The implementation of IDSP in all 34 districts of the state although encouraging, is only partially satisfactory. Significant progress has been made but gaps remain and the current transition of the system offers a unique opportunity to implement the necessary structural changes and should be exploited to its potential. The use of the Standard Case Definitions (SCDs) was poor at the periphery hinting that the syndromic SCDs need clarifications. All SCDs should be made available in Marathi language instead of the current “only English” versions in order to improve their use [27, 35]. Further, the reporting deadlines and definition of a reporting week were poorly understood affecting reporting quality. Annual circulation of job aids with SCDs and reporting deadlines should be implemented to improve data collection and reporting as demonstrated from studies in Tanzania, Mozambique, Uganda and Ghana [36–40].
Case registers were more complete for IPD patients and at the peripheral level, a finding similar to other studies from Mozambique and Uganda [39, 41]. Lack of reporting formats and office copies of reports sent thereof compromised data verification and institutional learning. Staff at periphery printed or used photocopies at their own costs. At state level, storage and distribution of large quantities of printed formats was a logistic problem and therefore provisions in local contingency funds should be made at district/facility levels for printing them. Alternately, printed IDSP registers should be considered at all levels to ensure adequate standardization and documentation at source [27, 42–44]. Second, the system does not currently collect data on disease mortality which should be addressed in the next restructuring .
Weak lab infrastructures at periphery compromise regular and outbreak surveillance functions and have been reported earlier from Tanzania, Ethiopia and South Sudan [2, 6, 46]. The PHCs are the first contact for diagnostics in rural areas, and 37% of them did not have a lab facility in our study. Further, only half of the districts could confirm all the priority diseases. Sample collection and transport was the weakest for stool samples, even when the maximum outbreaks and the burden from diarroheal diseases remained high in every district. Staff in referral labs was hesitant in processing samples from periphery due to inadequate, inappropriate or contaminated samples. Availability of transport media and cold chain boxes for sample transport needs immediate attention even in the light of vaccination programs such as polio. Annual cold chain audits should be considered for regular monitoring . Scaling up the use of rapid diagnostic tests to manage laboratory shortcomings at periphery should considered .
The referral network of ten labs established in the state through IDSP funding although a step, is sub-optimally efficient, given that four to five districts are covered under each RL. Second, the network is envisioned primarily for outbreak functions leaving regular laboratory functions still weak. A parallel strategy should be to strengthen the District Public Health Laboratories (DPHL) available at each district which currently covers regular surveillance function for IDSP. Capacity building in terms of personnel and equipment at each level should be planned consequently through core state budgets to strengthen the states laboratory infrastructure for both regular and outbreak functions [49, 50].
Electronic data processing is a major advantage in surveillance . However, the state fails to reap optimum benefits due to interrupted Internet services, unstable IDSP portal, poor staff training and lack of data entry operators. Currently all RUs send paper forms to the DSU and the data volume significantly overburdens the staff. Through NRHM, two computers, broadband Internet services, and a data entry operator have been provided to a majority of the PHCs . Secondly, under the Indian Public Health Standards increasingly PHCs that operate 24X7 are being provided with express electricity feeders . Shifting IDSP data entry progressively from DSUs to facility level is therefore pragmatic for several reasons. One it is equipment and personnel wise more feasible now than before, it eliminates the logistics, costs and burden of paper based reporting to district level, improves data quality by sheer reduction in data volume, speeds up surveillance which can support the installation of automated outbreak and aberration detection mechanisms within the system, and allows the DSU more time to analyze the data as the burden of data entry is taken away.
Weak data analysis at every level was observed on our study as from those in Ghana, Lesotho, Tanzania, Uganda and in other states of India [7, 35, 42, 50, 54–57]. The staff at the DSU is better trained and receives frequent feedback from the SSU as compared to facilities giving them a position of advantage for data analysis. However, a lack of logistic resources and the burden of data entry prevent them from applying their skills optimally. Developing clear guidelines for data entry, management and analysis at each level should be considered . Additionally, regular in-service training supported by adequate supervision of the surveillance staff at all levels should be incorporated .
Irregular and ad hoc feedback was observed at all levels in our study. Feedback at facility level was better than that at the DSU level and reason identified included frequent change in the SSO. At the facility level, routine monthly review meetings conducted by the block health officers, medical officers meetings and quarterly subcenter staff meetings served as a platform for IDSP review but differed from one district to the other. Feedback is an essential component for maintaining involvement and motivation of surveillance staff [38, 56, 57]. Formal mechanisms should be developed with accurate guidelines for frequency and components of feedback at all levels (essentially on a quarterly basis for DSUs) including budgeting for supervisory visits .
