
Originally established as the Cholera Research Laboratory, its scope was enlarged in 1975 and
renamed as NICED. The laboratory is primarily working on enteric bacteria but has enlarged its
interest to HIV, Rotavirus and Hepatitis. It is a very well equipped and staffed laboratory (15
Microbiologists and 47 technologists) with advanced equipment for molecular studies available.
The institute conducts courses in enteric diagnosis from time to time and is the only lab in the
world carrying out Vibrio phage typing.
21.8.3 Microbiology PGI Chandigarh as the regional IDSP laboratory for the Northern
region
This laboratory is well equipped, well staffed and has vast experience in antimicrobial
susceptibility testing. ICMR has designated laboratories as Reference centers for antimicrobial
susceptibility testing for rapidly growing aerobic bacteria. They are taking part in WHO-NET
programme for antibiotic resistance monitoring.
79
21.8.4 Microbiology Center at CMC Vellore regional Reference Center for the Southern
Region
This laboratory is well equipped, well staffed and has vast experience in antimicrobial
susceptibility testing. CMC has been successfully coordinating the external quality control
program for other laboratories in the country for many years. ICMR has designated this
laboratory as a Reference center for antimicrobial susceptibility testing.
21.8.5 National institute of Virology, Pune regional IDSP reference laboratory for the
Western Region
It is the WHO collaborating Centre for Abroviruses and Myxoviruses. It was established in 1960
as a Arbovirus research laboratory. It has done yeoman’s service in epidemiology, lab diagnosis
of virus diseases such as JE virus, dengue infection and other arbovirus diseases. It isolated and
characterized Kyasanur Foreste Disease and played an important part in its control. It is now
specifically working in the field of arboviruses, myxoviruses (surveillance of Influenza)
Hepatitis viruses. It is well equipped and staffed. It has P3 and P4 facilities. A new building is
ready for occupation. There are 15 scientists including virologists, epidemiologists and
entomologists and 45 technologists. It conducts postgraduate courses in virology and also
imparts individual training to scientists from India and abroad. It is a WHO collaborating center.
A monoclonal based IgM ELISA for diagnosis of flavivirus infections i.e., JE, West Nile and
dengue has been developed by NIV, Pune. The monocolonal antibody generated against JE virus
has now replaced polyclonal flavivirus cross reactive human serum. TgG-HRP conjugate as well
as biotinylated Mab are in use in IgM capture ELISA. Incorporating this reagent, NIV supplied
the kits to various institutes in India and also to WHO for distribution to institutes in South-East
Asia. Tests for diagnosis of Measles IgM and HAV IgM have also been developed here and are
supplied to other laboratories.
21.9 Role of ICMR centers in coordinating Disease Specific Reference Laboratories in the
country
There are a number of ICMR laboratories in different parts of India which could function as
reference laboratories for IDSP. The MOHFW and Central Surveillance unit will develop a
memorandum of understanding with ICMR so that ICMR can closely collaborate with MOHFW
in IDSP and the National reference laboratory network. Based on the present strength of the
laboratories they could help in :
 Characterization of the strain e.g.; sero-typing, phage typing, molecular finger
printing
 Repository of standard strains and reagents and their supply to constituent
laboratories
 Production of diagnostic anti-sera and supply to laboratories in the network
 Production of reagents for antibody detection and their supply to laboratories in
the network
80




Research in production of rapid diagnostic reagents
To standardize methods, procedures and equipment and to supply these to
constituent laboratories
To serve as a provider of quality assurance for constituent laboratories
To participate in International EQAS of laboratory disciplines
The following conditions will have designated reference laboratories. These laboratories will be
selected based on the expertise available and willingness to participate in IDSP.
BACTERIAL






Enteric bacteria: Cholera, Shigella, Salmonella
Streptococcus pyogenes and pneumoniae
C.diphtheriae
Neisseria meningitides and gonorrhea
Staphylococcus
Tuberculosis






Enteric viruses
Arboviruses
Myxoviruses
Hepatitis viruses
Neurotropic viruses
HIV


Malaria and filaria
Parasitology


Zoonoses
Antimicrobial susceptibility of rapidly growing organisms
VIRAL
PARASITIC
OTHERS
RELATED REFERENCE CENTERS
 Vector control
 Statistics
 Vaccines production and quality control
 Epidemiology
81
21.10 Additional Reference Laboratories for quality control and accreditation
21.10.1 National Institute of Biologicals with AIIMS Delhi and CMC Vellore
NIB will be requested to participate as EQA Provider for the IDSP laboratories at the state and
central level.
 For Peripherals laboratories – Provider Medical College laboratories
 For District laboratories – Provider State / Medical College laboratories
 For States and Regional Laboratories – Central coordinator NIB and IEQAS
 For designated central, state and regional laboratories. Liaise with International QA
laboratories coordinated by WHO
 Central coordinator – National Institute of Biologicals
 International collaboration with Quality Assurance Division, Central Public Health
Laboratory, Colindale, London
21.10.2 National Accreditation Board for Testing and Calibration of Laboratories
NABL will be requested to develop a compulsory accreditation process for all laboratories in the
country to assure quality. Refer to chapter on quality assurance.
22 BIOSAFETY AND BIO-MEDICAL WASTE MANAGEMENT
Currently, bio-safety issues and bio-medical management at all levels of health care delivery and
laboratory services are not explicitly prescribed and practiced. The written guidelines when
available are not implemented due to the health personnels poor knowledge, attitudes and lack of
training. With the rising HIV epidemic in the community there is a gradual increase in the
awareness of risk to the health personnel and of ‘Universal precautions’. There is concern that
universal precautions are not feasible and are expensive and may not protect individuals. This
has resulted in a reluctance, on the part of the health providers at various levels, to participate in
programs requiring collection of possible infected material and taking care of affected
individuals.
Some institutions in the country are taking steps to safely dispose bio-hazardous waste and in the
process are fulfilling their social obligations in this regard. For example, the Indian Air Force
hospital in Bangalore has developed an improved waste disposal system with a multi-option
approach, which is to be extended to all the major armed forces' hospitals in the
country. Keeping in view the danger posed by the hospital waste, the command Hospital Air
Force, Bangalore has developed a proper waste disposal system under a WHO project. The
system adopts a multi-option approach under which an inventory of waste is made and
hydroclave, microclave and autoclave incinerations are used to remove the toxicity. A similar
system is planned in 28 major hospitals of the armed forces for a total outlay of Rs 103 crores.
82
22.1 Bio-safety issues in the proposed IDSP
These are primarily related to transmission of infectious agents to individuals at risk. They
are:



Risk to health personnel during collection and handling of specimen.
Risk to community on transportation of infected material.
Disposal of hazardous waste in the program.
These risks can be reduced by:



Improving health practices by providers
Developing training programmes on collection and transfer of specimens and
cleaning and maintaining of laboratory
Specific facilities and guidelines for disposal of bio-hazardous waste
IDSP will address bio-safety issues related with health personnel and to the community by the
following measures.
22.2 Improving health practices especially handling of sharps




Developing a manual of Dos and Don’ts in mandatory day to day activities
Training to prevent accidents
Training in decontamination and sterilization
Universal precautions during collection, transportation of biological specimens.
22.3 Improving infrastructure



24.4
Bio-safety cabinets
Equipment for sterilization
Systematic approach for collection and disposal of waste
Management of bio-hazardous waste in IDSP
Waste generated within hospital premises has three main components:



Common wastes, for example, administrative office waste and kitchen waste;
Pathogenic or infectious wastes (these also contain sharps);
Hazardous wastes (mainly those originating in the laboratories containing toxic
substances).
The quantity of the first type of waste tends to be much larger than the second and third
types. Ideally, these three types of waste should be separated. However, separation is
possible only when there is significant management commitment, in-depth and continuous
83
training of personnel, and permanent supervision to ensure that the prescribed practices are
being followed. Otherwise, there is always a risk that infectious and hazardous materials will
enter the common waste stream. Hospital waste is the gruesome by- product of disease
control and of modern medicine. Blood-caked needles, body parts, acrid bandages and other
infectious waste pours, often unchecked, out of the hospitals every day. The only solution is a
safe waste-disposal technology.
Developing infrastructure for hazardous waste management at each laboratory. This will be
done as part of the program allocation for individual participating laboratories.
Combining strategy to dispose hazardous waste generated from laboratory with general
hospital waste. This would be part of a district waste management scheme and IDSP will link
up with the existing system in the districts of operation. Will encourage efforts in the
development of private / public systems for hospital waste disposal and enactment of
appropriate legislation so that this becomes mandatory for all health care delivery sites
generating bio-hazardous wastes.
23 INFORMATION TECHNOLOGY IN IDSP
At present, the state, district and block level units of IDSP have telephones connections or
can easily obtain the same, since connectivity can be obtained on demand in states like Tamil
Nadu and Maharashtra. This includes, CHC / Block PHC, District Surveillance office,
District Public Health Lab, State Surveillance office and state level laboratories. There are no
telephone connections available at PHCs / Addl.PHCs. Transfer of information on disease
outbreaks can be quickly passed on from Block level PHCs to District Surveillance office.
Current advanced technology is to be used for the computing and communication needs of
the program. It is proposed to provide connectivity initially up to District level. Connectivity
to CHCs would be taken up on a pilot basis, before replication of the same at CHC level.
Computers for data entry and receiving inputs from the district level would be available at
the periphery. Peripheral data entry units will dial into the dedicated server at the district
surveillance center for sending and receiving surveillance information.
At the district level, it is proposed to develop a dedicated surveillance network linking all
districts of the country. Back up of local data at the district will be available at District
Server, in case of data loss at the Central database. Regular back up of local data will be
taken in CD ROMs for storage.
The district surveillance officer will do basic analysis of data at the district level, in addition
to sending reports of the compiled data to the state surveillance unit. The state surveillance
unit will perform all advanced analysis and regular feed back reports will be provided to the
district and participating peripheral centers.
84
The network is expected to exist on the following levels:
CHC/Primary Health Center (Level-1) (Pilot Basis)
District Health Office (Level-2)
State Health Directorate (Level-3)
Directorate General of Health Services (Level-4)
Full vertical and restricted horizontal access for data will be provided in the program. The
network will be efficient in terms of data entry, personnel requirement, training needs, data
transmission, possible damages and costs.
23.1 Proposed IDSP information technology infrastructure and networking
Information flow in Integrated Disease Surveillance Program is as depicted in the figure
given below. Redundancy is built into the system at the server level. There is provision of a
Server with hot swappable hard disks at District level alongwith three client machines. There
is also a provision of a (Remote Access Server) RAS which would enable peripheral units to
dial into the server and transfer the data. The district units would have the ISDN/dedicated
connectivity to enable them to transfer the data to State and Central servers.
85
Rural Channel
Disease Surveillance System
-Information Flow
Health Worker and Nurses
Sub Centre
Urban Channel
Health Worker and Nurses
Sanitary Workers
PHC with Medical Oficer
Rural Lab Channel
Health Inspector
Block Hospital/ CHC /
BLOCK PHC with Civil Surgeon
and Medical officers
District Health Officer Information from National Programs
$
DDHS / DDHS National Program
District
Hospital with
Chief Medical
Officer
Wards
Urban Lab Channel
Block Laboratory
Zonal Laboratory
District Lab
Corporation Lab
Medical Colleges
State
Private Channel
Private Practitioners
Zones
Municipal
Corporation
Private
Nursing
Homes
Private Hospital
$
State
Private Agencies/NGOs
State Laboratory
National Unit
DHS
86
State Server
WAN Link to
adjacent State
Modem
Client 1
Switch
Router
Client 2
Switch
Modem
WAN Link to
adjacent State
Client n
29.2 State Network Configuration
87
The all-India WAN design will involve a trade-off between cost and fault-tolerance. One strategy
is to setup a partially-meshed network of links such that there are at least two independent paths
between any two adjacent states. An example of this is given below:
Fig 9.
State 1
State 3
State 2
State 4
Note that no single link failure will cause transmission failure. Also, note that the link from State
1 to State 4 is not strictly necessary but provides extra fault tolerance.
The infrastructure for the system will include:

State Servers: Each server will need to run Operating System, Database and Analysis
Server and the Data Entry and Analysis Application. It is expected that the maximum
amount of data storage requirements per state per year will not exceed 15 GB. Taking all
these factors into account, and allowing for future growth in the number of clients that
must be supported, the following configuration is recommended for each State server:
23.2 IT Infrastructure for IDSP
23.2.1 System Software and Packages:23.2.1.1 Operating System:
An appropriate Operating System will be required on every PC/ Server machine at Centre,
State and District levels.
The operating systems at various levels, for client and server machines, should be a userfriendly OS, providing secure and stable environment, as per operational needs at each level.
It should support all the prevalent and desirable functionalities of a modern day operating
system, including – all type of networking/ protocol features, virus/ intrusion protection,
crash-proofing and system recovery features etc.
For clients, it could be Windows XP or Linux or similar other Operating System and for
servers, Windows 2K/ 2003, Unix or Linux Server version or similar other Operating
88
System, matching the needs of the integrated IDSP application finalized (yet to) for
implementation at respective levels.
23.2.1.2 RDBMS:
Similarly, the need of RDBMS package will also vary at various levels, but it should be a
widely used and supported RDBMS, with all present day features of file/ record handling,
authentication, concurrent access, ODBC support etc The options may be --- Oracle, SQL
Server, DB2 or similar other package, matching the needs of integrated IDSP solution
finalized. For small volume/ versatility needs at Client level, MS-Access or similar other
Linux based package may also suffice.
23.2.1.3 Application Support/ Development Platform and GIS/ other tools:
The choices for the application support/ development platform and tools will completely
depend on the needs of the Integrated IDSP Application solution and the vendor’s approach
to the solution development. But with given intent of implementing Web based solutions at
every level, largely the requirements will confine to Web Servers/ Web Authoring & Site
management tools and GIS/ data-analysis tools at State and Central levels, apart from a Web
browser required on every PC. The options could be ASP/ .net or JAVA based development,
with Web service tools like IIS/ Front Page, IBM Web-sphere etc. and GIS/ statistical
packages like MapInfo etc at State/ Central levels.
23.2.2 Hardware and Networking:
23.2.2.1 District Level
District Surveillance Unit
One lower end server (512MB RAM, min. 2x18 GB hot swap HDD, SCSI controller,
CD/Tape Back-up, NIC etc.), with RAS, for multiple (up to three) dial-in access to the
server.
Two Client PCs (P-IV 2.4 GHz, 256MB RAM, 40 GB HDD, CD/DVD Drive, NIC etc.) on
LAN, supporting at least 4-5 extra ports for connecting more PCs.
One Dot matrix and one Ink-jet printer,
UPS 1 KVA with two-hour back up
Clients
Three Client PCs (similar as above) with dial-up modem, printer (DMP/Ink Jet) and UPS
(500 VA 30 Min. backup) for Dist. Level Govt. institutions.
89
Connectivity
ISDN/dedicated connectivity, at least 64 Kbps, through ISP or NICNET (NIC District Unit),
Provision for Stabilized and continuous power supply.
23.2.2.2 State Level
State Surveillance Unit
Two Mid Range Servers (Dual Xeon processor, min. 1GB RAM, min. 2x36 GB Hot swap
HDD, SCSI/RAID controller, CTD Back-up, NIC etc.) for Web services and Database,
Three Client PCs (similar to districts) on LAN, supporting at least 8-10 extra ports for
connecting more PCs,
One Dot matrix, one ink-jet printer, one Laser-jet printer and one scanner
UPS 2 KVA with two-hour back up
Clients
Five Client PCs (similar as above) with dial-up modem, printer (DMP/Ink Jet) and UPS (500 VA
30 Min. backup) for State level Govt. institutions/ Labs
Connectivity
ISDN/dedicated connectivity, at least 128 Kbps, through ISP or NICNET (NIC State Unit),
Provision for Stabilized and continuous power supply
23.2.2.3 Central Level
Central Surveillance Unit
Two Mid Range Servers (Dual Xeon processor, min. 1GB RAM, min. 2x36 GB Hot swap
HDD, SCSI/RAID controller, CTD Back-up, NIC etc.) for Web services and Database,
Three Client PCs (similar to districts) on LAN, supporting at least 8-10 extra ports for
connecting more PCs,
One Dot matrix, one ink-jet and one LaserJet printers, one scanner
UPS 2 KVA with two-hour back up
Clients
Ten Client PCs (similar as above) with dial-up modem, printer (DMP/Ink Jet) and UPS (500 VA
30 Min. backup) for State level Govt. institutions/ Labs
Connectivity
ISDN/dedicated connectivity, at least 128 Kbps, through ISP or NICNET (NIC Hqr Unit)
Provision for Stabilized and continuous power supply
90
Similar to Central IDSP Directorate, a similar set-up at National Institute of Communicable
diseases (NICD) and may be ICMR, are also envisaged, so that they are fully equipped to
support this activity.
23.3 Software licenses
The number of licensed software that will be required for the project, and the total licenses
required for the whole of India is given below.
SOFTWARE LICENSES
Software
Server Operating System
Database and Analysis Server
Messaging Server
Server Monitoring
Desktop Operating System
National
Level
2
2
1
1
10
State
Level
2
2
1
1
5
Distric
t Level
1
1
1
1
3
23.4 Administration
This will include security, network, database, and server administration.
23.4.1 Security administration
Secured Application with secured mailboxes are to be deployed to manage users and groups.
User sessions will be logged and input data will be tagged by session identity to allow audit.
23.4.2 Network administration
An exclusive IP address range will be allocated to each state. Client machines and other data
producers will be assigned static IP addresses in this range. Other client machines will be
dynamically assigned IP addresses in the given range at login time.
23.4.3 Database administration
Database administration will involve setting up replication and recovery procedures.
23.4.4 Server administration
Servers deployed at the State and District will be monitored and administered remotely.
An application will be developed for monitoring the health of the network components, servers,
and main clients of the system with provision for alerts to be issued to appropriate personnel.
91
23.5 Failure and disaster recovery
Redundancy will be built into the system at the server, network levels so that there are no single
points of failure. High-quality hardware components will be purchased, and hardware service
agreements guaranteeing low mean time to repair will be entered into. The effects of various
types of failures is discussed below.
23.5.1 Server failure
When a server in the state fails, the other server will automatically replace it. The hardware
maintenance company must repair the machine or provide a replacement within a day. Fitting the
new server with software and data can be done within stipulated hours.
23.5.2 Network failure
When a link in the network fails, the duplicate network link will automatically takeover. The
hardware maintenance company must repair the network within a day.
23.5.3 Inter-state network failure
If one of the WAN links between two adjacent states fails, the other will take over. If both WAN
links fail, inter-State data transfer will stop. The hardware maintenance company or the
responsible party must agree to repair the link within a day.
23.6 Computer virus attack
The approach used here will be to prevent rather than cure viruses. Normal users of the system
will not have the rights to install applications on client machines, and will not be able to access
the server except through the application. There will be no CD-ROM or floppy drives on client
machines. Sharing of folders will not be allowed on client machines. If there is suspicion of
infection on a client machine, the machine will be immediately replaced with a standby machine
and repaired. Repair will consist of formatting the hard disk of the machine and reinstalling all
software. The server will also be hardened against the possibility of virus attacks by shutting
down unnecessary services, and restricting access by clients to inter-process communication.
23.7 Management of total computer failure
If the data in a state is completely lost for whatever reason, it can be built back up from the
database replica at an adjacent State Server. This can be done within one day of the restoration of
the hardware and other infrastructure of the state.
24 TRAINING NEEDS IN IDSP
Integrated Disease Surveillance Program envisages to have a action oriented district centered,
decentralized surveillance program established in the country. Human Resource Development is
one of the important components of the program.
92
The following key issues underlie the development of the Training strategy and Plan
 IDSP doses not intend to employ additional staff considering the financial position of the
states and long term sustainability
 Existing personnel will be provided training to undertake surveillance activities more
efficiently integrating even non-health workers for this activity if necessary.
 As far as possible training will be provided locally at the sub-district level, some at
district and few at state and at the center
 Public private partnership is an important component in IDSP both in terms of training
provider and the trainee.
 Current method series mode of training and training of trainers has not been able to
provide good quality training and this will be taken into consideration in the development
of the training strategy for IDSP.
24.1 Training Needs Assessment:
An assessment of training needs was carried out in 6 states in India to understand the available
infrastructure, human resources and perceived needs of the program in terms of human resource
development. The key inferences that emerged from this assessment were as follows:
 Training and sensitization workshops for IDSP activities is essential for the successful
implementation of the program.
 There is a wide variation in the training needs and available infrastructure between
different states. While some of the states have established training centres and good
medical colleges, the training infrastructure (including human resources) in other states
leaves much to be desired.
 The male health workers are not being re-employed in most states and only 30-50% of
available posts are occupied. Over the next few years more vacancies are likely to be
present in this category.
 Qualified microbiologists even at diploma level are not present in the public health
system in most states for working in the district public health laboratories envisaged in
the program.
93
 Staff trained in Public Health are very few, especially at the District level and above. This
means that the training in surveillance needs to be imparted to all the relevant personnel,
including the district and state level officers
 Duration of training for IDSP should be short and it is not possible to spare health
workers and doctors for more than 2-3 days at a time.
 Consultant service at State level would be required at least for the first 2 years to
effectively implement the IDSP activities in addition to training of personnel.
 User friendly training manuals should be made available.
Based on training needs following matrix gives recommended curricula :
Training
Feedback
Supervision
and
Monitoring
Research
Response
Lab
confirmation
Analysis
Case
detection
Overview
TABLE : RECOMMENDED TRAINING CURRICULLA FOR EACH LEVEL
Central and State Nodal officers
++
++
++
++
++
++
++
++
++
Select Medical College trainers
++
++
++
++
++
++
++
++
++
Corporation Health Officers
++
++
++
++
++
++
++
++
++
State EIT members
++
+
++
++
++
+
-
+
++
SIHFW staff
++
+
++
++
++
+
-
+
++
District Nodal Officers
++
++
++
++
++
++
++
++
++
District EIT members
++
+
++
++
++
+
-
+
++
District Statisticians
+
+
+
-
-
-
+
-
+
District Lab technicians
+
+
+
++
+
-
++
-
+
District HFW Trg centers
++
++
++
++
++
++
++
-
++
SPM and Microbiology Depts of
Medical Colleges
++
++
++
++
++
++
++
++
++
State Directorate, State
Epidemiologists, Entomologists,
State Statisticians.
++
-
-
-
-
-
-
-
-
MHO
++
++
++
++
++
++
++
-
++
94
Pediatric, Medicine and
Emergency Dept. of Medical
colleges
++
+
-
-
-
-
-
-
-
MPs, MLAs, Mayors,
Commissioners
++
-
-
-
-
-
-
-
-
Private representatives
++
+
-
+
-
-
-
-
-
DHO, District Programme
managers, DMO, District Hospital
Physicians, Pediatricians
++
+
-
+
-
-
-
-
-
Officials of other Depts.
+
-
-
-
-
-
-
-
-
MO – PHC / CHC, urban
dispensaries, MHO
++
++
++
++
++
++
++
-
++
Sub block staff
++
++
-
-
-
-
-
-
-
Community representatives
++
-
-
-
-
-
-
-
-
24.2 Training Strategy:

