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PartI: Details about structure of Health Management Information System, Flow of Information, Sources, Innovations, Suggestion
Part II: Integrated Disease Surveillance Project, Outbreak Response, RRT, CSU, SSU, DSU, 1075 toll Line & Data Centre

Published in: Health & Medicine


  1. 1. Dr. Vikram Gupta Assistant Professor, Community Medicine,Dayanand Medical College & Hospital, Ludhiana, Punjab (India)
  2. 2. HMISHMIS is defined as a system that providesup-to-date,reliable , completetimely information to health managers,at various levels (Subcentre, SHC,PHC, CHC, SDH & District Hospitals.)in order to make well-informed management decisions about program performance and operations.
  3. 3. Most of information reaches the programme managers in the form of routine statistical and management “reports”.These reports which are generally standardized in format and produced on regular basis, constitute most viable part of health management and information system.Data becomes information when it is analyzed processed and interpreted.The timely information is thus generated is used for action and decision making at all the levels of management. Information is needed at all the levels.
  4. 4. CHC PHCSub Centres 7
  5. 5. HEALTH SYSTEM IN INDIA  Aim : Primary health careRURAL SET UP  Network of Integrated Health And Family Welfare Delivery System Rural Health InfrastructureCommunity Primary Health Sub centre Health Centre 5000 pop. Centre {30000 pop.} {3000 in hilly , tribal{80000 to 120000 {20000 in hilly, tribal & backward area} Population} & backward area} 10
  6. 6. Sub-Centres•Most peripheral contact point with primary health system•One ANM and one Male Health Worker•One Lady Health Worker (LHV) supervises six Sub-Centres.•Tasks relating to interpersonal communication wrt maternal andchild health, family welfare, nutrition, immunization, diarrheacontrol and control of communicable diseases programmes.•Provided with basic drugs•100% Central assistance to all the Sub-Centres since April 2002•There are 1,45,272 Sub Centre as on March, 2007 11
  7. 7. Primary Health Centres (PHCs)First contact point with Medical Officer.Envisaged to provide an integrated curative and preventive careEstablished and maintained by the State Governments under theMinimum Needs Programme (MNP)Manned by a Medical Officer supported by 14 paramedical andother staff.It acts as a referral unit for 6 Sub Centres.It has 4 - 6 beds for patients.There are 22,370 PHCs as on March, 2007 in the country 12
  8. 8. Community Health CentresEstablished and maintained by the State Government underMNP/BMS programme .It is manned by four medical specialists i.e. Surgeon, Physician,Gynecologist and Pediatrician supported by 21 paramedical andother staff.It has 30 in-door beds with one OT, X-ray, Labour Room andLaboratory facilities.It serves as a referral centre for 4 PHCs and also providesfacilities for obstetric care and specialist consultations.As on March, 2007, there are 4045 CHCs functioning. 13
  9. 9. HOME-BASED OR CLIENT BASED RECORDS AND INFORMATION VILLAGE BASED (1000) SUB CENTRE (5000) PHC (30000) CHC (1,00,000) District (>5lakh) MoHFW State Health Organization
  10. 10. DEVELOPMENT OF HMIS IN INDIAHealth for All by 2000 declaration in 1977 at Alma AtaThe National health policy adopted by the parliament in 1983 stated that “appropriate decision- making and programme planning in the health and health related fields is not possible without establishing an effective “health information system”.Exercises in development of more effective HMIS continued and version 1.0 and 2.0 of HMIS were evolved in 1990.
  11. 11. After a test run, it was decided in 1991 to implement computer compatible HMIS version 2.0 all over the country.Under NRHM the HMIS formats have been revised and put into effect from sept. 2008.The HMIS system is well planned and well thought over but it implementation is a problem because of problem of providing registers, stationary, training lack of motivation besides lack of use if information.