Training is significantly associated with data analysis, feedback and supervision [58, 59]. Training of DSO and epidemiologists was better than that of the peripheral staff in our study like in several others [37, 60]. Lack of adequate training schedule, funds, discrepancy with regards to state or district responsibility and vacant state training consultant position affected the availability of trained personnel in our study. Institutionalizing training for integrated disease surveillance in regular medical and paramedical curricula is considered the most sustainable strategy and should be incorporated . Practical on-site in-service trainings for surveillance and lab staff should be mandatorily planned as an annual activity [59, 61]. High attrition of trained staff was another reason for lack of trained personnel in our study including others in Ethiopia and Lesotho [46, 50]. A detailed updated database of trained personnel should be maintained at district level and trainings should be coordinated by districts rather than the state to allow efficient overview [27, 49].
Outbreak detection and response capacity, and rightly so, was better at the periphery compared to the DSU level. The peripheral staff had better understanding of the outbreak thresholds, was well supervised by the THOs, and had improved access to vehicles and logistic support as compared to the DSUs. Adequate supplies were observed at both the district and facility levels in our study indicating sufficient resources. Heavy focus on curative approaches and access to treatment manuals ensured proper case management and reductions in case fatality rates. As first responders are always the peripheral staff, all factors, to the advantage of the system, worked towards significantly improving outbreak response .
Some of the limitations included the fact that weak data management and analysis did not allow automated outbreak detection despite the availability of electronic data. This should be instated as the next step in improving the system structure . Outbreak indicators were well understood and implemented by peripheral staff, however poor filing of final outbreak reports jeopardized documentation and hence the assessment of response adequacy and institutional learning. A general tendency to under-report the total number of outbreaks was observed due to fear of action from the higher authorities. Supportive supervision with compulsory monitoring of identified IDSP indicators should be developed at each level to promote collective responsibility and avoid finger pointing [27, 36, 63, 64].
Availability of sustainable resources (human, logistic and equipment) are at the root of surveillance performance . Thirty per cent IDSP positions were vacant in the state despite availability of financial resources leading to multiple responsibilities on existing staff including the SSO and the DSOs. A finding commonly reported from several other low and middle income countries . Further the SSO and DSOs were selected ad-hoc, frequently transferred and saw surveillance as an additional burden. Contractual temporary positions are the main reason for high turnover of lab and IDSP staff in our study. Lack of job security, uneven and unrevised salary structure, with administrative delays in processing contracts and monthly pays demotivated district and facility staff to take on or continue IDSP positions (Personal communication with SSO). Retaining trained staff although a challenge is of utmost importance [36, 43]. Developing permanent cadre of skilled surveillance personnel holds the key to program viability and should be actively pursued .
Competent staff should be backed up with appropriate and adequate logistic and equipment support for effective communication, laboratory function and data management [6, 41, 48]. Currently, the IDSP provides annual procurement costs only for referral laboratories and none for rapid diagnostic testing at peripheral levels which should be re-considered. Although adequate communication equipment was in principle available, the availability at district level was weaker as compared to the facility levels. One time procurement of hardware/software for data management was made in the initial phases of the program. However, most equipment is now old, poorly maintained and requires repair or replacement. Effective communication systems for data transmission determine speed and completeness of reporting and provision of annual maintenance contracts for purchased equipment should be envisaged in annual budgetary planning [50, 51].
Availability of transport vehicles was weakest at sub-centre level where staff is expected to perform active syndromic surveillance on a bi-weekly basis. Chronic shortage of staff in the backdrop of rapid population growth has resulted in dis-proportionate personnel and facility distributions making active surveillance a horrendous task . Geographical areas are impossible to cover on foot and providing interest-free two-wheeler loans to sub-centre staff is suggested. ASHA (Accredited Social Health Activists) identified at the village level have been included in the IDSP to overcome some of these challenges and a minimal monetary compensation is offered for every outbreak reported. However, this arrangement is not fully exploited to its potential in all districts and delays in payments have affected the inclination of ASHA workers to participate. Additionally, active involvement and community interest should be sustained by organizing regular feedback meetings which less than half of the facilities were implementing in our study .
Vehicle availability was problematic in majority of the DSUs in our study hindering supervision and outbreak investigations. Similar findings have been reported from IDS assessments in Iraq and Nigeria [37, 69]. IDSP designated vehicles should be made available on priority basis and clear guidelines on the use of vehicle contingency funds within the program should be developed.
Weak inter-sectorial and inter- programmatic coordination was observed in our study despite availability of a designated focal person at all levels in majority of the districts in our study like in others from Uganda, Ghana, Ethiopia, other states in India and Mali [35, 46, 57, 58, 70]. Additionally, poor documentation of review meetings made its functionality rather doubtful. In order to avoid that the IDSP becomes another vertical disease surveillance program and to eliminate existing lacunae as identified in our study we suggest that the DSUs should be established as permanent structures within the district health care system in Maharashtra. Structural integration of the IDSP will allow gradual progressive channelling of surveillance activities of all major vertical disease control through these units resulting in effective coordination [36, 63, 70]. Further, instead of providing IDSP as an additional charge to existing ADHOs who overlook multiple programs, separate full time positions for SSO and 34 DSOs should be created. An ideal strategy would be to recruit existing contractual epidemiologists on long term or permanent basis. Given that the salaries of these officers were borne by the state since 2005, resources are not an issue, but the policy is!