Induction Training prior to initiating the program.

Continued training
•
On-the-job supervision and training
•
Web based training – credit system
•
regular refresher training
•
Annual peer interaction - CME
24.2.1 The Sensitization Workshops
The sensitization workshop is essential to make the program but this is considered in detail under
social mobilization and not being considered as part of training.
Short half a day to 1 day sensitization workshops will be conducted as part of IEC
activities to make stake holders aware of the IDSP and ensure their participation in the
program at different levels. These workshops are seen differently than training and is dealt
with in the IEC section. The groups which needs sensitization are mentioned below:
1. State Level – Policy makers and administrators at state, district including Health
secretaries, secretaries of related sectors. Heads of departments of medical education
and health services. Medical college principals, District collectors,
95
2. District Level - NGOs doing and interested in disease surveillance. Representatives of
Indian Medical Association (IMA) and Indian Association Paediatrics (IAP).
3. Block Level - Panchayat leaders, School teachers, Anganwadi workers, Sentinel
private practitioners and Medical practitioners of alternate systems of medicine alike
aurveda, unani, homeopathy and un registered practitioners in the locality.
24.2.2 Types of Induction Training Programs:
There are 8 separate training programs planned under the program to meet the needs of the
following groups of personnel in the program.
(a) Training of the State and District surveillance teams – The trainers
(b) Training of the Medical officers – The primary efferent arm of the project (PHC / CHC /
Urban Health services / Medical colleges)
(c) Training of the Medical officers – Important affarent arm of the project (Private Sector
hosptials, Including SSPs, MC, others)
(d) Training of the Peripheral workers – The work horses (MPWs, ANMs, Health
supervisors, NGO field workers etc)
(e) Training of Microbiologists and Lab technicians (State and District level)
(f) Training of Lab technicians (Sub District level)
(g) Training of Data entry operators (State, District and Sub District level)
(h) Training of Data Managers (District and State level).
24.3 Who will provide the training
The training plan was developed so that the training provided will meet the high quality required
for IDSP to function effectively. It also took into account the loss in quality with standard series
mode of training.
Three levels of trainers were identified:
 Level-1 Trainers
 Level-2 Trainers
 Level-3 Trainers
24.3.1 National Network of training Institutions – Level 1:
The responsibility of training in the program will be with a network of national institutions
selected on the basis of definite criteria. These institutions will take the responsibility for training
state and district surveillance teams coordinated by the central surveillance unit functioning
under the ministry of health and family welfare. These will be the Level-1 Trainers.
96
A Consortium of institutions may also qualify for with established memorandum of
understanding on the roles and responsibilities.
A total of 30 institutions will be chosen which would focus on training in surveillance activities,
and specific laboratory training. Institutions specialised in epidemiology and surveillance
activities may be chosen, even if they do not have training facilities in laboratory. In such cases
the State would have to choose a separate institution for training in laboratory activities.
The Central Surveillance Cell would short list the 30 institutions based on certain criteria. The
State Surveillance Unit would be free to chose the appropriate ones for their state. Some of the
criteria proposed for choosing a Training Institution are as follows:
Criteria: Epidemiology Training center
a. Recognized training institutions with experience in post graduate teaching in the field of
community medicine/ Public health, and microbiology
b. Adequate training infrastructure and equipments, ,
c. Key resource person in the area of epidemiology, microbiology, medicine and paediatrics
who are willing to be resource person for training if selected
d. Preferably, experience in health surveillance activities
Criteria for Laboratory Training:
1. Training institutions with experience in the field of microbiology
2. Adequate training infrastructure and equipments, ,
3. Key resource person with expertise in the filed of microbiology who are willing to be
resource person for training if selected
4. Preferably, experience in health surveillance activities
Criteria for Institutions for training in data management:
1. Institutions with prior experience in training in data management
2. Adequate training infrastructure and equipments,
3. Key resource person with expertise in the field of statistics and data management who are
willing to be resource person for training if selected
4. 4. Preferably, experience in health surveillance activities
24.3.2 Level -2 Trainers:
The level 2 trainers would be members of the district and state surveillance team who have been
trained by the Level 1 Trainers. They would take the primary responsibility of training the
district and sub-district personnel (Category II, III and V trainees).
97
24.3.3 Level 3 Trainers:
These would be the Block Medical officers who would in turn train the Sub Block staff
(Category IV trainees).
24.4 Quality Assurance:
Mixed model series and parrallel mode of training is planned for the program so that loss of
training quality in series mode is minimized.
 25% faculty for Health worker training at the sub-district level will be from state and
district surveillance team (2 levels higher)
 25% of the faculty for district Level training will be from the selected national institutes
of training
 Independent external evaluation of training is an important component
 Determine the continued funding for training by the institutions and groups
The trainees for the induction training are given below:
Table : THE TRAINEES1
Category
Level
I
State and District level
Surveillance Teams
II
Medical Officers
Trainees
State Surveillance Officer (SSO),
State Programme managers, State
Microbiologists / Lab technicians
and State level Data Managers
District Surveillance officer, 2
District programme Managers,
District Microbiologist / LT and
District Data Managers
RRT members
Numbers
10 per state
Medical Officers of the PHCs,
CHCs and Urban Health sector.
MOs of the SPM departments of
local Medical colleges. MOs of
NGOs / Mission Hospitals
70 per district
10 per district
1 Nodal Officers: It is clarified that nodal officer/District Surveillance Officer at district level does not
automatically imply the DHFWO but should be the officer who is actually involved with the programme
and would usually be a Dy DHO/ Dy CMO/ Programme officer dealing with surveillance. S/He should
preferably be a specialist in public health
98
III
Clinical Medical officers
IV
Sub Block staff
V
State and District Level
Laboratory training
VI
VII
Sub District Level
Laboratory training
Data entry operators
VIII
Data managers
Medical Officers of the Hospitals,
Subdistrict Hospitals, Medical
College Hospitals, SPPs,
MPWs (Male / Female), Health
Supervisors, NGO volunteers,
unregistered Medical practitioners
State and District level
microbiologists / LT. Also of the
urban health sector. Also
Microbiologists from local
Medical Colleges
PHC / CHC / Urban dispensary
LTs
DEOs at CHC, District and state
level
Statisticians at District and State
level
30 per district
350 district
5 per district
5 per district
15 per district
2 per district
24.5 Site of Training:
 Maximum time that personnel at district and sub-district level can be spared is 2-3 days.
 This means that most of the training is district and sub-district level itself.
 Training will be preferably at one level higher than the working environment
I
II
III.
IV
TRAINEES
District and State
Surveillance team
Medical Officers of
the PHCs, CHCs and
Urban Health sector.
MOs of the SPM
departments of local
Medical colleges.
MOs of NGOs /
Mission Hospitals
Medical Officers of
the Hospitals,
Subdistrict Hospitals,
Medical College
Hospitals, SPPs,
MPWs (Male /
Female), Health
TRAINERS
Level 1 – Selected National Level
Training Institutions
Level 2 – State and District
Surveillance Team
Site
Regional /
State
District HQ
Duration
6 days
District HQ
1 day
CHC
2 days
3 days
Support from Level 1 Trainers
Level 2 – State and District
Surveillance Team
Support from Level 1 Trainers
CHC Team with selected MO
PHCs. Support from Level 2
99
V
VI
VII
VIII
Supervisors, NGO
volunteers,
unregistered Medical
practitioners
State and District
level microbiologists
/ LT. Also of the
urban health sector.
Also Microbiologists
from local Medical
Colleges
Training for lab
assistants at CHC /
PHC
Data entry operators
Data Managers
district
Trainers.
Level 1 trainers - Identified
training institutions
Regional /
State
6 days
District Public Health laboratory
staff
Representatives from Level-1
institutions
Soft ware agency
Identified training institutions
District HQ
3 days
District HQ
Regional/ state
2 days
3 days
24.6 The Training Curricula
The training curricula for the IDSP would be focussed mainly on surveillance activities. While
all the staff would get an overview about IDSP, the stress would be on the practical aspects of
the programme that apply to their level, rather than esoteric epidemiology principles. The basis
for the IDSP curricula would be the Operational manual.
I
Trainees
Training of district
and state
Surveillance teams
Content of Training
 Overview and introduction to surveillance with special
reference to IDSP.
 Basic epidemiology pertaining to surveillance including
definitions like rates, ratios, IR, PR, CFR, spot maps,
graphs etc.
 Details of case detection, including case definitions,
reporting units and filling up forms, compilation and
transmission of data
 Collection and transmission of laboratory specimens and
bio-safety issues
 Details of analysis and Interpretation of data
 Details on Response to outbreaks
 Supervision Monitoring and Evaluation .
 Feed back
 Training methodology
 Inter-sectoral coordination
100
II
Medical Officers of
the PHCs, CHCs and
Urban Health sector.
MOs of the SPM
departments of local
Medical colleges.
MOs of NGOs /
Mission Hospitals

Overview and introduction to surveillance with special
reference to IDSP.
 Details of case detection, including case definitions,
reporting units and filling up forms, compilation and
transmission of data
 Collection and transmission of laboratory specimens and
bio-safety issues
 Basics of analysis and Interpretation of data
 Details on Response to outbreaks
 Supervision Monitoring and Evaluation.
III
Medical Officers of
 Overview and introduction to surveillance with special
the Hospitals,
reference to IDSP.
Subdistrict
 Details of case detection, including case definitions,
Hospitals, Medical
reporting units and filling up forms, compilation and
College Hospitals,
transmission of data
SPPs,
 Basics of lab confirmation – what specimens to be sent to
which lab, and in what manner for confirmation
Trainees
Content of Training
IV
MPWs (Male /
 Overview and introduction to surveillance
Female), Health
 Syndrome description
Supervisors, NGO
 Filling up of forms
volunteers,
 Transmission of data
unregistered Medical
 Collection of specimens
practitioners
 Biosafety issues
 Basic response to outbreaks
V
State and District
 Overview and introduction to surveillance with special
level microbiologists
reference to IDSP
/ LT. Also of the
 Hands on training on diagnosis of specific diseases.
urban health sector.
Especially Culture and sensitivity of stool and blood,
Also Microbiologists
Serology etc.
from local Medical
 Quality assurance mechanisms
Colleges
 Biosafety issues
VI
Training for lab
 Introduction to IDSP
assistants at CHC /
 Testing for sputum AFB, Malarial smear, Typhi Dot test
PHC
 Collection, storage and transportation of specimen
 Biosafety issues
VIII Training for data
 Introduction to IDSP
management at
 Extracting of data from the computers
district and state
 Analysis of data
level
101
24.7 Training Plan
Trainers
Level 1
(30
institutions)
Level 2
(230
districts)
Trainees
State and
District
Trainers
30x 9 states
W1
MOs of
PHCs / CHC
etc
70x230
districts
(16100)
Totally 60 – 70
trainees per district
One training team per
district
3 batches of 3 days
each
An average of 2
weeks
Totally 30 trainees per district
One training team
2 batches of 1 day each.
MOs of
Hospitals
30x 230
(6900)
Level 3
(230
districts)
Level 1
(30
institutions)
Level 2
(230
districts)
Level 1
MPWs etc
6x4x15x
230
(82800)
State /
District
Trainers Lab
2 x 30 x 9
LT of PHC /
CHC
10x 230
W2
W3
W4 W4 W5 W6 W7 W8 W9 W10
Totally 2700 trainees in 9 states.
30 Training institutions
An average of 90 trainees per training
institution
3 batches per training institution –30 trainees
per batch
One week training per batch
20 – 30 trainees per block
One training team per block
1 batch of 2 days each
~550 trainees
20 training institutions – an average of
30 participants per institution
1 batch per institution – of I week
10 LTs per district
One training team
One batch per district of 3
days
Data
~460 trainees
Management 20 training institutions – an
2x 230
average of 25 participants
per institution
1 batch per institution – of 3
days
102
24.8 Integrating existing public health training programs for training
Currently there are a number of training programs in public health organized by different
organizations in the country. These are:
 Two years Masters in Applied Epidemiology
- NIE
 Three months FETP
- NICD
 Ten day Epidemic preparedness and response
- NIE / NICD
 Ten days Training of RRT
- NICD
 Ten day Training on Computer Applications
- NICD
 Two year MPH course
- SCT – Trivandrum
 Three year MD course in PSM
- Selected Medical colleges
 15 days course on Basic Epidemiology
- CMC, Vellore
 Two year MSc in Epidemiology
- CMC, Vellore
 Two year MPH at TISS
- Mumbai
These are the various training programmes that are already existent and the IDSP can use some
of them to train their staff as well as utilize the materials already available.
24.9 Institutional capacity to undertake training in different states
There are some medical colleges that have existing public health departments and trained
epidemiologists and can be used for training purposes. Some of these are:
PROVISIONAL LIST OF MEDICAL COLLEGE/INSTITUTIONS
AIIMS – Delhi
MMC – Chennai
AIPHH – Kolkata
CMC – Vellore
NICED – Kolkata
NIMS – Hyderabad
NRS Medical College – Kolkata
SJMC – Bangalore
GMC – Guwahati
MIMS – Manipal
SGPGI – Lucknow
TMC – Trivandrum
PGIMER – Chandigarh
SCT – Trivandrum
CMC – Ludhiana
JIPMER – Pondicherry
IIHMR – Jaipur
INDIACLEN network of Medical colleges
AFMC Pune
TISS – Mumbai
BJMC Pune
NIE – Chennai
Grant Medical college – Mumbai
NICD – New Delhi
NIHFW
Other than these, there are other medical colleges which can play an important role in training at
sub-district levels.
103
24.10 Conclusion:
Total of ~112,000 personnel of different category will need to be provided training during the
induction phase of the Integrated Disease Surveillance Program. Even though the magnitude of
this training is very large. The phased induction of the program will make it feasible for the
induction training to be completed in time frame of 3-6 months time to cover 9 states considered
for the 1st phase of the program.
Most of the personnel will be provided specific training for performing the tasks for IDSP at subdistrict and at the district level and the duration for district and sub-district level training will be
short (2-3 days only)
The quality of training can be assured by developing a mixed model of series and parrallel
system where core trainers are represented in the lower order training sessions and having
random external evaluation and feed back to the system
Retrospective financing allowed in the program will make it feasible for the state and central
governments to initiate components of training even before the World bank financing is made
available.
25 SOCIAL MOBILIZATION AND COMMUNITY PARTICIPATION
Disease surveillance cannot be sustained unless the community stakeholders support the data
collection and the health system recognizes them as true partners. Therefore, a well planned
social mobilization strategy will have to be put in place to obtain valid and reliable data with
high sensitivity.
25.1 Current involvement of community
In areas where health workers enjoy a good relationship with their communities, people come
forward and volunteer the desired information. Several health workers are in regular contact with
village elders’ particularly ladies, pradhan, panchayat members, chauwkidar and other
community members who tell them about the occurrence of diseases. Current efforts are based
on individual initiative taken by some enthusiastic health staff. However there is no
institutionalized system of involving the community in health programs including surveillance
activities. In addition, the community consistently expected to get feedback about the activities
and data collected by health workers. When no feedback is given to the community, the people
consider the whole exercise as part of the health worker’s job responsibility which was irrelevant
and of no benefit to them.
The community members, press, and local leadership often give information about epidemics.
There are rumor registers kept in PHCs and sub-centers. Thus community is already contributing
significantly in the current efforts of disease surveillance and detection of outbreaks.
104
25.2 Socio-cultural issues to be taken up for social mobilization campaign
There are several socio-cultural barriers prevailing in the communities across the country that
influence the sensitivity of data collected for surveillance activities.
Social mobilization campaign in IDSP will need to address all diseases associated with sociocultural beliefs. Details have been provided in section 3.1.2
Religious minority groups in some areas are suspicious of the government health systems and
hence withhold information. Urban clients staying in high-rise buildings do not wish to utilize
public health services and therefore are non-cooperative even for surveillance activities. Due to
poor credibility of health systems, many clients consider surveillance activity is meant for health
departments with no benefit to common people.
Tribal and rural women felt that doctors in public sector health facilities do not provide good
care because they are poor. Local leadership may sometimes refuse to support public health
activities including surveillance if these hurt their personal interests.
25.3 Gender Issues in Surveillance
Focus group discussions with women in tribal, rural and urban areas consistently brought out the
gender disparity in seeking health care. Gender disparity would seriously influence the validity
of currently available surveillance data. Details about the perception on this issues are provided
in section 3.1.3.
25.4 Stakeholder who can be involved
All those individuals and organizations that operate as an interface between the health system
and the community will be identified as community stakeholders. The stakeholders will be
involved proactively during the planning and implementation phase of IDSP. To meet these
objectives, the stakeholders will be made members of the district surveillance and block
surveillance committee. The proposed list of stakeholders is provided under ensuing subsections.
25.4.1 Rural areas
Panchayat and its members; school teachers; community based organizations e.g. mahila
mandals and youth clubs; NGOs working in health areas; elected representatives from the area;
private rural practitioners.
25.4.2 Urban areas
Municipal councilors; representatives of professional bodies e.g. IAP, IMA, API; NGOs;
chemists organization; leading private practitioners and owners of hospitals / nursing homes.
105
25.5 Social mobilization strategies
The aim of the social mobilization campaign under the IDSP will be:






