2022 IANPHI Annual Meeting: Presentation of the IANPHI Integrated Disease Surveillance Project

 

On December 1, 2022, the IANPHI Annual meeting hosted a presentation of the IANPHI Integrated Disease Surveillance (IDS) Project, which received an award from the Bill & Melinda Gates Foundation (BMGF). The focus of the project was on the understanding and models of IDS and the role of National Public Health Institutes (NPHIs). The context of the IDS system was on epidemic and pandemic preparedness and response. 

The meeting provided background and approach of the project, findings from the workstreams including overview deep-dives from the National Institute of Health of Mozambique, the Public Health Institute of Malawi, the Uganda National Institute of Public Health, the National Institute of Health of Pakistan and the Public Health Agency of Sweden. An open discussion followed to share experiences and strategies related to specific challenges and opportunities to develop integrated disease surveillance. Dr. Quentin Sandifer, an IANPHI strategic adviser, moderated the event. 

Project Outline

Scoping Review and Survey

by Dr. Jean Claude Desenclos, Former Deputy Director of Science, Santé Publique France, and immediate past Secretary General, IANPHI 

The IDS project had three workstreams: a systematic scoping review, which has highlighted the fragmentation of evidence and the global lack of information on IDS effectiveness, a survey, launched among the membership of IANPHI with the objective of characterizing and understanding the development of integrated surveillance, and seven deep dives regarding the understanding and development of integrated disease surveillance.

Fifty-nine percent of IANPHI members responded to the survey. Although integration is a complex process involving multiple stakeholders and sectors and for which no universal definition exists, respondents tended to adopt a whole-system perspective and the survey results indicated issues with data integration across organizations and at the multi-sectoral level. 

Seven countries (Mozambique, Pakistan, Malawi, Uganda, England, Sweden and Canada), led by their NPHIs, produced qualitative data through interviews and discussion forums to help understand how context has shaped IDS and to identify strengths, weaknesses and challenges for its future evolution. There was a twinning of these countries’ NPHIs with IANPHI member NPHIs who had understanding and experience of working with the deep-dive countries. These included the Norwegian Institute of Public Health, the United States Centers for Disease Control and Prevention (U.S. CDC), the UK Health Security Agency (UKHSA), the Public Health Agency of Canada and the Public Health Agency of Sweden.

Deep Dives

Integrated Disease Surveillance Deep Dive in Mozambique. Overview, Findings and Recommendations

By Dr. Ivalda Maciame, National Director for Surveys and Health Observation, National Institute of Health of Mozambique  

During the course of the study, different perceptions of the levels of integration emerged. At the national scale, the government views data integration and disease surveillance at an analytical level, whereas at the provincial scale, integration is viewed more in terms of data collection. This finding highlights the need to consider the differences in understanding of integration between as well as within countries. 

In Mozambique, the national health observatory seems to have the potential to set up a disease surveillance system. It will be necessary to encourage a better integration between NGOs, which administrate multiple vertical systems and the government, to leverage existing initiatives and to achieve the migration from paper to electronic systems. Staffing needs should be prioritized and investments should be extended to the health workforce. The IDS project is a great opportunity for Mozambique not only to bring data together but also to bring people and institutions together. 

Integrated Disease Surveillance Deep Dive in Malawi

By Dr. Benson Chilima, Director, Public Health Institute of Malawi

Malawi is a country of 21 million inhabitants where the Public Health Institute is in charge of the Integrated Disease Surveillance system, while the One Health Surveillance system is part of the Ministry of Health. The study identified the correlation between the level of financial support and the quality of surveillance data. In Malawi, although the infrastructure and qualified workforce are present, IDS priority programs are not adequately funded, collection tools are weak, analytical capacity is insufficient, data is of poor quality and some outbreaks are missed.  

Integrated Disease Surveillance Deep Dive in Pakistan

By Dr. Mustafa Chaudry on behalf of Dr. Muhammad Khan, Chief information Officer, National Institute of Health of Pakistan

Health has been placed at the heart of Pakistan's 2010 constitutional review.Thus, the country has a disease surveillance system and a disease observatory. However, because of the federated system where responsibility is devolved to a provincial level, surveillance systems are fragmented and Pakistan faces governance challenges. This fragmentation is compounded by the political instability of the country. Significant work is being progressed in this area with the central NIH Pakistan working with provincial ministries to reduce duplication, integrate data systems and ensure the workforce required is in place. Due to healthcare system fragmentation, private sector laboratories and healthcare providers are also being integrated as part of the surveillance system and this is an area of on-going focus. 

