title: Assessment of the core and support functions of the Integrated Disease Surveillance system in Maharashtra, India.
abstract: BACKGROUND
  Monitoring the progress of the Integrated Disease Surveillance (IDS) strategy is an important component to ensure its sustainability in the state of Maharashtra in India. The purpose of the study was to document the baseline performance of the system on its core and support functions and to understand the challenges for its transition from an externally funded "project" to a state owned surveillance "program".
  
  
  METHODS
  Multi-centre, retrospective cross-sectional evaluation study to assess the structure, core and support surveillance functions using modified WHO generic questionnaires. All 34 districts in the state and randomly identified 46 facilities and 25 labs were included in the study.
  
  
  RESULTS
  Case definitions were rarely used at the periphery. Limited laboratory capacity at all levels compromised case and outbreak confirmation. Only 53% districts could confirm all priority diseases. Stool sample processing was the weakest at the periphery. Availability of transport media, trained staff, and rapid diagnostic tests were main challenges at the periphery. Data analysis was weak at both district and facility levels. Outbreak thresholds were better understood at facility level (59%) than at the district (18%). None of the outbreak indicator targets were met and submission of final outbreak report was the weakest. Feedback and training was significantly better (p < 0.0001) at district level (65%; 76%) than at facility level (15%; 37%). Supervision was better at the facility level (37%) than at district (18%) and so were coordination, communication and logistic resources. Contractual part time positions, administrative delays in recruitment, and vacancies (30%) were main human resource issues that hampered system performance.
  
  
  CONCLUSIONS
  Significant progress has been made in the core and support surveillance functions in Maharashtra, however some challenges exist. Support functions (laboratory, transport and communication equipment, training, supervision, human and other resources) are particularly weak at the district level. Structural integration and establishing permanent state and district surveillance officer positions will ensure leadership; improve performance; support continuity; and offer sustainability to the program. Institutionalizing the integrated disease surveillance strategy through skills based personnel development and infrastructure strengthening at district levels is the only way to avoid it from ending up isolated! Improving surveillance quality should be the next on agenda for the state.
authors.affiliation: Institute of Public Health (Former Department of Tropical Hygiene and Public Health) Im Neuenheimer Feld 324, University of Heidelberg, Heidelberg, Germany D-69120. rphalkey@gmail.com
authors.forename: Revati K
authors.initials: RK
authors.lastname: Phalkey
authors.forename: Sharvari
authors.initials: S
authors.lastname: Shukla
authors.forename: Savita
authors.initials: S
authors.lastname: Shardul
authors.forename: Nutan
authors.initials: N
authors.lastname: Ashtekar
authors.forename: Sapna
authors.initials: S
authors.lastname: Valsa
authors.forename: Pradip
authors.initials: P
authors.lastname: Awate
authors.forename: Michael
authors.initials: M
authors.lastname: Marx
mesh_terms: D003141:Communicable Diseases / Q000453:epidemiology*; D017281:Cost of Illness; D003430:Cross-Sectional Studies; D062665:Epidemiological Monitoring; D005260:Female; D006801:Humans; D007194:India / Q000453:epidemiology; D008297:Male; D011159:Population Surveillance; D011634:Public Health / Q000379:methods; D012189:Retrospective Studies