  12. 12. KEY REGISTERS AT SUB CENTRE LEVEL Survey registersSub centre village information Household informationEligible couple and children information  Continuous care registersFamily welfare servicesMaternal care servicesChild care and immunization servicesTuberculosis and leprosy controlMalaria and blood smear and treatment
  13. 13.  Other registersHome visit diaryClinic registersStock and issue registersBirth and death registersAccounts of untied funds and JSY(Janani Surakasha Yojna)
  14. 14. Registers at AWCAnganwadi workers (AWWs) have set of registers likehousehold survey register,birth and death register,beneficiary register for mother and children,immunization,growth charts and weight book andstock registers.
  15. 15. REPORTSThe sub centre ANMs Anganwadi workers are the responsibility centers for HMIS and they prepare monthly reports every month.The sub centre reports provide information on inputs (Health workers, material equipments, monthly stock position of drugs, vaccines received functional status of equipments, etc.).It also provides the information on processes and outputs or performance in terms of antenatal care, natal care, pregnancy outcome, postnatal care, newborn care, referral services, STI/RTI detection, immunization, disease surveillance, contraception services, malaria and tuberculosis output, and data on impact indicators like births and deaths.
  16. 16.  It also has information on interaction with community, besides general information on population and eligible couples-parity wise and age wise.Similarly, Anganwadi workers provide useful information on health and nutritional services and impact measurement.The information is generated every month and sent to PHC.
  17. 17. Aggregated report of subcentre activities. Staff position number of posts filled and vacancies category wise, transport or vehicles, equipments and supply poition.Malaria report- Monthly report of blood slides.Tuberculosis report. Revised national tuberculosis control programme. Monthly report of logistics and microscopy.School health report.Epidemic and notifiable diseases and IDSP.AFP-Surveillance.Family planning achievementsImmunization report.National child survival and safe motherhood programme report.
  18. 18. Input proforma for sterilization, Detailed report on sterilization cases ( age, sex, caste, education and number of children).Input proforma for IUD (age, caste, education and number of children).Department wise achievement of family planning.National planning on control of blindness monitoring.Monthly report of PHC and CHC.Medical termination of pregnancy.Monthly expenditure statement.
  19. 19. PART A: REPRODUCTIVE & CHILD HEALTHM1: Antenatal Care ServicesM2: DeliveriesM3: Pregnancy Outcomes and detail of NewbornM4: Post-Natal careM5: Family PlanningM6: Child ImmunizationM7: Number of Vitamin A DosesM8: Number of Cases of Childhood diseases reported during the month (0-5 years)
  20. 20. PART : HEALTH FACILITIES SERVICESM9: Patient ServicesM10: Laboratory TestingPART C: LINE LISTING OF DEATHS S. No. 34- Mortality Details
  21. 21. HMIS- MAJOR SOURCESRoutine reports from subcentres-PHC-CHC-(Primary health care).Routine report of hospitals/dispensaries and railways, armed force services and other.Surveillance reports on Malaria and AFP.National health programme data and information.Sample registration system (SRS) once a year provides state and national estimates on fertility and mortality.
  22. 22. Civil registration system- continuous surveillance.Model registration-survey of causes of death (rural) once a year up to 1994.HIV sentinel survey (annual) once a year.District level household survey report under RCH every alternate year.National family health survey data (NFHS-1-3) once every five years.Census-once every 10 years.Special survey like to map out problem of tuberculosis (1958 and 2003).Administrative reports on accounts, and personnel, etc.
  23. 23. COMMON PROBLEMS WITHROUTINE REPORTING SYSTEMThese are incomplete and coverage of population may not be total.Quality of information is poor in respect of causes of death and weighing of children.The information is seldom used at local level by the health workers or by team leaders (Medical Officers).The information is not shared with the community. The subcentres should report on performance to panchayats, hospitals to Rogi Kalyan Samitis and District Health Mission to Zila Parishad. Annual district reports on people’s health should be prepared and shared with people.The information is used as compliance and for transmission of reports to higher level only.