Integrated Disease Surveillance Deep Dive in Sweden

By Dr. Anders Tegnel, Senior Expert, Public Health Agency of Sweden

The case of the integration of disease surveillance systems in Sweden is a perfect example of the importance of taking into account the existing context in development processes. Indeed, there is more of a network of responsible agencies than a single integrated system in the country, which implies difficulties in cooperation between the levels. This fragmentation is partly compensated by the existence of a unique identifier for data exchange. However, this has not been possible without a long period of building relationships and mandates. The high level of dependence on the legal structure of the Swedish system is simultaneously a strength and an issue for its development. It gives a strong mandate to collect data from the provincial level but it also weakens the possibilities for adaptation. 

The deep-dive showed that a better flexibility, adaptation and integration of new data sources are necessary to compensate for the existing siloed systems that cannot be easily changed in the near future.  

Summation

By Professor Andrew Lee, University of Sheffield, UKHSA

Prof. Andrew Lee provided a brief summation of the project and said that the reason for integrating disease surveillance data is to provide information to decision makers to prevent and combat outbreaks. Therefore, integration is not done in a vacuum but in a situation where control processes are already in place. There is no one-size-fits-all solution, only adaptations.

The IDS project is not just about setting up or adapting structures. It must also allow people to create inter-professional links between sectors, organizations, countries. Integrated disease surveillance systems are nothing without a community of professionals who work on problems together, learn together and exchange ideas. 

Prof. Lee shared five key recommendations from the project:

1. The definition and purpose of Integrated Disease Surveillance must be clarified
2. Strategic planning and approach are essential; they need to be contextualized to the country and supported by governance
3. The infrastructure is important including the laboratories, the technology, etc.
4. Finances must be sustained
5. Shared learning must happen through collaborative networks

IANPHI is ideally placed to work across its membership to facilitate this and the project should be the start of taking this learning and evidence into practice. 

These findings are only a first step. There is a call for action table as part of the report, which is not intended to make prescriptive recommendations but rather to question and stimulate proposals and actions from different organizations both internationally and at a country level.

Discussion

Moderated by Dr. Bjorn Iverson, Senior Medical Officer, Norwegian Institute for Public Health 

Based on their own experience, participants were asked to share thoughts or insights on barriers or challenges to strengthening disease surveillance hat they did not hear mentioned in the presentation. They were also invited to make recommendations and identify tools that IANPHI can provide in the development of the IDS project.

Prof. Reada Alqutob, president of the Jordan Center for Disease Control, made the first participant comment on the involvement of the private sector, whether laboratories or clinics, in the integrated disease surveillance system. The contribution of the private sector can be a real challenge due to the impossibility of regulating this sector in some countries. For this reason, there may also be difficulties in obtaining a standardization of data collection and sharing methods. 

The second comment addressed the issue of integrating animal health data into the disease surveillance system, as it can be an essential element when predicting and fighting diseases. The response acknowledged and recognized that varying progress on One Health was reported through the survey and deep-dives although this was certainly identified as essential for an IDS system for epidemic and pandemic response. Dr. Benson Chilima, director of the Public Health Institute of Malawi, added that the integration of animal and environmental health data was a challenge since this data is much less numerous and is more recent than human health data.

The question of the duplication of pre-existing patterns in developed countries during the development of integrated systems in other countries highlighted the need to adapt the integration systems to their context and not to build an integration system parallel to the structure of the country.

During the discussion, the inclusion of the World Health Organization (WHO) in the project was mentioned. The team clarified that WHO, in particular the WHO Hub for Epidemic and Pandemic Intelligence, was included and involved in the IDS project. The IDS project team shared that the report will be shared with the BMGF and that WHO, like the other stakeholders, must be at the heart of the process so as not to copy prescriptions but to adapt them to the various local situations.

Dr. Neil Squires, director of Global Operations at UKSHA, commented on the WHO workforce recommendation framework to ensure action is taken globally and emphasized the need for explicit recommendations concerning the development of human resources. 

Dr. Ahmed Abdiwali, director general of the Ministry of Health of the Galmudug State of Somalia, questioned the integration of donors and their vertical programs into national surveillances systems. The team clarified that the issue was raised as part of the findings and recommendations of the project.

Professor Lothar H. Wieler, president of the Robert Koch Institut, added that during the COVID-19 pandemic data gaps had been identified and that beyond health data, it would be interesting to have the perspective of economic experts. Economic expertise allows a better understanding of the essential human behavioral questions when managing health crises. 

Lastly, Melinda Frost, unit head at WHO, reiterated WHO’s interest in cooperating with IANPHI in the implementation of the IDS project.