To create awareness among the partners, notably the private practitioners, NGOs and
the community about existing health programs, IDSP, the potential benefits, areas in
which their participation will be solicited
To establish an institutional mechanism to involve community and their leaders
Develop a system of providing regular feedback to the community about disease
occurrence, the responses to surveillance and impact of disease control programs
IEC must address all the issues that are likely to improve the sensitivity of the
surveillance data, particularly the prevalent socio-cultural beliefs and gender
disparities
To increase the reach of the campaign, all channels of communication are to be used;
these will include electronic media, press, hoardings, hand bills, posters, and interpersonal communication through health providers at all levels
Content and messages of the campaign targeted at health workers and private
practitioners will be different from that meant for the community, panchayat
members, local influential persons and NGOs.
In view of the above, resources will be required for following activities:
Central Level:
 Organizing a media campaign for creating mass awareness about the usefulness of the
surveillance, about core disease surveillance, dispelling common socio-cultural
beliefs and gender disparity
 Sensitization and mobilization meetings for central and state level functionaries of
IMA and other professional bodies to solicit their support for the program
 Some IEC material for health functionaries and selected sentinel private practitioners,
highlighting technical issues
State Level
 Organizing a media campaign for creating mass awareness about usefulness of the
surveillance, about core and state specific disease surveillance, dispelling common
socio-cultural beliefs and gender disparity
 Sensitization and mobilization meetings for state and district level functionaries of
IMA and other professional bodies, medical colleges, NGOs involved in health, to
solicit their support for the program
 IEC material for health functionaries and selected sentinel private practitioners
highlighting technical issues
 IEC material and messages to be prepared within the local context and in the locally
comprehensible language
 Bring out periodic reports on surveillance data and the consequent responses by the
health department as feedback to the community and local leadership
106
District Level and Periphery

Organize sensitization and mobilization meetings at district head quarters for local
IMA executive members, prominent practitioners, NGOs in health, elected
representatives of the local as well as state bodies, district panchayat board members,
teachers

IEC material and messages to be prepared within the local context and in the locally
comprehensible language; put up hoardings, posters, distribute hand bills to create
wide spread awareness. The IEC material has to be displayed in schools, all sentinel
sites, prominent locations in the village and busy street crossings in urban areas, and
in all places where mass human gatherings occur e.g. festivals, melas, exhibitions

At village and block level: organize meetings between medical officers of the area,
health workers and village health committees once in three months, with the purpose
of revitalizing this institution, enhance community participation in all health related
matters and identifying the community as partners in the planning and decision
making process.
107
PART – V
QUALITY ASSURANCE
108
26 QUALITY ASSURANCE IN IDSP
Assuring quality in IDSP activity is of primary importance. The quality of data must be valid,
reliable and timely to serve as an effective tool in health decision-making (to serve as an
effective tool in health decision making). To ensure quality in the program the following factors
have been incorporated:
1 Restricting the total number of diseases to be kept under surveillance based on priority
and thus preventing overloading the peripheral staff.
2 Proving training to all the essential staff of the program as specified in the training
section. These include:
a. Induction training
b. On the job training for the 1st 4 years of the program to all the stake holders.
3 Using information technology optimally in data entry and analysis. The large number of
reporting units in the periphery will make the quality of data unreliable unless IT is used.
Computer entry of data has been introduced till the block PHC level. Timeliness of
transfer of information will also be assured by this process. Details are included in the IT
chapter.
4 Development of Field Manuals for the program is of crucial importance to ensure quality
of surveillance. These will be user friendly and in local languages to enable the field staff
to utilize these for standardization and training.
5 Supervision will be a continuous process at all levels to maintain quality.
6 Monitoring, evaluation and feedback have been built into the system to improve on the
activity as the program evolves over time.
7 External evaluation will be mandatory and this will be used to facilitate mid course
corrections in the program.
8 External quality control programs exist for all participating laboratories.
9 A system of accreditation has been developed for participating laboratories.
One of the objectives of the component on laboratory support is to improve the quality of
laboratory services, particularly as they relate to the health conditions under surveillance. The
laboratory data are used to increase the specificity of diagnosis and verify the cause of suspected
outbreaks. As the current quality of laboratory activities across districts and states is unknown it
will be necessary to conduct a baseline survey of the quality of laboratory services for the
diseases under surveillance in the first year of the project. The survey results will form the
cornerstone and basis for a comprehensive external quality assurance scheme (EQAS) to be
implemented during the project.
109
EQAS is evaluation by an outside agency of performance by a number of laboratories on
specially supplied samples with the objective to achieve between-laboratory or between-method
comparability; if these specimens have been analyzed with a reference preparation, estimates of
accuracy can also be made. Such external assessment is essential for maintenance of quality
standards in laboratories. This external assessment should be complemented by laboratories'
internal evaluation through internal quality control and standardization of procedures.
The laboratory network for IDSP will be established at five levels of functions:
1.
2.
3.
4.
5.
Peripheral Laboratories and Microscopic centers (L1 Labs)
District Public Health Laboratory (L2 Labs)
Disease Based State Laboratories (L3 Labs)
Regional Laboratories IDSP and Quality control Laboratories (L4)
Disease based reference Laboratories (L5)
The activities to be undertaken at each level in this laboratory network are as shown in the
Tables 1 to 3 below:
Table 1. Activities to be undertaken in Peripheral Laboratories
PHC Laboratory /
Tuberculosis
Sputum AFB smear
Collect random sample of Sputum
for Culture at L3 Lab
Confirms 0.5%
Malaria
Typhoid
Blood smear for Malaria
Rapid diagnostic test
(Typhi Dot)
Collect blood for culture at L2
Level
Confirm 0.5%
Confirm 0.5%
Water Quality
Kit for chlorination test
Rapid test kit for fecal
Contamination collects random
sample of water for colony
count at L2 lab
Confirms 0.5%
Confirms 0.1%
Cholera
Collect random sample of stool
For testing at L2 lab
110
Table 2 - Activities to be undertaken by the District Laboratories
Conditions
Test
Confirmation
Tuberculosis
Sputum AFB Smear
Confirm 1% (both +ves and -ves)
from Peripheral Labs
Malaria
Blood smear
Confirms 1% from Periphery
Typhoid
Rapid Diagnostic test
and Blood culture
Confirms 1% Typhi Dot tests
positive samples
Blood culture on 1%
of suspected typhoid
Cholera
Stool culture Cholera
Toxin Test
ADD
Stool culture
confirmation in 0.1%
of suspected cholera
1% of samples from periphery
Colony count tested
in 5% of samples
Water Quality Chlorination tests and
colony count
Additional Tests
Rapid test for fecal
contamination
Table 3 - Activities to be undertaken by State Laboratories Test
Conditions
Test
AFB Culture and Sensitivity
Confirmation
Objective
1.
Tuberculosis
Perform 1% of positive culture
from district level
Identify magnitude of
MDRTB
2.
Malaria
3.
Typhoid
Sensitivity Testing in
S.typhi isolates
Confirm 1% of bacterial isolates
at District Level
Pattern of AMR for
S.typhi typing
4.
Cholera
Cholera culture and typing
1% of Cholera isolates from
districts
Identify pattern of
bacterial infection
Confirm 1% from districts
Cholera toxin test
5.
Water Quality Colony count
6.
NCD
surveillance
Blood sugar, HDL, LDL
Risk factor
surveillance for NCD
7.
Polio
Follow present procedures
Confirm Polio
8.
Measles
Kit for Measles IgM antibodies
Confirm Measles
9.
Leptospirae
MAT Test for Leptospira
Confirms 0.5% from district levels
Confirm Leptospirae
111
10. Dengue
IgM test for Dengue
Confirm Dengue
11. Hepatitis
Serology for Hepatitis A, E,
B, C
12. Anthrax
Identification of Anthrax
Confirm Anthrax
13. Plague
Identification of plague
Confirm Plague
Confirm 1% of
samples from district
Quality control
Hepatitis work
Study Tasks:
The Survey Organization selected for EQAS is expected to carry out the following tasks which
should be addressed in the proposal:







Prepare a detailed protocol for undertaking the survey including the overall approach to
the assessment of laboratory quality in a cross-sectional survey, survey methodology,
survey instruments, sample design, and sample size
Details of the manner in which quality of the specific laboratory tests will be made.
Pre-test tools and questionnaire
Carry out the survey
Data entry and analysis
Outline of report
Schedule of work through submission of the final report
26.1 Supervision
Supervision is a process of helping health staff to improve their work performance. Supervision
is not an inspection. The aim of the supervision will be to develop a good system wherein
supervisors and health professionals work together to review progress, identify problems, decide
what has caused the problem and develop feasible solutions.
Supervision will include following components:
- Specific job descriptions that to include surveillance tasks relevant to each category of
health staff.
- Preparation of a supervision plan.
- Conducting supervisory visits.
- Preparation of a supervisory check list.
- Preparation of a report of the supervisory visit.
- A check list of supervisory activities will be developed at every level to facilitate the
process. Supervision will be facilitatory rather than a policing mechanism.
26.2 Monitoring and evaluation
All surveillance activities will be continuously monitored and supervise using pre-defined
indicators. Process and performance indicators for response and management will be developed
for the project. This will ensure building an effective monitoring and supervisory system with
emphasis on developing high quality of surveillance activity in IDSP. The data from monitoring
112
and evaluation will be used to effect appropriate response mechanisms and conduct mid-course
improvement in the program.
The objectives of monitoring will be to assess:
1.
2.
3.
4.
5.
Timeliness and completeness of reports
Responses and action taken.
Delay between onset and identification of epidemics outbreaks.
Supervisory activities.
Actions/steps taken to modify/improve/IDSP are on the basis of data, reports and analysis.
The monthly meeting of the health staff responsible for surveillance at the health facility at the
district level will review and analyze the data reported during the month.
Disease outbreaks and the response of the health system will also be reviewed during these
meetings. A detailed report on the outbreak can be helpful in planning for the next meeting.
Following points will be discussed during the meeting:
- Any changes that were made to initial response activities;
- Recommended changes to improve epidemic responses in the future;
- Dissemination of a report on the outbreak.
When the disease surveillance system has been put in place, an independent external evaluation
of the program will be carried out once a year or once in two years to determine whether:
-
The surveillance objectives are being met.
Surveillance data are used for action.
The improved surveillance has had an impact on health events at district and state levels.
26.2.1 Surveillance Reports
High quality annual surveillance reports would be brought out at District, State and Central level
within three months of completion of each year. These would be treated as key project
deliverables. These reports would also be available on web site for wider dissemination.
113
26.3 Indicators for monitoring the program
Following matrix gives specific indicators to monitor various activities under the Project:
Annex 1: Project Design Summary
INDIA: Integrated Disease Surveillance Project
Hierarchy of Objectives Key Performance Indicators
Data Collection
Strategy
Critical Assumptions
Sector-related CAS
Goal:
To develop the capacity to
manage public health
programs effectively
Sector/ country reports:
National Family Health
Survey
NSSO surveys RCH
survey UNICEF MICS
SRS
(from Goal to Bank
Mission)
Improved management of
public health programs
will contribute to poverty
reduction in India
Project reports:
MOHFW reports at state
and central level
MOHFW reports at state
and central level Periodic
independent third-party
surveys of a sample of
'responses' each 6 months.
Third-party survey in
Years 1, 3 and 5.
(from Objective to Goal)
Improved information
does translate into better
management of public
health programs.
Sector Indicators:
(i) under-5 mortality rate; (ii)
maternal mortality rate; (iii)
nutritional status of under-5s; (iv)
contraceptive prevalence rate. All
in relation to the goals of the
MDGs.
Project Development
Outcome / Impact Indicators:
# and % of districts providing
Objective:
To improve the
monthly surveillance reports on
information available to
time - by state and overall. # and
the government health
% of responses to disease-specific
services and private health triggers on time - by state and
care providers on a set of overall. # and % responses to
high-priority diseases and disease-specific triggers assessed
risk factors, with a view to to be adequate - by state and
improving the on-theoverall. # and % of laboratories
ground responses to such providing adequate quality of
diseases and risk factors. information - by state and overall.
# of reports derived from private
providers. # of reports derived
from private laboratories. # and %
of districts in which private
providers are contributing disease
information. # and % of states in
which surveillance information
relating to various vertical disease
control programs have been
integrated under IDSP. # and % of
project districts and states
publishing annual surveillance
reports within three months of the
end of the fiscal year, publication
by CSU of consolidated annual
Surveillance report (print,
electronic, including posting on
the websites) within three months
of the end of fiscal year
114
Hierarchy of
Objectives
Output from each
Component:
Component 1 - Establish
and
operate a Central-level
Disease Surveillance Unit
Key Performance
Indicators
Data Collection Strategy
Critical Assumptions
Output Indicators:
Project reports:
(from Outputs to Objective)
CSU established and
Central unit reports
Central unit has required
functioning with adequate
staff and IT hardware.
Bank reports
Special surveys and
assessments
managerial and technical
capacity
IT software developed,
operating and national
network established.
GOI willing to adopt new
roles
Central reports on national
disease situation produced on
time.
Component 2. Integrate
and
strengthen disease
surveillance at the state
and
district levels
(a) State level
- establish SSUs linked
via IT
network to CSU
- support districts in
gathering
and entering information
on
time
- support districts in
timely
response to diseasespecific
triggers
Center has the capacity to
provide support and technical
assistance to the states
Number of SSUs established
with adequate staff, IT
Central unit reports
State unit reports
States willing to integrate
disease surveillance activities
hardware/software, linked to
national network.
Bank reports
Special surveys and
States and districts willing to
assessments
involve communities and the
Number and % responses to
disease-specific triggers
private sector
assessed to be adequate.
Number of districts linked to
the state and national disease
surveillance network.
(b) District level -
Number of DSUs established State reports
District and state units have
PHCs/CHCs
- ensure that district level
actions take place on time,
particularly training, QA,
installation of network;
- support reporting units in
gathering and entering
information on time
with assigned staff and
operating IT system.
adequate skills, resources and
authority to respond
Private sector has adequate
incentive to participate
Number and % responses to
disease-specific triggers
assessed to be adequate.
District reports
Number of private health care
115
- respond to diseaseproviders contributing to
specific
triggers promptly
surveillance reports.
- promote participation by
private providers and
laboratories
(c) Community level
Number of villages/urban
State reports
Communities and private
-provide information to
wards reporting occurrence of District reports
reporting units on disease health events.
levels and unusual health
Events
sector have adequate
incentives to participate
Component 3 – Improve
laboratory support
- # of laboratories to be
renovated/upgraded
- # of laboratories to be
equipped
- implementation of
quality
assurance program
Laboratory information is
available in a timely manner
and integrated into the
surveillance system
Laboratory information is of
good quality
# and % of district, state and
national laboratories
providing adequate quality of
information in a timely
manner.
Central unit reports
State unit reports
Bank reports
Special surveys and
assessments
# of reports derived from
private laboratories.
# of quality assurance surveys
completed.
Component 4 - Training
for
disease surveillance and
action
- design, implement,
evaluate,
and modify (as necessary)
training programs to
improve
surveillance activities
Number of staff trained in
• general orientation
• disease surveillance
epidemiology and
outbreak investigation
• use of software
• specific lab assays,
quality control methods
and reporting formats
Quality of training - % of
third-party assessments
favorable.
Central unit reports
State unit reports
Bank reports
Special surveys and
assessments
116
Hierarchy of
Objectives
Key Performance
Indicators
Data Collection Strategy
Critical Assumptions
Project Components /
Sub-components:
1. Establish and operate a
Central-level Disease
Surveillance Unit
Integrate and strengthen
disease surveillance at the
state and district levels
stakehold
3. Improve laboratory
Inputs: (budget for each
component)
USD 2.63 Million
Project reports:
USD 56.47 Million
Supervision reports
Special surveys
Adequate and timely flow of
funds from the states to the
districts
USD 26.57 Million
Supervision reports
Special surveys
4. Training for disease
surveillance and action.
USD 2.97 Million
Supervision reports
Special surveys
Timely assignment of staff
and consultants; equipment
purchased, staff trained, Q A
surveys implemented
Timely procurement
Evaluation and assessment of
training
Quarterly project reports
(from Components to
Outputs)
Adequate and timely flow of
funds from GOI to the states
26.4 Independent external evaluation of the surveillance and response
Depending on the development status of surveillance in a state, program management, process
and performance indicators will be identified. The IDSP will be then evaluated by an
independent external agency using both qualitative and quantitative research methods. First
external evaluation will be done at the end of first year and thereafter every two years.
Recommendations of the external evaluation will be used to improve and modify the existing
systems and also to follow up on the IDSP project.
26.5 Quality assurance of laboratory services in IDSP
Practice of quality assurance should be an integral part of the program and mandatory for all the
constituent laboratories of the Government. Quality assurance comprises of internal quality
control and external quality assessment. It is planned to establish a network of external quality
assessment providers, with the ICMR as the central coordinator. It is proposed to involve
colleges in the country to be EQAS providers. A list of suggested centers is given below.
For Peripherals laboratory – Provider Medical College laboratory
For District laboratory – Provider State/ Medical College laboratory
For States and Regional Laboratory – Central coordinator NIB and IEQAS
For designated central, state and regional laboratory. Liaise with International QA laboratory
coordinated by WHO
117
Central coordinators for Quality Control for Laboratories:
National Institute of Biologicals
In collaboration with
Quality Assurance Division
AIIMS New Delhi (North)
Central Public Health Laboratory
CMC Vellore (South)
Colindale, London
At the initiation of the program, a training workshop for conducting EQAS will be carried out for
state providers. The state providers will then conduct workshops for participating laboratories to
sensitise them and to learn the basic principles of quality assurance. Quality assurance in
laboratory medicine is the means by which reliability, precision and accuracy of investigation
used in support of optimal patient care can be achieved. Quality assurance comprises of internal
quality control and external quality assessment.
Very few laboratories are part of an external quality control program. There is need to develop
this optimally in all levels for the laboratory network as part of the quality assurance program.
Quality control of the peripheral laboratories will be the responsibility of the district public
health laboratory. Confirming 5-10% of laboratory results of PHC laboratory should be made
mandatory at the district laboratory. Private laboratories participating in the IDSP will enroll in
the mandatory accreditation process for which established quality control procedures will be
specified. Laboratory manuals for work on specific diseases will be made available to peripheral
laboratories, both private and government, under IDSP program. Training, on job evaluation and
retraining will be provided to the laboratory personnel as part of quality assurance.
Quality control of the district laboratory will be done by the state laboratories. In addition to
rules in the operational manual of procedure, detailed internal quality control procedures will be
laid down. 5-10% of the results will be counter checked by the state laboratories as part of the
quality control. Regular once a monthly feedback will be provided to the laboratories on the
results of the quality control.
All state and medical college laboratories will participate in the well established external quality
control programme specified by MOHFW. Under the guidance of ICMR, selected reference
laboratories and partner organizations will take up the responsibility for establishing external
quality control mechanisms at the state level.
26.5.1 Role of National Centers for Quality Control