  24. 24.  The feedback to health workers who collect huge or voluminous data is not available and consequently there is no sustained motivation. The initial training and continuing education of health workers and medical officers is weak, not much emphasis laid on HMIS. There is tendency to over-report the performance and figures are inflated quite often. Data gathered under RCH and other programmes are seldom analysed, poorly understood, and not acted upon locally for decision- making or to improve the quality of services. The system remains data driven rather than action driven. The planning and management staff rely primarily on “gut feeling” to formulate adhoc decisions rather than seek pertinent data base information support. The supply of registers and reporting formats are erratic and frequent stock outs is a common feature.
  25. 25. Right now, health worker depend on formulae to prepare their action plans and they borrow the birth rate of the state and apply this to population of sub centre to get a magic figure of antenatal, births, eligible couples, etc.If they have HMIS in operation, they can rely on it for planning the services at local level and sharing the information with local community.
  26. 26. OTHER DATA USED BY POLICY MAKERSSince the routine reporting and information system is inadequate, the policy makers and health administrators make use of other systems of information (SRS, NFHS-1-3 censes, sentinel data, hospital data and special data generated through surveys and studies).National Nutritional Monitoring Bureau, Hyderabad generates data on dietary consumption and nutritional status.Similarly, universities and medical colleges generated tremendous and robust data on maternal and child health under the banner of ICDS,
  27. 27. INNOVATIONSHome-based or client-based records, e.g. immunization card or antenatal card are available at home with mothersRegisters have been combinedComputer system have been introducedNational Information Centre ( NIC) has been set upGeographic information system ( GIS ) : This envisages creation of an electronic database of health care facilities, education institutional, training centres and other health care establishments in India.
  28. 28. SUGGESTIONSRole of Supervisors and team leaders must be supportive and not fault findingAWC & Sub-centre should display all health information so that people get aware of local situation.This would generate a cycle- people may seek more information and that leads to improvement of system of information.The health workers, Anganwadi workers during each contact with the client/community (home visit- Mahila Swasthya Sangh meeting) should share the
  29. 29. USES OF HMISTo support decision-making and taking actions.To help to assess community needs, e.g. community needs assessment approach under RHC can make use of HMIS for preparing sub centre action plans, e.g. who need immunization? And who need it?To prioritize the health needs, e.g. under CNNA we prioritize or segment the eligible couples who need services for sterilization, spacing by contraception or priority is given to economical weaker section.To assess the performance of the health workers or institutions like sub centre –PHC- CHC –District or State.
  30. 30. To evaluate the programme or to measure its success and failure.For better planning of services and programmes at local level.To justify the resources spent (staff, money and material).For operational and epidemiological research purposes.HMIS is useful for training of workers and medical officers and the supervisors.Helps to provide database or information to client or community whose lives it affects profoundly.
  31. 31. Launched in November, 2004
  32. 32. Hon’ble Prof. Laxmi Kanta Chawla launching the project formallyat BhawaniGarh (Distt. Sangrur) in 2007.
  33. 33. What is Integration?Sharing of Surveillance information of disease control programmesDeveloping effective partnership with health and non health sectors in surveillanceIncluding communicable and non communicable diseases in the surveillance systemEffective partnership of private sector and NGOs in surveillance activitiesBringing academic institutions and Medical Colleges into primary public health activity of disease surveillance.
  34. 34. Introduction to Disease SurveillanceWhat is public health Surveillance? Surveillance is defined as the ongoing systematic collection, collation, analysis and interpretation of data; and dissemination of information to those who need to know in order that action be taken . Surveillance is monitoring of behavior.Clinical surveillance- monitoring of disease or public health indicators. The ongoing systematic collection, analysis and interpretation of data essential to planning, implementation, and evaluation of public health practice closely integrated with timely dissemination of these data to those who need to know. The final link in the surveillance chain is the application of these data to prevent and control diseases.
