title: Challenges with the implementation of an Integrated Disease Surveillance and Response (IDSR) system: systematic review of the lessons learned.
abstract: BACKGROUND
  Despite a realistic strategy and availability of resources, multiple challenges still overwhelm countries grappling with the challenges of communicable disease surveillance. The Integrated Disease Surveillance and Response (IDSR) strategy is by far the most pragmatic strategy in resource-poor settings. The objective of this study was to systematically review and document the lessons learned and the challenges identified with the implementation of the IDSR in low- and middle-income countries and to identify the main barriers that contribute to its sub-optimal functioning.
  
  
  METHODS
  A systematic review of literature published in English using Web of Knowledge, PubMed, and databases of the World Health Organization (WHO) and the Centers for Disease Control (CDC) between 1998 and 2012 was undertaken. Additionally, manual reference and grey literature searches were conducted. Citations describing core and support functions or the quality attributes of the IDSR as described by WHO and CDC were included in the review.
  
  
  RESULTS
  Thirty-three assessment studies met the inclusion criteria. IDSR strategy has been best adopted and implemented in the WHO-AFRO region. Although significant progress is made in overcoming the challenges identified with vertical disease surveillance strategies, gaps still exist. Mixed challenges with core and support IDSR functions were observed across countries. Main issues identified include non-sustainable financial resources, lack of co-ordination, inadequate training and turnover of peripheral staff, erratic feedback, inadequate supervision from the next level, weak laboratory capacities coupled with unavailability of job aids (case definitions/reporting formats), and poor availability of communication and transport systems particularly at the periphery. Best outcomes in core functions and system attributes were reported when support surveillance functions performed optimally. Apart from technical and technological issues, human resources and the health care system structures that receive the IDSR determine its output.
  
  
  CONCLUSIONS
  The challenges identified with IDSR implementation are largely 'systemic'. IDSR will best benefit from skill-based training of personnel and strengthening of the support surveillance functions alongside health care infrastructures at the district level.
authors.affiliation: Institute of Public Health (Former Department of Tropical Hygiene and Public Health), University of Heidelberg, Im Neuenheimer Feld 324, D-69120 Heidelberg, Germany and Integrated Disease Surveillance Project, Ministry of Health and Family Welfare, Pune, Maharashtra, India rphalkey@urz.uni-heidelberg.de.
authors.forename: Revati K
authors.initials: RK
authors.lastname: Phalkey
authors.affiliation: Institute of Public Health (Former Department of Tropical Hygiene and Public Health), University of Heidelberg, Im Neuenheimer Feld 324, D-69120 Heidelberg, Germany and Integrated Disease Surveillance Project, Ministry of Health and Family Welfare, Pune, Maharashtra, India.
authors.forename: Shelby
authors.initials: S
authors.lastname: Yamamoto
authors.affiliation: Institute of Public Health (Former Department of Tropical Hygiene and Public Health), University of Heidelberg, Im Neuenheimer Feld 324, D-69120 Heidelberg, Germany and Integrated Disease Surveillance Project, Ministry of Health and Family Welfare, Pune, Maharashtra, India.
authors.forename: Pradip
authors.initials: P
authors.lastname: Awate
authors.affiliation: Institute of Public Health (Former Department of Tropical Hygiene and Public Health), University of Heidelberg, Im Neuenheimer Feld 324, D-69120 Heidelberg, Germany and Integrated Disease Surveillance Project, Ministry of Health and Family Welfare, Pune, Maharashtra, India.
authors.forename: Michael
authors.initials: M
authors.lastname: Marx
mesh_terms: D003140:Communicable Disease Control / Q000379:methods / Q000458:organization & administration*; D006801:Humans; D016730:Program Development; D015397:Program Evaluation; D062486:Public Health Surveillance / Q000379:methods
keywords: Assessment; Integrated Disease Surveillance and Response (IDSR); challenges; implementation; lessons learned