To provide technical supervision and guidance to the Quality Assurance Providers in
the country.

To standardize methods, procedures and equipment and to supply these to QA
Providers.
118

To prepare standard manuals of techniques for the constituent QA Providers.

To serve as a center for the preparation and distribution of certain reagents and
biological reagents for the constituent QA Providers.

To serve as a training center for laboratory personnel and coordinate training
programs for all QA Providers.

To participate in international EQAS along with designated regional QA providers.

To serve as a Repository of standard strains and reagents and regulate their supply to
constituent QA Providers.
26.6 Accreditation
Accreditation is a procedure by which an authoritative body gives formal recognition that a
laboratory is competent to carry out specific tasks. Some countries have made it mandatory for
laboratories to be inspected and accredited before they can start operating. In India Department
of Science and Technology has established National Accreditation Board for Testing and
Calibration Laboratories (NABL). NABL has started the process of accreditation of medical
laboratories both in government as well as in private sector.
Accreditation of constituent laboratories of IDSP will be the pre-requisite of starting the
program. There are various national and international standards for accreditation, some designed
for general purposes such as ISO9000 series and some specifically for laboratory accreditation,
such as ISO 25, and the current ISO 15189.
After program accreditation, the laboratories may be reassessed every 3 years.
26.7 Role of National Institute of Biologicals

Initiate accreditation of laboratories taking part in communicable Disease
Surveillance network.

Follow a policy of reaccreditation
Co-ordinate with CMC Vellore and AIIMS Delhi for information on quality assurance being
followed by accredited laboratories.
119
Fig.
Network of Quality Assurance
Labs-
Network of Diagnostic Health labs
Govt. Army Rail ESI Private national
EQAS Provider – State Lab/Med. Col
District
EQAS Provider NIB and IEQAS
State
Network of Reference
Labs of Infectious
Pathogen
Reference Labs of
Infectious pathogens
Central Coordinator NICD
International Collaboration
IEQAS
Coordinator NIB
International Collaboration –WHO International
Collaboration
International Ref.Ctrs
Coordinators NCD
Coordinators ICMR
120
PART – VI
ENVIRONMENT MANAGEMENT PLAN &TRIBAL
DEVELOPMENT PLAN
121
27 ENVIRONMENT MANAGEMENT PLAN
27.1 Project Context
India has high incidences and frequent outbreaks of diseases like tuberculosis, malaria, cholera,
plague, encephalitis, typhoid, measles, hepatitis and dengue. The Ministry of Health and Family
Welfare (MOHFW), Government of India, has initiated the Integrated Disease Surveillance
Project, to strengthen the backbone of information network for effective public health delivery
system in the country. The project will cover the whole country with the objective of improving
diagnostic facilities in public health laboratories.
27.2 Scope of the Project
The objective of the project is to support improved health outcomes by providing decision
makers with specific timely information on selected priority health conditions and risk factors, so
that preventative and control measures can be planned and implemented. The main components
of the project are i) coordination and decentralization of disease surveillance activities; ii)
strengthening of surveillance activities, especially at state and district levels; and iii) improved
laboratory support to the surveillance system. The project will be implemented in phases across
all the states and Union Territories.
27.3 Environmental Issues
Disease Surveillance Laboratories carry out testing for infectious and contagious diseases, such
as malaria, typhoid, cholera and hepatitis, tuberculosis and HIV/AIDS. These laboratories
therefore generate waste which includes infected human tissues and blood samples, microbes,
discarded chemicals, sharps, etc. Such waste, if not managed properly, carries the risk of
infection for waste handlers and to the larger community and is also a potential environmental
hazard, through pollution of land, water and ground water. Although the amounts of waste
generated from such laboratories is small, its varied and hazardous composition requires
comprehensive management of the waste lifecycle, from source to disposal, to prevent adverse
impacts on the environment and public health.
Adequate waste management in laboratories will not only improve overall environmental
performance but also facilitate in providing a safe workplace for the laboratory personnel. In
addition, laboratories have to comply with the environmental regulations of the Government of
India, specifically the Bio-Medical Rules (prepared in 1998 and amended in 2000).
As part of a baseline assessment of laboratories carried out by an international team in 3 states
(Tamilnadu, Maharashtra and Uttar Pradesh), a review of waste management practices was
carried out. Key findings included:
122



There is little awareness among the staff at State, district or peripheral laboratories of the
existing GOI regulations and of good waste management practices.
Standard safety precautions are not followed in laboratory operations
At the district and peripheral levels, adequate waste management practices are not being
implemented.
However, the team also noted that Maharashtra has instituted basic processes of bio-medical
waste management, under the existing Health System Development Project, and this can provide
an initial framework in that state for dealing with laboratory waste. In addition, the Indian
Council of Medical Research has developed and disseminated a document on bio-safety and
hazardous waste (Standard Bio-safety Guidelines), which addresses safety for health workers and
the importance of implementing the concepts of universal precautions and proper infectious
waste disposal.
27.4 Actions to be taken under this project to address these issues.
The main tool to be developed under the project, to address safety and waste management issues
are Standard Operating Procedures for Laboratories. Under the project, Operations Manuals
have already been prepared which focus on, among other technical topics, good laboratory
practices, decontamination and Bio-safety issues. Given the related nature of the activities for
ensuring good practices in laboratory operations, the SOPs on waste management will be
integrated into the Operational Manuals for the laboratories.
(Annex 1 provides a draft outline for an SOP. The USEPA “Environmental Management Guide
for Small Laboratories” would also be a good reference document.)
A Waste Management Program will also be formulated to define the processes required for
dissemination and implementation of the SOPs at laboratory levels and for monitoring. The
SOPs and WM Program will be finalized through a consultative process, involving the directors
and operators of the national-owned and private laboratories to ensure a feasible and pragmatic
program.
27.5 Project Implementation
A Central Surveillance Unit (CSU), which is to be established at the MOHFW will be the
responsible authority for project implementation at the national level. Surveillance Committees
and Surveillance Units will be established at the state and district levels for implementation and
monitoring of project activities. Waste management activities will be included as part of the
laboratory support and training components of the project.
At the laboratory level, the responsibility for the implementation of the SOPs will rest on the
appropriate officer in-charge of the laboratory.
123
27.6 Key Activities under the project:

Undertake a baseline assessment to review the health and safety and environmental
practices and assess the quantum of waste generated. (This will build wherever
possible on broader health care management and related activities, ongoing in a
number of states.)
 Develop draft Standard Operating Procedures (SOPs) as guidelines for disease
surveillance laboratories.
 Formulate a draft Waste Management (WM) Program for the dissemination of the
SOPs, awareness and training at laboratory levels, including the roles and
responsibilities of various parties, timetable and an estimate of the costs (investment
and operating) and sources of funds for implementation. The initial program will be
subject to refinement and adjustment in the initial stages of implementation, taking into
account the overall health care waste management system in each state.
 Organize a national workshop to discuss the assessment findings and the draft SOPs
and the WM Program. In addition to representatives from MOHFW and state
authorities and municipal bodies, the group should include technical experts,
representatives from WHO, NGOs and industry.
 Design and implement a training program for the implementation of the SOPs. The
training will be divided into modules appropriate for the different responsibilities and
skills of different groups, such as Medical Officers, laboratory personnel, technicians
and cleaners. The training on WM practices will be incorporated within related training
being proposed under the project.
 Support the implementation of SOPs in the laboratories in the various states, in phases
as appropriate. The provision of basic equipment and infrastructure will be in
accordance with the wider laboratory upgrading activities under the project and under a
similar timetable.
 Establish an effective monitoring and reporting system.
27.7 Costs and resources
The project will fund the CSU, including specialist technical support on issues such as waste
management. The project will not provide for the on-going running costs of the SOPs, beyond
support with the initial start up. It is therefore critical that implementation plans at laboratory
levels are designed to be consistent with the level of resources that is expected to be available on
a regular basis. More details on the estimated budget of the WM component will be provided
after appraisal.
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27.8 Monitoring
The implementation of the waste management program will be subject to the same internal
quality assurance systems and external audit provisions as apply to each laboratory under the
project.
27.9 Schedule of Implementation
Task
Undertake baseline
survey
Draft Standard
Operating Procedures
for different types of
facilities
Formulate a draft Waste
Management (WM)
Program
National workshop to
discuss assessment
findings, draft SOP and
discuss proposed
implementation
Finalize SOP,
dissemination and initial
implementation
Develop training
module, schedule,
manual and checklists.
Implementation of
training program
Monitoring and
evaluation
Output
Responsibility
Time-schedule
st
Information on
scale of WM
issues at different
types of facility.
Draft documents
State authorities
1 3 months of Year 1
(of each phase of
implementation)
CSU
1st 4 months of Year 1
Draft documents
CSU
1st 4 months of Year 1
Consensus on
scope and content
of SOPs
CSU
by 1st 8 months of
Year 1
Set of SOPs,
applicable to
different
circumstances
Set of standard
training material
for different
audiences
CSU, state
authorities
Before end of Year 1
CSU, with
technical
support
Before end of Year 1
State authorities
Starting from year 2,
aligned with related
project training; to be
implemented in phases
To be incorporated into overall project monitoring
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28 STRATEGY FOR TRIBAL POPULATIONS
The Integrated Disease Surveillance Project (IDSP) covering all states in India, seeks to assist
the central and state governments to shift from a centrally driven, vertically organized disease
surveillance system to one which is coordinated by the center and implemented by the states,
districts and communities. Since the tribal population constitute the poorest and the most
vulnerable of the social groups in the Project, a Tribal Development Plan is proposed as an
integral part of IDSP. World Bank’s Operational Directive 4.20 related to Indigenous People is
triggered in IDSP.
There are 635 tribes in India located in five major tribal belts across the country. Based on 1991
Census data, tribals account for 8.08 percent of the country’s population (68 million out of 846
million). 7 Indian states account for more than 75 percent of the tribal population. The main
concentration of tribal people is the central tribal belt in the middle part of the India and in the
north-eastern States. However, they have their presence in all States and Union Territories except
the State of Haryana, Punjab, Delhi and Chandigarh. The predominant tribal populated States of
the country (tribal population more than 50% of the total population) are: Arunachal Pradesh,
Meghalaya, Mizoram, Nagaland and Union Territories of Dadra & Nagar Haveli and
Lakshadweep. There are 533 tribes (with many overlapping types in more than one State) as per
notified Schedule under Article 342 of the Constitution of India in different States and Union
Territories of the country with the largest number of 62 being in the State of Orissa (details in
annex 1). The prominent tribal areas constitute about 15 percent of the total geographical area of
the country and correspond largely to under developed areas of the country, wherein tribals
inhabit isolated villages and hamlets.
28.1 Tribals in IDSP
Widespread poverty, illiteracy and malnutrition, lack of personal hygiene, absence of drinking
water, sanitary living conditions and health education, poor maternal and child health services,
and ineffective coverage by national health and nutritional services, have been identified as
conditions responsible for poor health status of the poor. Tribal settlements tend to be small and
isolated and difficult to reach with facilities and services. Even when rural tribal people live in
larger villages, they may be separated in hamlets. However, there are some tribal people who are
relatively well integrated into the communities and access and utilize facilities as other subgroups do. Some tribal groups are nomadic and undertake seasonal migration in response to the
need for livelihood or employment. In addition, economic development is forcing out-migration
from traditionally tribal areas into cities, and often to the margins of such agglomerations. The
ways in which the project would reach these different residential situations are outlined in the
sections on Institutional mechanisms and Implementation and Local Participation.
The project seeks to involve all stakeholders including tribals in disease surveillance to enable
rapid identification of disease conditions and outbreaks to prevent large scale impacts and also is
geared towards a quick response from the health system to this information. Involvement of
tribals in the project would contribute to improved heath status among them.
126
For tribal populations this means that there is (i) strengthened link between the tribal
communities and the health system leading to greater credibility of the health system, (ii) less
reached and unreached areas where the tribals live are brought into the fold of disease
surveillance; (iii) increased disease identification and reporting by tribal communities
overcoming their socio-cultural and economic barriers; (iv) improved health awareness for
disease prevention and treatment amongst the tribals; and (v) improved surveillance of the health
of the tribals – project is expected to monitor a set of communicable and non-communicable
diseases.
28.2 Integrated Disease Surveillance Project
The project covers the entire country though the coverage will be phased with Tamil Nadu,
Andhra Pradesh, Karnataka, Maharashtra, Mizoram, Orissa, Madhya Pradesh and Himachal
Pradesh to be taken up in the first phase. Many of these states have substantial tribal populations
with 2 states having tribals constituting more than 20 percent of the state population and the
others have significant tribal populations.
The major project objectives are:
(i)
(ii)
the establishing of state-based system of surveillance for communicable and noncommunicable diseases and their risk factors so that timely and effective public health
actions can be initiated in response to health challenges in the country at the state and
national level, and
to improve the efficiency of the existing surveillance activities of disease control
programs and facilitate sharing of relevant information with the health administration,
community and other stakeholders so as to detect disease trends over time and
evaluate control strategies.
The project also acknowledges that disease surveillance cannot be sustained unless the
community supports data collection and the health system recognizes them as true
partners.
The project has four major components:
Component 1. Coordinate and decentralize disease surveillance activities. This component will
address the constraints of lack of coordination despite central control of surveillance activities
and the need for changing the diseases included in the system. Effective coordination (as
compared to control) of disease surveillance activities depends on establishing the appropriate
processes and institutional arrangements at the central level. This will be done through the
creation of a small disease surveillance unit to support the states' disease surveillance efforts.
Component 2. Integrate and strengthen disease surveillance at the state and district levels, and
involve communities and other stakeholders, including the private sector. This component will
address the constraints imposed by lack of coordination at the sub-national levels, the limited use
127
of modern technology and data management techniques, the inability of the system to act on
information and the need for inclusion of other stakeholders.
Component 3. Improve laboratory support. This component will address the constraint imposed
by inadequate laboratory support for surveillance through provision of equipment, minor
renovation of laboratories and state level programs for quality assurance of laboratory data.
Component 4. Training for disease surveillance and action. The changes envisaged under the
first 3 components will require a large and coordinated training effort to reorient health staff to
an integrated surveillance system and provide the new skills needed.
The core set of communicable diseases, non-communicable disease (NCD) risk factors, and
environmental factors included in the surveillance system are: malaria, acute diarrheal disease
(cholera), typhoid, tuberculosis, measles, polio, plague, meningo-encephalitis, hemorrhagic
fevers, HIV, road accidents, water quality, outdoor air quality and NCD risk factors (height,
weight, physical activity, blood pressure, tobacco, nutrition and blindness).
28.2.1 Project Benefits
Project beneficiaries would consist of all the tribal population in the project states and districts.
The major benefits from the decentralization of disease surveillance mechanisms to the state,
district and community levels would be increased interaction between the health system and the
community, enhanced community knowledge of the community of disease and control measures,
and improved monitoring and tracking of the disease burden of tribal groups. The propensity of
sub-groups such as tribals and women to seek the necessary treatment is low for various reasons:
 their knowledge regarding symptoms is inadequate;
 myths, superstitions and stigma associated with many diseases are widely prevalent;
 there are widespread misconceptions about the cause and method of spread of diseases;
 there is low awareness of availability of treatment/drugs, and there is greater reliance on
indigenous medical practices.
The integration of the various disease surveillance programs would provide more complete and
coherent health information, better monitoring of disease burden and improved health system
response in the tribal areas too. In the tribal areas also, community-based information is a key
input to the District Surveillance Unit (DSU) which will coordinate all the analysis, response and
feedback of information. These should have a positive impact on the health of the tribals.
28.2.2 Legal Framework
The Fifth and Sixth Schedules of the Indian Constitution provide protection to tribal populations
on account of their disadvantages. The Fifth Schedule designates ‘Scheduled Areas’ in large
parts of central India in which the interests of the ‘Scheduled Tribes’ are to be protected. The
“scheduled” or “agency” areas have more than 50 percent tribal population. The Sixth Schedule
applies to the administration of the states of Assam, Meghalaya, Tripura and Mizoram in the
128
North-East. This schedule provides for the creation of autonomous districts, and autonomous
regions within districts as there are different Scheduled Tribes within the districts. The broad
strategy that evolved from the constitutional mandates was the adoption of the Tribal Subplan
since the Fifth Five Year Plan of the Government of India and the Integrated Tribal Development
Approach, adopted and implemented with some modifications by subsequent government
programs.
Articles 46 and 47 of the Constitution of India provide a framework for tribal policy. Article 46,
for example, provides the following directive: “The State shall promote with special care the
educational and economic interests of the weaker sections of the people, and in particular, of the
Scheduled Castes and Scheduled Tribes, and shall protect them from social injustice and all
forms of exploitation”. Article 47 states that it is the duty of the State to raise the level of
nutrition and the standard of living of the people, as well as to improve public health.
An important objective of the National Health Policy, 2002 is the overriding importance to be
given to ensuring a more equitable access to health services across the social and geographical
expanse of the country and ensure that the access to, and benefits from, the public health system
is ensured for tribals along with women, children and other socially disadvantaged sections of
society.
In response to these Constitutional provisions, the health sector has generally treated tribal areas
as requiring higher health facility : population norms and are provided service accordingly. There
are no laws or statutes that would prevent or constrain tribal access to health care. And on the
basis of available data, it does not appear that either traditional or modern laws affecting tribal
livelihood patterns (e.g.; land tenure, access to forest produce) mobility or other aspects of social
or economic status would in any way cause tribal people to suffer more from diseases or deny
them participation in, or the benefits of, this project.
28.2.3 Methodology for Preparation of Tribal Strategy
The following methodology was followed for developing this Tribal development plan.
28.2.3.1 Consultations with Communities and Health Workers
Two Districts each from the states of Maharashtra (Thane & Nagpur) and Tamil Nadu (Vellore
& Dharmapuri), one each from Uttar Pradesh (Agra) and Chattisgarh (Bilaspur) were selected for
carrying detailed consultations with communities and with health workers. While both men and
women from urban and rural areas were consulted in Maharashtra, Tamil Nadu and Uttar
Pradesh; in Chattisgarh state, the focus of the consultations were on women mainly in the tribal
areas.
A methodology based on rapid assessment procedures (RAP) was used because it permitted
quick but systematic and valid data collection. Opinions, attitudes, constraints and suggestions
regarding the surveillance activities of the respective areas from health workers as well as client
were obtained through Focus Group Discussions (FGDs). Data was collected through focus
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group discussions (FGDs) with grass root level male and female health workers (ANMs, AWWs,
MPHWs and health supervisors) and tribal, rural and urban clients. A total of 15 FGDs were
conducted in the four selected states of which 5 were carried out in Chhattisgarh state with
women. To ward off most of these limitations in RAP, professional training for practitioners of
RAP is of paramount importance. The study design had laid great emphasis on initial training of
the investigators along with in built mechanism of quality assurance measures.
28.2.3.2 Quality Assurance Measures
Several quality assurance measures were implemented/adopted right from the time of
conceptualization of the study so as to improve the validity and reliability of the observations
and the inferences which included:







Guidance notes for Focus Group Discussions (FGDs) prepared by a multi-disciplinary
team with diverse professional backgrounds, training and socio-demographic variability;
who also analyzed the data;
Guidance notes translated into local languages (Hindi/ Marathi/ Tamil) to help
investigators;
FGD notes piloted with mothers attending pediatric out-patient and in-patient services of
All India Institute of Medical Sciences, New Delhi;
All FGDs were conducted in the presence of at least two CCT members, one from the
partner medical college and another from the team at AIIMS, CEU;
During FGDs it was ensured that the discussion site was easily accessible and acceptable
to all the respondents; respondents screened to ensure client category and socio-cultural
group, homogeneity;
Help was sought from experienced facilitators to guide (focus) the discussion in the right
direction;
Consent was obtained from the respondents and all the discussions were tape-recorded.
The transcripts written during the discussion were supplemented from the audiotapes.
The translation and interpretations were accordingly carried out with group consensus.
The details of FGDs conducted in the four states and client characteristics are given in table 1.
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Table 1 : Details of FGDs conducted and client characteristics
S
No
Status
Location
District
Urban/Rural/
Tribal)
State
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Female Clients
Female Clients
Female Clients
Female Clients
Female Clients
Male H W
Female H W
Male H W
Female H W
Male H W
Female H W
Male H W
Female H W
Male H W
Female H W
Gopalpur
Goodbani
Talapar
Koni
Vikas Nagar
Lalapet
Lalapet
Dharmapuri
Dharmapuri
Fatehpur Sikri
Bich puri
Thane
Thane
Gumthala
Kalmeshwar
Bilaspur
Bilaspur
Bilaspur
Bilaspur
Bilaspur
North Arcot
North Arcot
Dharmapuri
Dharmapuri
Agra
Agra
Thane
Thane
Nagpur
Nagpur
Tribal
Tribal
Rural
Urban
Urban
Rural
Rural
Urban
Urban
Rural
Rural
Urban
Urban
Rural
Rural
Chattisgarh
Chattisgarh
Chattisgarh
Chattisgarh
Chattisgarh
Tamil Nadu
Tamil Nadu
Tamil Nadu
Tamil Nadu
Uttar Pradesh
Uttar Pradesh
Maharashtra
Maharashtra
Maharashtra
Maharashtra
Major findings
The major findings based on consultations with women clients in the tribal areas, as well as in
the rural and urban areas are captured below.
1. Socio-cultural and economic barriers: Many of the prevalent beliefs about diseases and
treatment prevented people from using the existing health facilities particularly in public
sector. Both men and women expressed that since they were shy and embarrassed to talk
about diseases related to sex and reproductive organs, particularly if they did not have a good
rapport with the health workers. Thus, information related to HIV-AIDS, RTI, and STD was
difficult to elicit. Similarly, tuberculosis and leprosy were considered diseases with social
stigma. Occasionally mothers would not tell the illness of their children to health workers
because they feared further wrath of evil spirits on their offspring. Limited cooperation from
community and facilitators (Gram Panchayats, RMPs, NGOs etc) were also barriers in
approaching health care systems.
2. Decision making process about health issues : Elders in the families influenced decisions
regarding the place, type and timing of seeking health care especially in tribal areas. Tribal
women perceived their education and financial status as important factors in taking
independent decisions in matters of health for themselves and their children. Education and
jobs for women was perceived by all as a necessary factor to bring about changes in their
status and role in the society. Interestingly there were a few tribal and rural women,
131
especially those in nuclear families, who mentioned that husband and wife took all the
decisions jointly as both were equal.
3. Seeking health care : Due to poverty, poor accessibility to health facilities and various sociocultural beliefs, home remedies are first resort. When symptoms do not ameliorate, help was
sought from traditional healers. Thus, it was often quite late when they reached existing
health facilities for their illnesses. However, for diseases that were perceived as serious in the
community, patients were taken to hospital early. Use of herbal cures is more prevalent
among tribal households.
4. Socio-Cultural factors in the care of sick: Illnesses are often viewed as a curse for which
gods have to be placated by making offerings at the local temple. The offerings ranged from
fruit and flowers to goat, chicken and liquor. Use of emulets, etc was also quite prevalent.
5. Gender barriers: Discussions with women in tribal areas consistently brought out the gender
disparity to seek health care. When men fell sick, family got worried, and treatment was
promptly sought. In contrast, attention was not given to the initial symptoms in women. If the
symptoms did not subside on their own or with home remedies, then they were taken to
health care providers. When it came to visit to hospital or doctor the males wanted their
wives to accompany them but did not reciprocate this gesture. The women had to not only go
alone for their illness but also had to take children, without their husbands accompanying
them. Women face social, physical and economic barriers to seeking healthcare and are
often seen to accord very low priority to their health needs. Further, the indifferent attitude of
the doctors in the public health system, often force women to approach private providers –
unregistered and registered. As a result, the surveillance data most often does not capture the
conditions of women
6. Credibility of health system : Tribal women perceived that doctors in public sector health
facilities did not provide good care to them because they were poor. Patients were either not
given medicines or inadequate medicines were dispersed. The women also felt that whole
treatment was ineffective because injections were given less often at government health
facilities. Another reason for not visiting public health facilities was the lack of any health
center near their homes.
7. Information sharing: While there was no voluntary sharing of information on symptoms and
diseases, on enquiry there was sharing of information. Especially women expressed that no
disease could be concealed for long and moreover concealment may lead to deterioration in
the condition. However, tribal men did show resistance to information sharing.
8. Participation in Surveillance : Greater involvement of Panchayats, overall improvement in
government health services in their area, greater awareness generation on disease
surveillance through campaigns, were identified as important steps in enthusing communities
for getting involved in reporting of various health conditions of public health significance.
132
9. Common health conditions/illnesses in the community: The Health conditions considered
important by men and women in different settings are placed in table 2 below.
Table 2: Health conditions perceived as important in Bilaspur District, Chattisgarh State
Client Categories
for Surveillance
Men
Women
Children
Tribal
Rural
Fever
Jaundice
Malaria
Cough
Fever
Jaundice
Malaria
Cough
Dysentery
Fever
Body ache
Headache
Stomach ache
Malaria
Cold
Diarrhoea
Dysentery
Fever
Body ache
Headache
Stomach ache
Malaria
Cold
Diarrhoea
Urban
Flatulence
Chest Pain
Diminished vision
Depression
Diabetes
Hypertension
Goitre
Diarrhoea
Joint pains
Increase in weight
Allergies
Diarrhoea
Allergies
Pneumonia
Eczema
Ear ache
Cough
In order to ensure active involvement of the tribals and that they benefit in a culturallycompatible manner, the project would ensure that:





Focal social mobilization efforts in the tribal areas to elicit cooperation from the tribal
community including the tribal leaders and tribal panchayat members;
Training and involvement of local tribal volunteers in awareness generation campaigns for
the tribal community; and for information collection in coordination with the health
system staff
Sensitization of health system staff working in the tribal areas and health facilities in the
tribal sub-plan areas to develop a good working relationship with the tribal population;
Design and use of culturally-compatible IEC material in the tribal areas;
Monitoring and evaluation based on data disaggregated by tribal status and gender to
allow tracking of efficacy of the IDSP among these groups.
28.3 Study of community-based disease surveillance systems
In order to better understand the basic principles that would govern the setting up of communitybased surveillance systems under this project, an in depth study was undertaken of the strengths
and weaknesses of existing efforts across the country. Of the systems studied were the North
133
Arcot District Health Information Network (NADHI), Kerala Government project on District
disease surveillance program, BAIF surveillance, the Gadchiroli health program, Comprehensive
Rural health system project, among others. The findings from this study, point towards the need
for the following basic tenets as critical for involving communities including tribals in disease
surveillance under the IDSP. Some of he key findings related to:











Communities that are involved in the program are convinced and are confident that this
effort is for their common good, People’s collectives like self help groups could be
effective partners and their involvement could help sustain the process;
local volunteers could be trained to assist in disease surveillance especially in difficult to
reach areas where the presence of health staff is limited;
Training of health staff for collection of high quality data, proper supervision;
Integration of communicable and non-communicable diseases in the program;
Selection of conditions that have significant association with public health action;
Translation of information into public health action initiation and flexibility to, where
necessary, modify prevalent approaches based on this information;
Integration of private practitioners and Medical colleges in disease control efforts would
strengthen the state’s effort;
Higher level of technology – computerization with networking across Districts;
Appropriate automated and predetermined responses built into the system based on trigger
levels;
Establishing systems for efficient sharing of information across vertical disease control
programs and stakeholders belonging to departments other than health;
Good laboratory support is to establish clinical rather than symptomatic evidence of
disease occurrence.
28.4 Institutional Mechanisms
The Government of India’s special provisions in tribal sub-plan areas include additional health
facilities. In tribal areas, one Primary Health Centre caters to 20,000 persons instead of 30,000
and one sub-centre to 3000 instead of 5000 people. Tribal areas are also provided with more
mobile clinics, allopathic, homeopathic, ayurvedic, unani and siddha dispensaries. In the project,
the health workers at these facilities will be trained to be responsive to the tribals, provide them
treatment and counseling activities, will help identify and train tribal volunteers and ensure
information collection and response to the tribals with the tribal volunteers.
The National and state-level Project Implementation Plans identify tribal populations as a target
group with unique problems of physical and social access requiring culturally sensitive
strategies. The project emphasizes two institutional initiatives which would address the needs of
the tribal people:
1. Decentralization of planning and implementation to the state and district levels. This would
increase the involvement of states and build capacity to manage and administer the IDSP
over the long term. Guided by local needs, states will prepare and implement state-specific
134
annual plans with emphasis on the needs of special groups. This includes carrying out special
mobilization campaigns in the tribal areas; and
2. Better relationship between the health system and the tribals through volunteers will lead to
improved geographical coverage, particularly in remote and unreachable tribal areas.
The project will coordinate with other health activities being carried out by the State Health
Directorates for tribal areas. Representatives of Tribal Development Departments (TDD) would
be included in state/district committees in those areas where tribal population is significant.
TDD would assist in providing mapping and group-specific socio-cultural information on tribal
groups and channels to expand outreach. They could also play a role in the participation of tribal
groups. Population specific information will be used to develop culturally sensitive IEC
materials for both public and providers.
28.5 Implementation and Local Participation
The project seeks to address this by:

Social mobilization strategies: Disease surveillance cannot be sustained unless the
community stakeholders support the data collection and the health system recognizes them as
true partners. Therefore, a well planned social mobilization strategy is to be put in place to
obtain valid and reliable data with high sensitivity. The focus would also be on tribals and
their collectives including tribal women self-help groups and mahila mandals;

Preparation of simple case definitions for diseases: for use by tribals including women can
use;

Sensitization and training programs: planned under the project will be adequately
“gendered” so as to sensitize field level staff to the special needs of tribal women;

IEC plan : That specifically addresses the tribal perspective, will be developed by based on
the state-specific context.
Social mobilization campaigns under the IDSP are for:
 Creating awareness among the partners, notably the private practitioners, NGOs and
the community about existing health programs, IDSP, the potential benefits, areas in
which their participation will be solicited;
 Establishing an institutional mechanism to involve community and their leaders;
 Developing a system of providing regular feedback to the community about disease
occurrence, the responses to surveillance and impact of disease control programs;
 Designing IEC to address all the issues that are likely to improve the sensitivity of the
surveillance data, particularly the prevalent socio-cultural beliefs and gender
disparities;
135


Increasing the reach of the campaign, all channels of communication are to be used;
these will include electronic media, press, hoardings, hand bills, posters, and interpersonal communication through health providers at all levels;
Creating targeted campaigns in terms of content and messages for health workers and
private practitioners; and for the community, panchayat members, local influential
persons and NGOs.
At different levels of the project; the following will be undertaken:
Central level:
 Organizing a media campaign for creating mass awareness about the usefulness of the
surveillance, about core disease surveillance, dispelling common socio-cultural
beliefs and gender disparity
 Sensitization and mobilization meetings for central and state level functionaries of
IMA and other professional bodies to solicit their support for the program
 Some IEC material for health functionaries and selected sentinel private practitioners,
highlighting technical issues
State Level
 Organizing a media campaign for creating mass awareness about usefulness of the
surveillance, about core and state specific disease surveillance, dispelling common
socio-cultural beliefs and gender disparity
 Sensitization and mobilization meetings for state and district level functionaries of
IMA and other professional bodies, medical colleges, NGOs involved in health, to
solicit their support for the program
 IEC material for health functionaries and selected sentinel private practitioners
highlighting technical issues
 IEC material and messages to be prepared within the local context and in the locally
comprehensible language
 Bring out periodic reports on surveillance data and the consequent responses by the
health department as feedback to the community and local leadership
District Level and Periphery
 Organize sensitization and mobilization meetings at district head quarters for local
IMA executive members, prominent practitioners, NGOs in health, elected
representatives of the local as well as state bodies, district panchayat board members,
teachers
 IEC material and messages to be prepared within the local context and in the locally
comprehensible language; put up hoardings, posters, distribute hand bills to create
wide spread awareness. The IEC material has to be displayed in schools, all sentinel
sites, prominent locations in the village and busy street crossings in urban areas, and
in all places where mass human gatherings occur e.g. festivals, melas, exhibitions
136
Village and Block level