  35. 35. Key Elements of a SurveillanceSystemDetection and notification of health eventInvestigation and confirmation (epidemiological, clinical, laboratory)Collection of dataAnalysis and interpretation of dataFeed back and dissemination of result- Disease AlertResponse - a link to public health programme specially actions for prevention and control
  36. 36. Important Information in DiseaseSurveillance- OUTBREAKS Who get the disease? How many get them? Where they get them? When they get them? Why they get them? What needs to be done as public health response?
  37. 37. Components of SurveillanceActivity Collection of data Compilation of data Analysis and interpretation Follow up action Feed back- IDSP ALERT
  38. 38. Surveillance - Uses• Monitoring trends of health event• Estimting magnitude of health problem• Epidemic detection & prediction• Monitor progress towards control objective• Monitor programme performance• Estimate future disease impact• Evaluating an intervention• Understand characteristics of health events• Facilitate planning
  39. 39. Weaknesses in Disease Surveillance• Lack of integration of Private Sector in surveillance activity• Poor Laboratory capacity• Lack of surv. infrastructure in urban areas• Slow & inefficient sharing of surveillance information at district level• Limited capacity to undertake analysis & response at district level• Non-inclusion of NCDs in Surv. Program
  40. 40. Objectives of the IDSPTo establish a decentralized state based surveillance system for communicable diseases to detect the early warning signals, so that timely and effective public health actions can be initiated in response to the health challenges in the country at the district, state and national level.To improve and efficiency of the existing surveillance activities of disease control programmes 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.
  41. 41. MAJOR PROJECT COMPONENTSIntegration and decentralization of surveillance activities.Strengthening of public health laboratories.Human resources development –training of state surveillance officers, district surveillance officers, rapid response team, other medical and paramedical staffUse of information technology for collection ,collation, compilation, analysis and dissemination of data.
  42. 42. HIGH SPEED BROADBANDThe network on completion will enable 800 sites on a broadband network of network of which 400 sites will have dual connectivity with satellite and broadband.This network enables enhanced speedy data transfer, video conferencing , discussions, training , communication and in future E-learning for outbreaks and programme monitoring under IDSP
  43. 43. Types of Surveillance in IDSPSyndromic: Information of diseases on the basis of clinical pattern by paramedical personnel and members of community.Presumptive: Diagnosis made on typical history, pattern and clinical examination by medical officersConfirmed: Clinical diagnosis by medical officer confirmed by positive laboratory investigation.
  44. 44. DATA COLLECTIONUnder IDSP data is collected on a weekly(Monday- Sunday) basis.The information is collected on three specified reporting formats, namely “S”(suspected cases),”P”(presumptive cases) and “L”(laboratory confirmed cases )filled by health workers ,clinician and clinical laboratory staff respectively. Clinical data collection has been simplified as only the number of cases of diseases under surveillance is to be reported.It includes 20 diseases/syndromes . besides these there is provision for reporting of a state specific disease and any unusual syndrome, not included in the list of 20 diseases.
