title: Disease surveillance and private sector in the metropolitans: a troublesome collaboration.
abstract: BACKGROUND
  An effective response to health problems is completely dependent upon the capacities of the health system in providing timely and valid information to take action. This study was designed to identify various reasons from various perspectives for underreporting disease by physicians in the private sector in big cities in developing countries setting.
  
  
  METHODS
  In this qualitative study, we used focus group discussions (16 manager), and in-depth semi-structured interviews.
  
  
  RESULTS
  Themes were classified in 6 categories: Infrastructure and legal issues, the priority of disease reporting, workflow processes, motivation and attitude, human resources and knowledge and awareness. As the main reasons of under reporting, most physicians pointed out complicacy in reporting process and inadequate attention by the public sector. Managers emphasized instituting legal incentives and penalties. Experts focused on physicians' knowledge and expressed a need for continuing medical education programs.
  
  
  CONCLUSIONS
  Independent interventions will have little chance of success and sustainability. Different intervention programs should consider legal issues, attitude and knowledge of physicians in the private sector, and building a simple reporting process for physicians. Intervention programs in which the reporting process offers incentives for all stakeholders can help improving and sustaining the disease reporting system.
authors.affiliation: Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Ayat
authors.initials: A
authors.lastname: Ahmadi
authors.forename: Saharnaz
authors.initials: S
authors.lastname: Nedjat
authors.forename: Jaleh
authors.initials: J
authors.lastname: Gholami
authors.forename: Reza
authors.initials: R
authors.lastname: Majdzadeh
keywords: Iran; notification; public health practice; reporting