organize meetings between medical officers of the area, health workers and village
health committees once in three months, with the purpose of revitalizing this
institution;
enhance community participation in all health related matters and identifying the
community as partners in the planning and decision making process.
While some of the activities like strategies for mobilization and training are common, the case
definitions across states for common disease identified for surveillance would be similar but each
state will develop sate-specific definitions for the specific conditions that they will be tracking.
Similarly successful approaches of IEC already being implanted in the states will be used for
furthering disease surveillance.
28.6 Cost estimate and financing plan
No separate costing or financing plan has been prepared for tribal populations, because the
project addresses all groups including marginalized groups such as tribals and women.
28.7 Monitoring and Evaluation
Sampling design of evaluation studies would include tribal districts/blocks on a representative
basis. The project will monitor increased knowledge of communities and their involvement in
surveillance activities. Community monitoring, a key project issue, would strengthen inputs to
M&E by helping to capture information that would have gone unrecorded due to socio-cultural
barriers and gender discrimination faced by communities, especially vulnerable groups. These
data would demonstrate the extent to which tribal people have participated in and benefited from
the project.
137
Table : Major Tribes of India
STATES
Andhra Pradesh
Assam
Bihar & Jharkhand
Gujarat
Himachal Pradesh
Karnataka
Kerala
Madhya Pradesh and
Chhattisgarh
Maharashtra
Meghalaya
Orissa
Rajasthan
Tamilnadu
Tripura
West Bengal
Mizoram
Arunachal Pradesh
Goa
Daman & Diu
Andaman & Nicobar
Islands
Dadra & Nagar Haveli
Uttar Pradesh &
Uttaranchal
Nagaland
Sikkim
Jammu & Kashmir
TRIBES
Bhil,Chenchu, Gond, Kondas, Lambadis, Sugalis etc.
Boro, Kachari, Mikir (Karbi), Lalung, Rabha, Dimasa,
Hmar, Hajong etc.
Asur, Banjara, Birhor, Korwa, Munda, Oraon, Santhal etc.
Bhil, Dhodia, Gond, Siddi, Bordia, etc.
Gaddi, Gujjar, Lahuala, Swangla, etc.
Bhil, Chenchu, Goud, Kuruba, Kammara, Kolis,
Koya,Mayaka, Toda, etc.
Adiyam, Kammrar, Kondkappus, Malais, Palliyar,etc
Bhil, Birhor, Damar, Gond, Kharia, Majhi, Munda, Oraon,
Parahi, etc.
Bhil, Bhunjia, Chodhara, Dhodia, Gond, Kharia, Nayaka,
Oraon, Pardhi, Rathwa etc.
Garo, Khasi, Jayantia, etc.
Birhor, Gond, Juang, khond, korua, Mundari, Oraon,
Santhal, Tharua, etc.
Bhil, Damor, Garasta, Meena, Sahariya etc.
Irular, Kammara, Kondakapus, Kota, Mahamalasar,
Palleyan,Toda etc.
Chakma, Garo, Khasi, Kuki, Lusai, Liang, Santhal etc.
Asur, Birhor, Korwa, Lepcha, Munda, Santhal, etc.
Lusai, Kuki, Garo, Khasi, Jayantia, Mikir etc.
Dafla, Khampti, Singpho etc.
Dhodi, Siddi (Nayaka)
Dhodi, Mikkada, Varti, etc.
Jarawa, Nicobarese, Onges, Sentinelese, Shompens, Great
Andamanese
As in Daman & Diu
Bhoti, Buxa, Jaunsari, Tharu, Raji
Naga, Kuki, Mikir, Garo, etc.
Bhutia, Lepcha
Chdddangpa, Garra, Gujjar, Gaddi, etc.
138
PART – VII
STRATEGIES FOR INVOLVEMENT OF PRIVATE
SECTOR IN DISEASE SURVEILLANCE
139
29 STRATEGIES FOR INVOLVEMENT OF PRIVATE SECTOR IN DISEASE
SURVEILLANCE
29.1 Initiate Partnership With Private Health Providers For Disease Surveillance
There is need to develop MOU with Indian medical Association, Indian Pediatric Association
and other professional bodies at the Central and state level for partnership under Integrated
Disease Surveillance Project. Discussions with the IMA and IAP at the state level felt that
Memorandum of Understanding with the organizations are necessary both at central and state
levels for effective participation at the district level. Central Surveillance Unit would develop a
MOU with the National Office bears of IMA and IAP as the initial step. An official letter of
invitation for partnership is needed from the MOHFW to initiate this process both at the central
and state level.
The state branch of IMA and IAP will enter into separate MOUs on participation in IDSP. This
MOU should specify the number of units of SSPs that is expected from each of the state and
districts of the country and specify that the final selection may be made in consultations based on
criteria of selection.
29.2 Selection of SSPs
Type of Health Facility that would be suitable to function as sentinel surveillance Unit include
a). Hospitals,
b). Nursing homes,
c). Clinics
Wherever available, the choice of the institutions can be prioritized based on the number of
patients of specific interest to surveillance seen. Volume of patients is usually higher in hospitals
followed by nursing homes and then clinics. Popular Indian system of medicine private health
providers and Registered Medical Practitioners may also be recruited in specific situations.
There is need to include both inpatients and outpatients in the surveillance since severe
presentations and mortality will be reflected in the inpatients and milder and earlier disease will
be reflected in the outpatient surveillance data. Though health clinics overall see the bulk of the
outpatient load. However per unit recruited it is less efficient than larger nursing homes and
hospitals regarding outpatient and inpatient services. Since IDSP is focusing on sentinel level
surveillance from the private sector, efficiency (number of cases of general practice, Medical and
pediatrics) would be the primary criteria to choose a reporting center.
29.3 Method of Selecting the Sentinel Surveillance Unit
DSU should verify list of health facilities and health providers in consultation with district
chapter of IMA & IAP and Directorate of Public Health. If such lists are not available, the state
could initiate a rapid assessment to enlist all health facilities in the district. The final selection of
140
the participating units should be in consultation with the district chapter of IMA or IAP so that
the associations take responsibility and ownership of the reporting unit.
The list should include names, contact numbers and other information on type of cases seen by
them. District Surveillance Officer will choose additional centers as required based on specific
situational analysis in the district. This would include, geographical representation, tribal areas,
urban slums etc.
There may be tribal and rural areas where sufficient number of health clinics manned by
qualified health care providers may not be available. In these areas there are informal private
health providers (RMPs) and qualified providers under Indian systems of medicine who can be
chosen to function as sentinel sites.
29.4 Number of Sentinel Surveillance Units
Recruiting the SSUs can be initiated in a phased manner. Number can be increased over time
during the course of the Project.
Though ideally all the selected conditions required to be under surveillance need to be covered
by all the SSPs, this is unlikely to happen since a pediatrician is not likely to report on leprosy
and general medical practitioners are unlikely to be reporting on Acute Diarrheal Disease which
is primarily a child hood problem. Where hospitals are fewer (rural areas in some districts) it is
likely that more SSPs will need to be identified, while in other districts where sufficient hospitals
and nursing homes are available, SSPs may be limited.
In large metros, there is no dearth of hospitals. There will be at least 20 sentinel hospitals
selected from each city / municipal limits as SSPs.
29.5 Data Collection and Transmission
Following will be highlights of data collection from the Private Sector:
a) Regular Weekly report: All selected Sentinel sites should provide weekly reports on the
conditions under surveillance agreed upon with the District Surveillance Office
b) If no cases are seen Nil report is mandatory
c) Number of conditions under surveillance will be decided in consultation with DSU. Sentinel
surveillance unit can be given freedom to choose and limit the conditions under surveillance
by each unit. Hospitals would be encouraged to report all diseases of interest but nursing
homes and health clinics may choose from the list of diseases under surveillance.
d) A choice of methods for transmission of data to the district level will be given to SSPs..
Flexibility will be provided in the method of reporting by the SPPs. Each PHC may choose
an optimal method that is suitable in the situation. The method of sending the report will be
finalized appropriately for each reporting unit so that if there is delay in reporting this can be
quickly addressed and will be noted at the appropriate level. Any of the following methods
may be used:
141




Telephone followed by mailing of IDSP format by hard copy
Fax to DSO
Electronic mailing direct to DSO
Courier
a. Office of the DSO / CHC
b. Direct contact with Health Worker if necessary
c. Private Courier can be contracted
Telephonic reports will be encouraged during epidemic situations so as to avoid delay. MO
Block PHC / computer entry person / District Surveillance Officer will be able to receive
information from the periphery. Routine reporting will be facilitated by the health worker
visiting the SPPs in the rural areas on specific days assigned for reporting. In urban areas,
telephones can be used or the health workers can collect reports from SPPs as done in the
polio program.
e) Simplified formats for reporting will be used to identify cases on a weekly bases as given
below:
Reporting Format for Sentinel Sites
District Code Number:
Sr.
No.
Suspected Diseases/ Syndromes
(New cases)
1
Ac ute Wa ter y D ia rr hoea
M
/Cho lera
F
Tot
2
Fever > 7 d a ys / Typ ho id
M
F
Tot
3
AFP < in le ss t ha n 15 years
M
of a ge / Po lio
F
Tot
4
Fever w it h ra s h / Mea s les
M
F
Tot
5
Fever /Ma lar ia
M
F
Tot
6
Caugh > 3 we eks /
M
Tuberc ulos is
F
Tot
7
U nus ua l s yndro me s ca us ing M
deat h or hosp ita l ad miss io n F
T
8
Fever w it h Bleed ing /
M
De ngue
F
T
9
Fever w it h A lte red
M
Consc io us ness o r
F
Convuls io ns / J E
T
10
O ther s Spec ify
M
F
T
Unique identifier for Reporting unit:
Patients treated
OPD
IPD
Total
<5
>5
<5
>5
<5
>5
Death
<5
>5
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If no cases are seen ‘0’ will be marked against the corresponding disease and the results
submitted to the DSO or MO PHC/CHC
29.6 Integrating Private Sector under IDSP
The SSPs will act primarily as an afferent arm of surveillance in data collection Health
inspectors from PHC, CHC, District Hospitals will function as the link person between SSPs
and Public sector units responsible for surveillance action. In Tamilnadu, the Health inspector
is currently the key integrating person. This model could be expanded under IDSP. Health
Inspectors or equivalent officials are posted currently in all PHCs and many urban hospitals.
With training these personnel could be the integration factor between private and public
health system at the rural and urban levels of the state. Each of the sentinel private sector unit
participating in the surveillance is under the supervision of one health inspector. On a weekly
(in outbreaks daily) basis, he/she would visit sentinel sites in different regions and collect
information on the cases of interest. The routine allows once a week visit to each of the
sentinel sites. The data will be collated by the Health Inspectors and passed on to the PHC
doctor for forwarding to DSU.
29.7 Increasing Sensitivity of Reporting Units
There has been some pilot projects which has shown partial success in integrating private
health providers in sentinel surveillance. The lesions from NADHI and Kerala district
surveillance model could be used to increase the sensitivity of reporting in IDSP. Pre-paid
post cards with the names of the diseases/syndromes of interest are distributed to all health
providers who are encouraged to mail the cards to the DSU as and when there is a change in
trends of disease or some unusual syndromes in the locality. Since this is similar to the rumor
registry but with better organization the DSU or PHC/CHC medical officer will undertake
epidemic investigations as warranted to confirm changing trends or emerging outbreaks.
There is no insistence on zero reporting and a wide spectrum of private health providers can
effectively participate in this program. To be effective active distribution of pre-paid post
cards will need to be carried out. Feed back need to be provided to participating health
providers by the DSU.
The same system can also encourage a wider group of RMPs and Indian system of medicine
doctors also to participate reporting unusual trends in disease through prepaid post cards.
29.8 Maintaining quality of Reporting
To ensure that quality of information is maintained, following steps will be taken:



Ensure Availability of Operations Manual
Training of SSPs on IDSP should be provided.
Each SSPs should state the diseases of interest which will be under surveillance
and mode of transmission of this data to the next level
143


Health Inspectors / Leprosy inspectors may need to visit the units at regular
intervals to facilitate regular reporting
Feed back from DSU is very important for maintaining quality of reporting
All the private health providers who participate in the program as SPPs should have the hard
copies of operations manuals provided by the district surveillance team. This along with training
should ensure quality of reporting. Private health providers are busy during regular working time
and short duration half day training programs particularly during weekends are suitable for
improving their knowledge, attitudes and skills under IDSP. These programs need to be
separately arranged from the health workers and unqualified private health providers. The
respective associations may be requested to organize this activity in which the district
surveillance officer and the district training team can participate. The training should include






An overview of the IDSP and its objective
Data collection
Specimen collection
Reporting formats and frequency
Trigger levels and type of public health measures
Feed back
Feed back from the District surveillance officer should specify the accuracy of reporting, the
timeliness and regularity to individual SSPs at monthly intervals.
29.9 Sustainability of Partnership
To sustain partnership with private sector, following initiatives will be made:




Incentives
Maintain confidentiality in sensitive information.
Consider SSPs as equal partner in the program
Feedback
There seems to be general agreement that financial incentives for SSPs are not possible for their
participation. Experience with NADHI surveillance system in Vellore and Kerala Model of
District based surveillance have shown that the following incentives are sufficient for private
sector participation. These include:






Actual cost of participation may be re-imbursed without delay as done in polio program.
This may be postal or telephone charges.
Inclusion of name in the network directory.
Representation in the District surveillance committee
Certificate of recognition and participation for participation in National IDSP.
Access to IDSP computer web reports.
Quarterly bulletins on health status of the region from District Surveillance Officer.
144


Feedback on surveillance from the district surveillance officer on a regular basis.
Membership in village health committee meetings on rotatory basis.
29.10 Continuing Medical Education Session:
One of the important felt needs of the private practitioners is method to improve their patient
care by updating the current knowledge about management options. The IMA meeting and IAP
meeting this factor emerged as an important incentive to be a part of the sentinel surveillance
unit. The association may be provided support money to conduct once a year CME session at the
state capital to their members participating in IDSP. These CMEs should be allowed to be
organized and conducted by the organizations themselves and be seen as a clear incentive for
their participation in the program. The choice of the subjects for CME and also the choice of the
resource persons invited for these CMEs should be primarily decided by the respective
associations. Participation of the medical colleges and other experts could be facilitated by the
state IDSP committee. The forum could also be used to give feed back on the role of SSPs in
IDSP and provide further reinforcement on the methodologies in surveillance.
29.11 Other Determinants of Sustainability:
In the discussions with IMA members regarding their experience with participating in
government program, one of the most important factors that determine success was listed as
respect for the private sector. There is lot of good being performed by both private and public
health sector for the health of the country and there are a number of success stories where true
partnership has shown a new way of success. There is need to highlight these success stories in
the training programs for IDSP.
There should be mutual respect and consideration as equal partners rather than as junior officers
of the government service since independence is the most important reason why private
providers remain as private providers.
The participating units and doctors has to feel that they are benefiting the society through the
activity and at the same time gain regarding pattern of diseases in the community. Both these
factors can be achieved through a proper feed back mechanism, which has to be built in as part
of private sector partnership.
Printed quarterly reports will be sent to all participating SPPs from the district surveillance unit.
This bulletin will list all the SPPs who are contributing to the program in the district and the
number of cases reported by them I-n each quarter.
The experience of NADHI has shown the importance of a motivating person or group which is
needed for successful sustainability of the program. There is need for hand holding and constant
support and encouragement from this person or group for the private practitioners. In IDSP the
district surveillance office necessarily have to take on this responsibility of bringing together and
integrating the private and public health systems in the region.
145
29.12 Evaluation
The district and state surveillance officers will make internal assessment of private sector
participation every year which include
Process Indicators:
 Number of SSPs identified and participating in the program

Percentage of SSPs completed training for IDSP

Percentage of SSPs reporting with more than 80% regularity

Timeliness of reporting by SSPs

Total number of interactions of Health inspectors with SSPs

Number of feedback reports received by the SSPs from DSU

Number of CME programs conducted with support from IDSP
External Evaluation will be conducted on the level of success of private sector participation in
IDSP. The strategy of private sector participation will be evaluated at the end of 2 years to assess
the status of functioning. The indicators for evaluation will include the following in addition to
the process indicators mentioned above
Performance Indicators:




Number of outbreak investigations carried out in response to information from SSPs
Number of pre-paid cards received by DSO from private sector health providers
Number of disease outbreaks detected through private sector
Feedback from partners
146
PART – VIII
PROCUREMENT OF GOODS & SERVICES
147
30 PROCUREMENT OF GOODS AND SERVICES
Integrated Disease Surveillance Project aims at developing a surveillance system capable of
monitoring occurrence of selected communicable and non-communicable diseases in an
integrated manner with the objective of forecasting situations where risk of outbreak of specific
diseases could be predicted. This would help in curbing outbreaks at early stages. The project
would also help in assessing trends of common communicable and non-communicable diseases
over time, which would help in effective planning and resource allocation in the health sector.
Diagnosis of target diseases, assessment of emerging situation through use of information
technology and rapid response to prevent and control target diseases are the key activities of the
project. The project would be implemented throughout the country in all 592 districts. For
effective implementation of the project, the project would be introduced in 3 phases in the first 3
years of the project as given below:
Phase I (2004-05): Tamilnadu, Maharashtra, Karnataka, Andhra Pradesh, Uttranchal, Himachal
Pradesh, Madhya Pradesh, Kerala and Mizoram covering 206 districts;
Phase II (2005-06): Gujarat, Haryana, Rajasthan, Orissa, Chattisgarh, West Bengal, Delhi, Goa,
Chandigarh, Manipur, Meghalaya, Tripura and Pondicherry covering 176
districts;
Phase III (2006-07): Remaining States/UTs covering remaining 210 districts.
Phasing has been decided on the basis of preparedness of the States to launch the project.
Phasing would also help in proper monitoring and supervision of the Project.
Procurement of works, goods and services would be done at Central, State and District level
based on method of procurement, availability of goods and services, capacity of the
States/Districts, logistics and sustainability. Level and method of procurement is described in
each section of this chapter. At the central level and in some cases at the State level (depending
upon the method of procurement of quantity of goods), services of Procurement Agents would be
sought. Component-wise details are given below:
30.1 Civil Works: Renovation and Repair [Annexure 1]
The project does not envisage any new construction activity. Civil works proposed under the
project are basically renovation/repair of existing structure and in some cases there may be need
for extension of facilities. These works would be required at all levels: Peripheral (Laboratory
and Peripheral Surveillance Unit at CHC), District (District Public Health Laboratory/District
Surveillance Unit), State (State Public Health Laboratory/State Surveillance Unit) & Central
Surveillance Unit. Estimated Number of Works, Unit Costs and Total Costs are given below:
148
No. of
Works
I. Peripheral 3356
II. District
1184
III. State
62
IV. Central
2
Total
4604
Level
Unit Costs
(Rs. in million)
0.02
0.14
0.14
1.00
Total Costs
(Rs. in million)
67.12
165.76
8.68
2.00
243.56
Method
DC
NS
NS
NS
Civil works would be undertaken through following methods: Level I: Direct Contracting (DC), as the works are small and widely distributed
Level II & III: National Shopping (NS) - District wise
Level IV: National Shopping (NS) by Central PWD
Civil works will be completed in the first three years of the project. State-wise and year-wise
distribution of civil works is given at Annex 1.
Year-wise number of packages and their values are indicated below:
(Rs. in million)
Works at:
Peripheral
Laboratories
District
Laboratories &
Surveillance
Units
State
Laboratories &
Surveillance
Units
Central
Laboratories &
Surveillance
Unit
Grand Total
Estimated
Cost
Year 1
Year 2
Total
Cost
Year 3
No. of
Packages
Cost
No. of
Packages
Cost
No. of
Packages
Cost
0.02
1,634 *
32,68
989 *
19.78
733 *
14.66
67.12
0.14
412 #
57.68
352 #
49.28
420 #
58.80
165.75
3.64
18 #
2.52
8.68
-
-
-
0.14
18 #
2.52
26 #
1.00
2#
2.00
-
-
2,066
94.88
1,367
72.70
* Direct Contracting ; # National Shopping
1.171
75.98
149
243.56
30.2 Goods & Equipment
Procurement, installation and commissioning of Laboratory & Information–Technology
equipments are a major component of the project. These are grouped in six categories: (a)
Lab Equipments: [Annexure 2, 2/I, 2/II]
Laboratory equipments are required at 4 levels-Peripheral, District, State and National level
Laboratories. Requirements would be worked out by assessing existing availability of
equipment. Total estimated numbers of labs at various levels along with estimated costs are
given in Annexure 2. Total estimated cost of this component is Rs. 641.94 million. Method of
procurement and number of packages along with their values are summarized below:
(Rs. in million)
Method of
Procurement
ICB
NCB
NS
Total Value
Year I
Year II
Year III
No. Of Packages
Value
Range
4
93.20
30.00-60.00
4
104.50
30.00-60.00
No. Of Packages
Value
Range
3
16.30
10.00 –
14.00
216
137.01
0.10 - 0.80
246.51
4
85.50
30.0060.00
3
15.95
10.00 –
14.00
189
86.61
0.10 - 0.80
188.06
No. of Packages
Value
Range
3
15.45
10.00 –
14.00
219
87.42
0.10 - 0.80
207.37
Current availability of Lab equipments at each facility would be assessed as early as possible
to determine requirement of each item enlisted for Laboratories at each level. The equipments
would be grouped as minor and major and procured through following methods: 
Minor instruments & equipments (each item costing less than Rs. 100,000): National
Shopping (NS) by Districts/States; and