  45. 45. Disease Conditions under IDSPSurveillance Group of Diseases ExamplesRegular Surveillance Vector Borne Malaria Water Borne Acute Diarrhoeal Disease Respiratory Diseases (Cholera), Typhoid Vaccine Preventable Diseases Tuberculosis Diseases under eradication Measles Others Polio Other International commitments Road Traffic Accidents Unusual clinical syndromes Plague Menigoencephalitis / Respiratory (Causing death / hospitalization) Distress Hemorrhagic fevers, other undiagnosed conditionsSentinel Surveillance Sexually transmitted diseases/Blood HIV/HBV, HCV borne: Water Quality, Outdoor Air Quality Other Conditions (Large Urban Centers)Regular periodic surveys NCD Risk Factors Anthropometry, Physical activity, Blood Pressure, Tobacco, Nutrition, BlindnessAdditional State Priorities Each state may identify up to five additional conditions for surveillance
  46. 46. FOR EARLY WARNING OF OUTBREAKSThe two speciality branches crucial for generating early warning signals are medicine and paediatrics.Since reporting from the health centres is not regular , emphasis is on reporting of data by major hospitals , both government and privates as well as infectious disease hospitals as these sites act as sentinel sites and provide data useful for depicting disease trends that help in early warning of disease outbreaks.Provision of Rumour Register and Media Scanning Cell (2010 year had 388 media alerts till October)
  47. 47. ADMINISTRATIVE ORGANIZATIONCENTRAL LEVEL:1. National Disease Surveillance Committee: Secretary Health And Family Welfare and DGHS to act as chairperson. Members include DG (ICMR), Senior Officials from the ministry ,National Programme Officers and representatives from other concerned Ministries.Director NICD is the project director (IDSP),2. Central Surveillance Unit : located at NICD, New Delhi. . It will execute the approved annual plan action for IDSP and monitor progress in states. Production and dissemination of standard guidelines ,manuals and modules.
  48. 48. STATE LEVEL1. State surveillance committee: it will be chaired by health secretary2. State surveillance unit: This unit will be responsible for :The collation and analysis of all data 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.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.
  49. 49. 1. Principal Secretary Health & Family Welfare Chairman2. Director Health Services Co-Chairman3. Programme Officer of PH, TB, Malaria, HIV, Polio Member4. Director Research and Medical Education (DRME) -do-5. Representative from Department of Environment -do- & Home6. Coordinating member from State Medical -do- College Surveillance Team7. Representative from the state Unit of the -do- Indian Medical Association8. NGO representative -do-9. Head of State Public Health Laboratory -do-10. State Surveillance Officer Member Secretary
  50. 50. DISTRICT LEVEL1. District surveillance committee: It will be chaired by district collector/District magistrate2. District surveillance unit(DSU): It will be headed by district surveillance officer and will be responsible for the implementation of the project activities.
  51. 51. 1. Deputy Commissioner of Distt. Chairman2. Civil Surgeon of Distt. Co-Chairman3. Programme Officer of PH, TB, Member Malaria, HIV, Polio4. Representative of Medical college (if -do- any)5. Representative of SSP in District -do-6. Representative from the Department -do- of Water Supply and Sanitation7. NGO representative -do-8. Chairman Zila Parishad -do-9. Head of Distt. Public Health -do- Laboratory10. The Distt. Surveillance Officer Member Secretary
  52. 52. Role of Dist Surveillance Officers under IDSP• Supervision & Quality Control of Active Surveillance by field staff- as under NVBDCP• Conduct Passive Surveillance of important diseases listed in IDSP- from institutional data.• Supervise compilation & transmission of periodical reports- weekly under IDSP.• Integrate selected Sentinel Private Practitioners in program from area- signing of MOU.• Initiate Emergency Response to surveillance reports received in the Unit- outbreak response.• Facilitate Epidemic Investigations & Outbreak response by State & Distt. Surveillance Unit through involvement of RRT.
  53. 53. Development of Software for DiSeaSeSurveillance District Surveillance Network under the IT Network :-
  56. 56. DATA MANAGEMENTUnder IDSP data is collected on a weekly( Monday- Sunday)basis. The weekly data gives the time trends.Whenever there is a rising trend of illnesses in any area , it is investigated by the Medical Officers/ Rapid Response Teams(RRT) to diagnose and control the outbreak.>85% of districts are reporting weekly disease surveillance data now.
  57. 57. OUTBREAK SURVEILLANCE & RESPONSEFrom Jan to Oct 2010, 871 outbreaks have been reported mainly of Diarrhoea, Food Poisoning, Measles & Chickenpox.M.O.(PHC) is to verify reports of outbreak from health worker within 24 hours, start disease specific control activities immediately and report suspected and confirmed cases to DSU within 24 hours .