Major equipments (each item costing Rs. 100,000 or more): National/International
Competitive Bidding. (NCB/ICB).
Lab equipments would be procured in the first 3 years of the project. Lab equipments by
NCB or ICB would be procured centrally. Normally States/Districts would procure the
150
equipment under National Shopping. States having capacity and successful experience of having
procured goods under World Bank projects can also undertake procurement under NCB.
However, at the request of the States/UTs, equipment could also be procured at the Central
Level. Total number required for each of the above items at all levels for Phase I states is being
worked out in consultation with the States. Similar assessment will be worked out for Phase II
and III.
Provisional lists of items along with numbers required at each level is given at Annexure 2/I.
Year wise number of packages according to procurement procedure is given at Annexure 2/II.
(b) Computer Hardware and Operating System[Annexure 3, 3/I]
Development of IT network connecting peripheral, district, state and central surveillance
units is a major component of the project. The goods included in this component are computers
of different configurations, printers, and modem, UPSs along with accessories required for
networking. These would be procured as packages through International Competitive Bidding.
Total estimated cost for this component is Rs. 451.85 million. State-wise and facility wise
estimates are given in Annexure 3.
Computer Hardware alongwith Operating System on Clients is proposed to be provided
at various levels as given at Annexure 3/I. As states would be covered in 3 phases, the bidding
process would be undertaken Phase wise in each of the first three years as per details given in
Annexure 3.These items will be procured as 3 ICB packages during the first 3 years of the
project, value of packages being Rs. 156.87 million, Rs. 139.14 million and Rs. 155.84 million.
(c) Office Equipments: [Annexure 4, 4/I]
Office equipments include photocopiers, overhead projectors; fax machines, telephones,
LCD projectors, air conditioners etc. These items are usually not manufactured by the same firm
and therefore would be procured as individual items. Districts/States would therefore, procure
these items through National Shopping and/or NCB at the central level as indicated in Annexure
IV. Items like Telephones and Air Conditioners, which require frequent maintenance services,
have been included under National Shopping. State wise and unit wise estimates are given in
Annexure 4. Total estimated cost for this component is Rs. 102.59 million.
List of office equipment at various levels is given at Annexure 4/I. These items will be
procured as NCB and NS packages in first 3 years of the Project as per details given below:
151
(Rs. in million)
Method of
Procurement
NCB
National Survey
Total Value
No. of Packages
Value
Range
No. of Packages
Value
Range
Year I
Year II
Year III
5
18.28
2.00 – 11.00
434
22.99
0.05 – 0.10
41.27
4
15.18
2.00 – 11.00
378
15.56
0.05 - 0.10
30.74
4
16.68
2.00 - 11.00
438
13.90
0.05 - 0.10
30.58
(d) Operating System for Server, RDBMS, Website tools and GIS software: [Annexure 5, 5/I]
Operating system is required for carrying out various functions (data entry, data analysis,
transmission of information and reporting) of networking the computers. These are off the shelf
available items and will be procured centrally under ICB procedures. Total estimated cost of this
component is US $4.42 million equivalent. There will be three ICB packages, one for each phase
of the project at an estimated cost of US $1.55 million for phase 1 (year 1), US $1.34 million for
phase 2 (year 2), and US $1.53 million equivalent for phase 3 (year 3) of the project.
To carry out various functions related to data entry, transmission of information, data
analysis and reporting, OS for Server, RDBMS, Website tools and GIS software would be
procured and installed in Surveillance Units at all levels. These are readily available items and
would be procured off the shelf as packages through ICB at the central level to ensure uniformity
throughout the country. Total estimated cost of OS for Server, RDBMS, Website tools and GIS
software is Rs. 200.76 million.
State-wise & year-wise requirements of software at various levels are given at Annexure 5.
OS for Server, RDBMS, Website tools and GIS software to be procured at various levels are
given at Annexure 5/I. These software items will be procured as 1 ICB package each in the first,
second and third year of the project and value of the packages is Rs. 70.22 million, Rs. 61.00
million and Rs. 69.54 million respectively.
(e)
Furniture & Fixtures [Annexure 6, 6/I]
Laboratories and surveillance units at various levels would require furniture and fixtures
i.e. tables, chairs, laboratory platforms, washbasins, etc. These would be procured through
National Shopping (3 quotations) procedure as requirements are to be tailored according to local
conditions existing at the laboratory/surveillance unit level. Total estimated cost of furniture is
Rs. 142.48 million. State wise and unit wise estimates are given in Annexure 6.
152
Items required at laboratory and surveillance unit levels are given at Annexure 6/I. These
items will be procured by National Shopping at District, State and Central level, the number of
packages being 217, 189 and 219 packages in the first, second, third year of the project,
respectively. District will procure for Peripheral units also and the cost of each package will not
exceed Rs. 0.40 million.
(f) Laboratories reagents, chemicals & other consumables including glassware (Material &
Supplies) [Annexure 7, 7/I]
Laboratory consumable goods and supplies would be required continuously for undertaking
various diagnostic tests. A maximum of 15 items by peripheral labs, 21 items by district/state
laboratories will be procured. Details of the items required by the peripheral, district and state
laboratories are given in Annexure 7/I. All these items would be procured through National
Shopping at the District and/or State level except some items like HIV kits (incremental over and
above provided by NACO), Rapid Test kits for Typhoid etc. Since these items may not be
available in all the districts, these would be procured through National Competitive Bidding at
the Central level. Total estimated cost of these goods at various levels is Rs. 310.50 million with
details in Annexure 7.
Each items of Rapid Diagnostic Kit for Typhoid, Rapid test kit for faecal contamination and
HIV diagnostic kit ELISA will be procured separately as 3 NCB packages in each of the first 3
years of the project. Number of National Shopping Packages will be as under:
(Rs. in million)
Method of
Procurement
NCB
National
Shopping
Total Value
No. of
Packages
Value
Range
No. of
Packages
Value
Range
Year I
Year II
Year III
Year IV
Year V
3
3
3
3
3
3.87
1.00 –
2.00
215
7.53
2.00 –
4.00
404
10.53
3.00-5.00
10.53
3.00-5.00
10.53
3.00-5.00
623
623
623
26.00
0.15 –
0.30
29.87
45.40
0.15 –
0.30
52.93
65.37
0.15 –
0.30
75.90
65.37
0.15 –
0.30
75.90
65.37
0.15 –
0.30
75.90
District will procure for Peripheral units also and the cost of each package will not exceed
Rs. 0.30 million.
153
30.3 Services
For hiring of consultancy services under Quality and Cost Based Selection (QCBS) method,
technical and financial weightage will be in the ratio of 60:40 for hiring of services of a
procurement agent, 90:10 for development of application software for surveillance and 70:30 for
other consultancy services. The leasing for Wide Area Networking (WAN) would be through the
least cost selection method subject to the qualification parameters agreed to by GOI and the
Bank.
a)
Procurement Consultants
For procurement of goods, equipment, IT hardware and software and selected lab material
etc. at the central level, a procurement agency would be identified through Quality & Cost Based
Selection (QCBS) (weightage: technical 60% & financial 40%) method of hiring of consultancy
services. For calling expression of interest, criteria would also include experience in procurement
of goods/equipment under World Bank project. Estimated costs of procurement at central level
during the project period, would be approx. Rs. 1250 million. Estimated fees of procurement
consultant would be approximately Rs. 25 million.
b)
Individual Consultants & Contractual Services [Annexure 8, 8/I]
For various specialized services, consultants/contractual personnel would be needed for the
entire period of project. These would be engaged following World Bank procedure of Short
Term Consultants i.e. by preparing & getting T.O.R. approved, advertisement in leading
newspapers and selection of the most suitable candidates. The job description, minimum
qualification and experience, terms of employment and selection procedure shall be cleared by
the World Bank. Respective units at District, State and Central level would hire these
individuals. Number of Surveillance Units where consultants/contractual personnel would be
required and estimated costs are given below:
Level
No. of Units
II. District
III. State
IV. Central
Total
592
31
1
624
Unit Costs/Year
(Rs. in million)
0.20
0.60
2.40
Costs for 3-5 Years
(Rs. in million)
472.80
74.40
14.00
561.20
Numbers of consultants/contractual personnel at various levels along with annual proposed
consultancy fees are given in Annexure 8. State-wise & year-wise requirement of personnel at
various levels and costs involved are given in Annexure 8/I. Total number of personnel to be
hired year wise and their costs are given below:
154
Year I Year II
Year III
Year IV
Year V
No. of Personnel
902
1697
2600
2600
2600
Costs (Rs in
million)
51.00
92.00
139.40
139.40
139.40
c) Consultancy for Development of Application Software for Surveillance :
A specific type of application software would be required for effective surveillance of
various diseases. This would require identification of application software development agency
to carry out the job of developing, testing, operating, training and maintenance of Application
Software. This application software will ultimately be the property of the client (Government of
India).
Development of application software and its application is the most critical input of
the project. Successful implementation of project activities including rapid response
to outbreaks of diseases and efficient utilization of the computer hardware would
largely depend on effectiveness of this specifically designed software. It is therefore
proposed to select software agency through Quality & Cost Based Selection
(weightage: technical 90% & financial 10%) QCBS – 90% & 10%). As per the
procedure, TOR would be got cleared with the World Bank. Estimated cost of this
component for entire period of the project is Rs. 75 million.
d)
Information, Education and Communication (IEC) Activities [Annexure 9, 9/I, 9/II]
IEC activities would be carried out at district, state and national levels. Advertisement in
newspapers is for public awareness to take preventive action against various target diseases.
Therefore this activity should be funded as part of IEC services. Procedures proposed to be
adopted at various levels are as follows: (i) District: Cost Estimates of each of the following activities are given in Annexure 9:




Organization of sensitization workshops;
Organization of review meetings of District Surveillance Committee;
Publication of advertisement in local newspapers (selected on the basis of circulation);
Printing of material (leaflets, brochures, formats for reporting etc.) would be
undertaken by calling 3 or more proposals by giving advertisement in minimum 3
newspapers and
155

Indigenous methods (like street plays, puppet shows, weekly bazaars, drum beating),
counseling and motivation of public through interpersonal communication. Most of
these activities would be undertaken by single source or through NGOs.
District Surveillance Units will arrange for these activities at peripheral level also. Costs
include expenditure at district as well as peripheral levels.
(ii) State: Cost Estimates of each of the following activities are given in Annexure 9.






Organization of sensitization workshops;
Organization of review meetings of State Surveillance Committee;
Press Advertisement: By calling 3 or more proposals by giving advertisement in
minimum 3 newspapers. Selection of newspapers would be based on circulation ratings
in various languages;
Print Media: by calling 3 or more proposals by giving advertisement in minimum 3
newspapers;
Telecasting: Selection of channels would be based on viewers-ship ratings and reach.
Services would be hired through Consultant Agencies following Quality & Cost Based
Selection (QCBS) procedure; and
Broadcasting: Selection of channels would be based on audience ratings and reach.
Services would be hired through Consultant Agencies following Quality & Cost Based
Selection (QCBS) procedure.
(iii) National: Cost Estimates of each of the following activities are given in Annexure 9.


Organization of workshops;
Organization of National Surveillance Committee meetings and review meetings;

Press Advertisement – Development of advertisements and thereafter publication of the
same in national papers. Services would be hired through Consultant Agency following
Quality & Cost Based Selection (QCBS) procedure;
Print Media - Printing of Manuals, guidelines, training modules and other prototype
materials would be undertaken at central level. For this activity Consultant Agency
would be hired through Quality & Cost Based Selection (QCBS) procedure;
Production of TV/Radio Spots - Services would be hired through Consultant Agency
following Quality & Cost Based Selection (QCBS) procedure; and
Telecast & Broadcast – Selection of channels would be based on viewers-ship ratings
and reach. Services would be hired through Consultant Agency following Quality &
Cost Based Selection (QCBS) procedure.



State-wise and year-wise estimated costs for IEC are given at Annexure 9/I. Activity wise with
year wise costs method to be adopted are given in Annexure 9/II
156
e)
Evaluation Studies: [Annexure 10]
Independent evaluation studies would be carried out during initial stage (baseline study),
3rd year (mid-term study) and in the final year (end-line study) of the project. These would
include the following:
 Quality Assurance of Laboratory Services including Laboratory Waste Management
Practices
 Survey on Risk Factors of Non Communicable Diseases
 Evaluation of training activities at various levels
 Effectiveness of Information Technology
 Cost benefit analysis of the project
In all, 14 studies would be undertaken covering eight subjects as indicated in Annexure
10. These studies would be carried out through independent agencies, which would be selected
through QCBS procedure at the Central level. Total estimated costs of evaluation studies would
be Rs. 55 million. Year wise number of Evaluation Studies are given below:
(Rs. in million)
f)
Year I
Year II
Year III
Year IV
Year V
Study S.No.
1, 4
2, 5
3, 6, 9, 10
7
8, 11, 12, 13, 14
Districts Covered
41
38
141
20
220
Estimated Cost
7.05
6.90
19.05
6.00
16.00
Training [Annexure 11, 11/I]
Training would be undertaken at various levels as per standard guidelines, curriculum and using
prototype-training manual developed centrally. Main training courses to be undertaken during
the project are as under:
157
i. Training of District & State Surveillance Teams, Laboratory Technician and Data
Managers: These are the most important training courses and basically aim at developing
capacities at various levels for undertaking disease surveillance and laboratory services.
Such training courses would be organized in institutions that fulfill qualifying criteria and
would be identified through QBS (Quality Based Selection). About 25 institutions will be
hired for each training i.e. Laboratory Technicians, Data Managers and District/State
Surveillance Teams. Thus there will be 75 packages for each year. The training would be
independently evaluated through selected agency as described in Para 3(e) above.
ii. Training of Medical Officers of PHCs & CHCs etc. This training would be organized by
District Surveillance Units at the district level and conducted by members of District
Surveillance Unit and other resource persons. This activity will not be out-sourced.
iii. Training of Multipurpose Health Workers (MPW) and Lab. Assistants. Their training is
job-related and interactive in nature and would be carried out by the selected Community
Health Centres (CHCs) within each District. These CHCs would also be the peripheral
nodal points for Disease Surveillance. This activity will not be out-sourced.
Number of personnel to be trained and estimated costs are given below: (Rs. in million)
Training Category
MPW
Lab. Assistant
2004-05
No.
66158
Costs
2005-06
No.
51.934 44836
Costs
2006-07
No.
Costs
35.196 49159 38.590
on Training
125.72
1634
1.479
989
0.895
10894
19.990
6957
12.766
Lab. Technician
824
2.563
704
2.189
840
2.612
7.364
Data Managers
206
0.641
176
0.547
210
0.653
1.841
DST Team
824
5.727
704
4.893
840
5.838
16.458
SST Team
45
0.513
65
0.741
45
0.513
1.767
57.228 60174 64.186
204.261
Medical Officers
Total
80585
82.846 54431
733
Total Costs
0.663
3.037
8347 15.317
48.073
Unit Costs for each type of training course has been computed at Annexure 11. State-wise &
year-wise personnel to be trained and estimated costs are given at Table 11/I.
g)
Leasing of Wide Area Networking (WAN) [Annexure 12]
Leasing of WAN will be in the years 2 to 5 as procurement of computer systems will start
in year one. Hiring of agency for leasing of Wide Area Network for the project period will be
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through Least Cost Selection procedure subject to the qualification parameters agreed to buy
GOI and the World Bank. Estimated costs for leasing of lines are given in Annexure 12.
30.4 Incremental Operational Cost [Annexure 13 & 13/I]
Maintenance of buildings will not be undertaken under the Project and this would be
responsibility of the States/UTs. Other costs covered under this category are given below:
 Travel Costs, POL and maintenance of available Government vehicles used for
Surveillance activities. In case Government vehicles are not available, hiring of vehicles
by Direct Contracting at prevailing Government/market rates
 Maintenance of equipment, computer hardware and accessories (after warranty period)
 Allowances to staff including per diem during tours
 Expenditure on Telephone, fax, postage, courier, electricity and other services
 Office Stationery and other consumables items
 Other miscellaneous activities required for effective surveillance.
Total estimated operational cost is Rs. 580.60 million. Details of operational costs for each
unit are given in Annexure 13. State-wise and year-wise operational costs are given in Annexure
13/I.
The state would be contributing a proportion of incremental operational costs on an
increasing scale over the project period and assume the entire responsibility of this component
after the project is over. This contribution will be guided by the following table :
Project States
Phase I
Phase II
Phase III
Year 1
Year 2
Year 3
Year 4
Year 5
20%
20%
30%
40%
50%
20%
20%
30%
40%
20%
20%
30%
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GOI would release the funds in two half-yearly installments to the state society on the basis
of approved Annual Work Plan, the existing unspent balance, if any, and the funds to be
provided by the state. The project states will fund from their resources, a part of incremental
operational costs through the same fund flow mechanisms i.e. via the selected state society
acceptable to GOI and IDA.
30.5 Prior Review Thresholds
Following procurement of goods and services would be subject to prior review by the World
Bank :

All contracts for works with an estimated value of more than US $500,000 equivalent.

Contracts for goods/equipment estimated to cost the equivalent of US $500,000 or more,
provided, however, that subsequent contracts for the same goods/equipment with respect to
which prior review has been carried out and completed in an earlier contract shall be subject
to post review only. With respect to such subsequent contracts, the Borrower shall: (A) notify
the Association of the initiation of the process for the procurement of goods/equipment; and
(B) provide to the Association for its approval, any proposed changes to the bid documents
from the earlier contract relating to the method of procurement, specifications, and
qualifications and evaluation criteria.

The first NCB contract for goods valued more than US $30,000 but less than US $500,000
equivalent.

Consultant's contracts with an estimated value of US $100,000 equivalent or more for firms
and US $50,000 equivalent or more for individuals, provided, however, subsequent contracts
for the employment of consulting firms or individuals for the same type of activities with
respect to which prior review has been carried out and completed in earlier contracts shall be
subject to post review only. With respect to such subsequent contracts, the Borrower shall:
(A) notify the Association of the initiation of the process for the selection of consultants; and
(B) provide to the Association for its approval any proposed changes to the terms of
reference, qualifications and experience of the consultants.
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PART – IX
FINANCIAL MANAGEMENT
161
31 FINANCIAL MANAGEMENT
31.1 Summary Project Description
Disease surveillance has long been recognized as an important tool for measuring the disease
burden, studying morbidity and mortality trends and early detection of outbreaks for instituting
effective control measures in a timely manner. Though the health care infrastructure in our
country has grown immensely over the years, disease surveillance system did not get the desired
attention resulting in frequent outbreaks. The outbreaks of plague (1994), malaria (1995), and
dengue haemorrhagic fever (1996) in different parts of the country further highlighted the
weaknesses in the surveillance system and brought an urgency for its strengthening so that early
warning signals of outbreaks are detected and appropriate preventive and control measures are
applied timely to minimize the impact of the outbreak. The proposed five-year project would
aim (i) to establish a decentralized state based system of surveillance for communicable and
non-communicable diseases and their risk factors so that timely and effective public health
actions can be initiated in response to health challenges in the country at the state and national
levels and (ii) to improve the efficiency of the existing surveillance activities of disease control
programs and facilitate sharing of relevant information with the health administration,
community and other stakeholders so as to detect disease and risk factor trends over time and
evaluate control strategies.
The project will be coordinated by the Ministry of Health and Family Welfare (MOHFW), New
Delhi. A Central Disease Surveillance Unit (CDSU) will be established for this purpose. It will
also act as the Project Secretariat. This unit, which will report directly to both the Secretary for
Health and the Secretary for Family Welfare, will be responsible for overall implementation of
the project, its financial management, central level procurement, annual work-plans,
management and technical support to the states and an annual progress review of the program.
This cell would also include a senior level finance functionary of rank of Director/ Deputy
Secretary who would be responsible for overseeing the Financial Management arrangements of
the project. The Joint Secretary, MOHFW (Administrative Head) and the Deputy Director
General (Technical Head), would have overall responsibility for the proposed project. The
Project Secretariat would be assisted by a central procurement agent (national level), who would
procure goods and equipment and consultancy services proposed to be financed under the
project.
The state departments will be responsible for implementation of the disease surveillance
activities of the project in conformity with national guidelines. The states will establish a State
Surveillance Unit (SSU) which integrates disease surveillance activities in the state and reports
to the Secretary for Health and Family Welfare (or equivalent). The officer in-charge of SSU will
be responsible for financial management of the project within the state, state level procurement,
annual work plans management and technical support to the districts and annual progress review
of the program in the state.
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Implementation of the various disease surveillance activities at the district level will be funded
through an identified & existing District Disease Control Society (or District Health Society)
under the overall supervision of the State Department of Health and Family Welfare. The
society will be responsible for district procurement and implementation of district annual work
plans and financial management systems.
The project is to be implemented in a phased manner (in three phases) as under:
Phase I would cover nine States. These are Andhra Pradesh, Himachal Pradesh, Karnataka,
Kerala, Madhya Pradesh, Maharashtra, Mizoram, Tamil Nadu, and Uttaranchal. (Total number
of districts in all the nine states - 206).
Phase II would cover thirteen States. These are Chandigarh, Chhattisgarh, Delhi, Goa,
Gujarat, Haryana, Manipur, Meghalaya, Orissa, Pondicherry, Rajasthan, Tripura, and West
Bengal. (Total number of districts in all the thirteen states – 176).
Phase III would also cover thirteen States. These are Arunachal Pradesh, Assam, Andaman &
Nicobar Islands, Bihar, Daman & Diu Island, Dadra & Nager Haveli, Jammu & Kashmir,
Jharkhand, Lakshadweep, Nagaland, Punjab, Sikkim and Uttar Pradesh. (Total number of
districts in all the thirteen states - 210).
The Phase I states have identified the state and district societies that are to be involved
in the implementation of the project. These societies have been selected after a
evaluation based on criteria developed by MOHFW and approved by IDA ( refer
annexure 1). The states joining in the Phase II and III will also follow the same criteria
for selection of the society at the state and district level for the implementation of the
project.
It is estimated that the World Bank assistance would be available for nearly 70-75% of the
project costs. The remaining share would be from domestic budget. A provision of Rs. 260 crore
has already been made for the tenth plan and this should be adequate to meet the domestic
component of the project and thus there would be no additional financial implications on the
domestic budget. As the funding from the WB is on reimbursement basis budget for both the
receipt and the gross expenditure would need to be made.
The proposed Integrated Disease Surveillance Project would be funded by Government of India
for the duration of the project (2004-2009).
31.2 Implementing Agency:
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31.2.1 Central level
The Project would be implemented by Central Surveillance Unit (CSU) in the Directorate
General of Health Services, Ministry of Health & FW, Government of India. This unit would
execute decisions taken by National Disease Surveillance Committee which will be constituted
as per Structure and Terms of References given in chapter on Administrative Structure Chapter20 of PIP/ Pages : 50-52).
31.2.2 State level
The Project would be implemented by State Surveillance Unit (SSU) in the Directorate of Health
Services of the States. This unit would execute decisions taken by State Disease Surveillance
Committee which will be constituted as per Structure and Terms of References given in chapter
on Administrative Structure (Chapter-20 of PIP/ Page : 53).
31.2.3 District level
The Project would be implemented by District Surveillance Unit (DSU) under Chief Medical
Officer of the District. This unit would execute decisions taken by the District Disease
Surveillance Committee which will be constituted as per Structure and Terms of References
given in chapter on Administrative Structure (Chapter-20 of PIP/ Pages : 55).
31.3 Finance Staffing and Training:
For efficient Financial Management, dedicated personnel would be identified at the Central and
State level. They would be engaged either through redeployment or on a consultancy basis. The
finance wing of the project at the CSU would have one qualified finance professional, designated
as Finance Consultant for the project and one other finance professional who is experienced in
govt. accounting procedures. They would be responsible for establishment of the agreed financial
management arrangements including Project Financial Management System (PFMS), providing
timely financial reports to the stakeholders including the Bank, ensuring smooth and timely flow
of funds and providing overall guidance in respect of the financial management issues for the
project. The other members of the finance team would include 2 junior level accountants & and
other support level staff as required under the project.
At the state level a State Accountant (Finance Manager) will be hired on a competitive basis and
shall meet the minimum skill set and TOR approved by IDA. At the district level, the officer
dealing with parent society, through which funds would flow, would be given additional charge.
He would be supported by Accountant, who should be computer literate, and a Data Entry
Operator.
Finance Managers at all levels would undergo training on Basic Finance Management and
Accounting. To ensure uniformity and adoption of standard protocols, training in Finance
Management would be a National level activity for central and State level Finance Managers
who in turn would organize training of District level officers. Prototype training manual and
operational guidelines for Finance Management would be developed for this activity.
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32 BUDGETING
The funding to the Integrated Disease Surveillance Project would be through the budget of the
Ministry of Health and Family Welfare. A separate budget head would be allocated to the Project
at the Central and State levels. At the National level, the account would be operated by the
Central Disease Surveillance Unit, which is proposed to be headed by Joint Secretary
(Administrative Head) and a Deputy Director General (Technical Head). Annual budget of the
Project would be allocated as per National PIP with component-wise break up. Budget would be
allocated to each State based on State PIP and utilization of funds released.
32.1 Funds Flow:
Annual budget allocated to each State would be released only in two installments during the 1st
and 3rd quarters of each Fiscal Year. Funds required to implement the Project will be released
through existing State Health and Family Welfare Society or a disease specific State Society to
ensure effective and efficient implementation of the Project. The State level society would
release necessary funds to District level society twice a year. A resolution would be adopted by
each society to incorporate IDSP funds management. Amount of installment would depend upon
requirement and utilization of funds released earlier. To ensure adequate funds to Districts,
mechanisms will be developed to regulate flow of funds. A minimum balance amount of
Rs.100,000 would be sustained to meet any emergent situation. The funds flow to the various
levels is described below:
32.1.1 Central level:
At the central level, a special account will be maintained in the Reserve Bank of India and
operated by the Department of Economic Affairs by the Government of India. The authorized
allocation of the special account would represent six months of initial estimated disbursement of
IDA credit. The reimbursement from the account would be made based on reimbursement claim
submitted by the Government of India in agreed formats based on statements of expenditures
received from states. After the reimbursement is given, the revolving credit would be recouped
to the pre-existing level by the IDA.
32.1.2 State level
State Disease Surveillance Committees would be formed in each state as per composition and
Terms of References given in the chapter of Administrative Structure (Chapter-20 of PIP/ Page :
53) This would be an empowered committee to take major decisions including approval of
annual plan of action. Under the umbrella of the State Level Societies, a separate bank account
in the name of “State Surveillance Unit (name of State)” would be opened in a Nationalized
Bank. Funds would be released by the State Finance Department as a cheque/demand draft. The
books of accounts at the state level would be maintained using double entry book keeping
principals.
The State Surveillance Unit (SSU) would release funds to District Surveillance Units (Name of
District) and other organizations/agencies, also by cheque/demand draft. SSU would maintain
vouchers for the various receipts and expenditures. The Bank Account would be operated by at
165
least two of the three signatories, Chairperson, Vice-Chairperson and Member Secretary of State
Surveillance Committee.
32.1.3 District level
The District Surveillance Units will receive funds by cheque/demand draft from the SSU and a
separate bank account would be operated under the umbrella of the existing District level
Societies. The bank account will be operated by two of the three signatories: Chairperson, Vicechairperson and Member Secretary (District Surveillance Officer). Funds for the purpose of
activities envisaged at the primary health center and CHC level would also be released at the
district level itself and generally no flow of funds is envisaged at a lower level. Funds would
generally not be managed below district level. If necessary, funds would be released to
Community Health Centres as advances for training and other activities and accounts settled
within 2 weeks of completion of activity. Transaction vouchers would be maintained for all
receipts and expenditure by the District Surveillance Unit.
32.2 Books of account, accounting policies and procedure:
The project costs incurred at the PCU and those incurred by the Central Procurement Agent (is
there any) would be recorded in the books of the PCU at MoHFW in accordance with procedures
and policies prescribed in the Finance manual. The accounting policies & procedures and the
formats for existing financial reports for GoI are captured in the various accounting forms
(‘Books of Forms’), cash book, the reports, the public works account code, the CPWD manual
and General Financial Rules (GFR) as issued from time to time. These policies and procedures
are exhaustive and capture the requirements of the A.G., Department of Finance and other
stakeholders requiring financial information. These guidelines also lay down the internal control
procedures and the formats of the reports and books of accounts. In spite of an well established
system of accounting and reporting the expenditures, this system, however, has no established
method for capturing physical information and integrating / linking it with the financial
information.
A Financial Management System (FMS), for the project, based on a manual system supported by
the use of excel spreadsheets has been designed to accurately record and timely report the project
expenditures at the aggregate project level within the overall reporting system as required within
the government. Expenses would be recorded on a cash basis and would follow the government
classifications, project components and activities for ease in reporting to various stakeholders.
Standard books of accounts on a double entry basis (cash and bank books, journals, fixed assets
register, ledgers, work registers, contractor registers etc.) will be maintained under the project by
the PCU would be based on the existing Government accounting system with a modified focus
on using the financial information and reports for managerial decision-making.
A finance manual laying down the financial policies and procedures, periodic & annual reporting
formats including financial statements, flow of information and methodology of compilation,
budgeting & flow of funds, format of books of accounts, chart of accounts, information systems,
166
disbursement arrangements, external & internal audit for the project and operation of the
Financial Management System (FMS) has been prepared for guiding the project personnel both
at the CSU and the State and district Societies. The Financial manual is an integral part of the
PIP.
The FMS, inter alia, documents and encompass detailed accounting system (including the Chart
of Accounts - accounting for GoI budget heads; formats of various financial and other reports
that the department requires), internal control mechanisms, budgeting and forecasting system and
the auditing arrangements for the project. A subsidiary chart of Accounts has been developed for
the project as part of the Finance Manual to enable data to be captured and classified by
expenditure center, budget heads, project components, activities and disbursement categories.
Internal control systems would include:

Establishment of small appropriate budgeting systems and regular monitoring of actual
financial performance with budget and targets.

Development and adoption of simple and transparent financial and accounting policies
including identification of components and expenditures to be charged to the project, the
categories under which expenditure would be charged and policies of transfer of funds
and accounting of expenditures.

The State unit will send a quarterly financial management reports which would include Comparison of budgeted and actual expenditure
 Analysis of major variances, including source and application of funds (by
component and summarized expenditure categories)
 Progress in key physical parameters
 Forecasts of expenditure for next two quarters.
32.3 Information and Reporting System:
The states will send detailed expenditure statements on a quarterly basis containing details of
expenditure under the various heads by components and summarized expenditure categories to
allow the Government of India to claim reimbursement from the World Bank. The releases to the
State Government will be based upon receipts of State of Expenditure in agreed formats on a
quarterly basis.
At the district level, similar expenditure statements will be sent by the DSU on a quarterly basis
to the State Surveillance Unit, in order to allow the State Government to submit the consolidated
statement of expenditure to the Central Surveillance Unit.
Formats for the Financial Monitoring Report (FMR) are given at Annexure 14.
32.4 Audit (External )
The IDSP accounts at Central Level will be audited by the Controller and the Auditor General of
India (CAG). A TOR for this purpose has been approved by IDA and the consent of the CAG
167
has to be obtained for this purpose. The District and State Units will be audited by chartered
accountant firms empanelled by the CAG/SAG based on the terms of reference approved by
IDA. All the district audited financial statements will be consolidated into one single audited
financial statement for the state . It is proposed that one auditor will be appointed at the state
level for audit of all the District SU and State SU and such auditor will also be responsible for
the audit of the consolidated financial statements. The auditor may engage another firm for the
audit at the districts . This will provide independence of the auditor from the district SU where
the bulk of the expenditure is to be incurred and also ensure uniformity in the reporting For large
states with large number of districts joint auditors may be appointed with joint responsibility for
consolidation.
The detailed terms of reference and qualifications of the chartered accountants appointed to audit
the State and District Level Units have been approved by the World Bank. The audit certificates
and UCs of the district units will be sent to the state societies within 3 months of the closure of
the financial year. Similarly the audit certificate and UCs of the State Societies will be sent to
the central units within 6 months of the closure of the financial year. Release of funds from the
central to the state level, and state to the district level would be incumbent on the receipt of the
audit certificates and UCs. No further release of funds would be affected to the concerned units
from central/ state level in case audit certificates and UCs are not received in time.
32.5 Internal Audit:
As the project is widely spread (being implemented in all the 580 districts of the country) it will
not be possible to have a meaningful and comprehensive internal audit. This is sought to be
mitigated by means of developing a checklist against which six monthly review would be
conducted by the state society accountant and also by supervision teams from the PMU and the
IDA. This checklist would be made an integral part of the finance manual and included in the
TOR (job responsibilities of the state accountant).
32.6 Retroactive Financing:
Retroactive financing will be provided for project preparation and project expenditures
amounting to approximately $2.00 million for expenditures incurred after April 1, 2003. The
following activities would be eligible for retroactive financing - workshops, pilot testing of
manuals, pilots for involvement of private practitioners, training, software development, baseline
surveys, IEC, NGO activities and setting up the Central and State Surveillance Units. Bank
guidelines and procedures will be followed for claiming retroactive financing.
32.7 Disbursement and Payment Arrangements:-
168
GOI would open a special account with RBI to receive the disbursements under the project from
the Bank. Disbursement of funds from IDA would be based on actual expenditure incurred by
implementing agencies. However, these would be subjected to audit reports and disallowances, if
any, would be rectified. The disbursement would follow provisions of Credit Agreement between
Government of India and the World Bank as summarized below : -
Amount of the
Credit Allocated % of Expenditure to be
S.No.
Category
(Expressed in
Financed
SDR Equivalent)
1
Works
2,760,000
2
Goods
21,240,000
100%
of
foreign
expenditures, 100% of
local expenditures (exfactory cost) and 80% of
local expenditures for
other
items
procured
locally
3
(a) Consultants’ services including
4,050,000
90%
IEC, MIS and studies (other than
services provided by tax-exempt
providers)
(b) Consultants’ services including
5,202,000
100%
IEC, MIS and studies provided by
tax-exempt providers, training and
workshops
4
Incremental Operating Costs
(a) For the Borrower and Project
3,600,000
80% until September 30,
States executing Memorandum of
2006; 70% from October
Understanding in Fiscal Year 20041, 2006 to September 30,
05
2007; 60% from October
1, 2007 to September 30,
2008 and 50% thereafter.
(b) For Project States executing
3,080,000
80% until September 30,
Memorandum of Understanding in
2007; 70% from October
Fiscal Year 2005-06
1, 2007 to September 30,
2008; 60% thereafter
(c) For Project States executing
80% until September 30,
Memorandum of Understanding in
2008; 70% thereafter
Fiscal Year 2006-07
5
Unallocated
4,700,000
TOTAL
46,900,000
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A Special Account would be maintained in the Reserve Bank of India; and would be operated by
the Department of Economic Affairs (DEA) of Government of India (GOI). The authorized
allocation of the Special Account would be USD 6.8 million) from the IDA credit. The Special
Account would be operated in accordance with the Bank’s operational policies. The project will
submit withdrawal applications to Controller of Aid, Accounts and Audit (CAA&A) in DEA for
onward submission to the Bank for replenishment of the special account or reimbursement.
ANNEXURES
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