  58. 58. Trigger 1:-Clustering of 2 similar cases of Dengue cases in a village.Single case of Dengue Hemorrhagic fever.Trigger 2:-More than 4 cases of Dengue fever in a village with a population of 1000.
  59. 59. Trigger 1:- Single Case of Measles in a particular Geographical Area.
  60. 60. (a.) Trigger Level I- Suspected Outbreak-local response by HW/MO.(b.) Trigger Level II-ConfirmedOutbreak/Epid. - local & regionalresponse.(c.) Trigger Level III- Widespread Epidemic- local , regional
  61. 61. ENTOMOLOGICAL SURVEILLANCEON VECTOR BORNE DISEASESVector borne epidemic prone diseases like Malaria, JE, Dengue, Chikungunya, Kala Azar and Plague are most important of public health concern.These outbreaks are now reported more frequently and from newer and newer areas.To monitor and evaluate the timelines and quality of indoor residual spray, Insecticide treated nets and distribution of Larvivorous fishes.Undertake entomological Surveillance. Map and monitor entomological density and bionomics and sensitivity to insecticides.
  62. 62. DATA CENTRENational Informatics Centre has established broadband connectivity at 776 out of 800 sites.Training Centre Equipments installed at 378 out of 400 sites.Video Conferencing: Indian Space Research Organization (ISRO) has installed 367 out of 400 EDUSAT/V-SAT sites.IDSP PORTALTRAINING: Completed in 27 states and partially in 4 states.
  63. 63. STRENGHTHENING OF LABORATORIES50 districts laboratories are being focused for strengthening in the country for laboratory diagnosis of epidemic prone diseases.Till date 26 labs in 18 states have procured equipments, and 13 are fully functional.In 9 states a referral lab network is being established by utilizing medical colleges labs.
  64. 64. L1- Peripheral Labs (PHC/CHC)L2- Distt. LabsL3- State Public Health lab.L4- Focal Laboratory PGI Chd.L5- NICD LabL6- Disease Specific National Labs (National Virology Lab, Pune, Avian Influenza Lab, Bhopal)
  65. 65. INFECTIOUS DISEASE HOSPITALSURVEILLANCE NETWORKNew DelhiKolkataChennaiMumbaiBengaluruAhmedabadHyderabad
  66. 66. SWINE FLU & AVIAN INFLUENZAA networking model has been developed with 112 laboratories, out of which 10 labs are functional.The animal component of influenza is being looked after by Ministry of Agriculture (Department of Animal Husbandry)
  67. 67. State-Specific Diseases• Diphtheria, Leprosy – Madhya Pradesh, Uttaranchal• Diphtheria, Leptospirosis – Maharashtra• Filariasis – Andhra Pradesh• Filariasis,Leptospirosis, Chickengunya – Karnataka• Leprosy, Leptospirosis, Chickengunya – Tamil Nadu• Leptospirosis – Kerala• Dengue, Malaria, Gastroenteritis- Punjab• Cancer, Acid Peptic Disease, Pneumonia – Mizoram
  68. 68. TOLL FREE NUMBER UNDER IDSPA 24x7 call centre with toll free telephone 1075 accessible from BSNL/MTNL telephone from anywhere in the country and diverges the information to the respective state/district surveillance units for verification and initiating appropriate actions wherever required.
  69. 69. Outbreak/Epidemic Investigation under IDSPDisease Outbreaks Source of data for Outbreaks investigated bydetected in last 7 months identification of these State / District RRT outbreaksDistt. Ludhiana- Local workers & Health District RRTHepatitis Cases in StaffKotmangal Singh on9/03/08 & in Mayapurion 10/3/08.Bareta Mandi (Distt. Mansa) Through SMO District RRT Hepatitis 16/02/08 to04/04/08Fazilka(Distt. Ferozepur) Through SMO Distt RRT AND SUBHepatitis 02/05/08 DIV.RRT