From Data to Action: From Data to Action: Evaluating Infectious Disease Surveillance in Pakistan

Research summary

Diseases have no borders. A disease anywhere in the world may become a health threat everywhere. It takes less than 36 hours for an outbreak to spread from a remote village to any major city in the world, therefore, the most effective – and cost effective – way to protect people from such health threats i.e measles, cholera and COVID-19 is to stop them before they spread to others and cross borders. Here comes the role of public health surveillance. Public health surveillance is the continuous, systematic collection, analysis and interpretation of health-related data. An effective disease surveillance system is essential to detecting disease outbreaks quickly before they spread, cost lives and become difficult to control. Digital technologies can improve the ability to both detect and respond to disease outbreaks by sharing data swiftly thus helping us to understand how and where diseases are spreading. This information is crucial for deciding what health policies and strategies to make and follow. Significance of this research is not limited to one country but it has global health dimensions. It can help to address the critical issue of global health security by evaluating the impact of digital technologies on public health surveillance.
Low and middle income countries (LMICs) including Pakistan have fragile health systems therefore the risk of spreading diseases, even beyond their borders, is high. Disease surveillance system in Pakistan has largely been outdated and paper based, frequently leading to delayed detection of measles, cholera and other communicable disease outbreaks. In 2017, Ministry of Health Pakistan, with support of World Health Organization (WHO), launched Integrated Disease Surveillance and Response (IDSR) system which uses electronic health information system (District Health Information System – DHIS-2) as a platform for rapid and near real time reporting for selected diseases. From 2017 to 2022, the new system was implemented in 52 districts of the country while remaining 104 districts are still using paper based system. The dual existence of different reporting systems presents a unique opportunity for a comparative analysis, allowing for insights into the effectiveness of the digital transition.
As a doctoral researcher, I will conduct an evaluation to address the existing knowledge gap regarding the effectiveness of transitioning from traditional paper-based disease data reporting systems to new digital systems. Specifically, my research will focus on evaluating the impact of Integrated Disease Surveillance and Response (IDSR) and District Health Information System 2 (DHIS-2) initiatives in Pakistan. This evaluation aims to assess the effectiveness of new electronic infectious disease surveillance system in enhancing the country's health system capabilities. I aim to conduct a comparative analysis of the performance between DHIS-2, an electronic system, and traditional paper-based systems through cross sectional study, evaluate the effectiveness of the Integrated Disease Surveillance and Response (IDSR) framework and the District Health Information System 2 (DHIS-2) through a comprehensive assessment and explore the determinants influencing the adoption of electronic surveillance systems through a mix method study. The local research infrastructure is well-established, with the National Institutes of Health (NIH) Pakistan under Ministry of Health serving as a central data hub for disease surveillance and public health information. The presence of this infrastructure is vital for the success of the research project, as it provides access to comprehensive and up-to-date data on disease surveillance, outbreaks, and response efforts across Pakistan. The NIH website hosts weekly epidemiological IDSR reports. These reports serve as a rich source of information, forming the foundation for the research and ensuring the reliability and relevance of the data collected. Furthermore, the International Doctoral Programme in Epidemiology and Public Health at Tampere University, drawing on its expertise and research strength, will help to improve the quality and depth of the research findings. Together, these elements of the research infrastructure will contribute to the robustness of the study. The research project is feasible as IDSR implementation, led by Ministry of Health Pakistan, is already in progress with support of WHO. I have five years of practical experience, as a public health expert, in disease surveillance, monitoring and evaluation with World Health Organization, US Centers for Disease Control and Prevention (CDC), and UK Health Security Agency. My previous role as the Training Coordinator in the Integrated Disease Surveillance and Response (IDSR) project has been very relevant. Research will be implemented in phased manner starting from kick off meetings, ethical approvals to data collection, data analysis, reporting and dissemination and finalization and publications.
The results of this study may help to improve global health security by examining how well digital health information systems detect and respond to diseases quickly. In Pakistan, the findings might help strengthen the healthcare system, providing useful guidance to policy makers and contributing to practical strategies for better public health monitoring. My research is in line with the European Union's recent Global Health Strategy, which is a cornerstone of the EU's external policy. Addressing and mitigating health threats, particularly pandemics, is highlighted as a key priority within this strategy. Through my research, I aim to contribute to this overarching goal by examining the effectiveness of infectious disease surveillance systems, ultimately working towards a healthier and more resilient global community.

Description

Introduction
Diseases have no borders. A disease anywhere in the world may become a health threat everywhere. It takes less than 36 hours for an outbreak to spread from a remote village to any major city in the world(1), therefore, the most effective – and cost effective – way to protect people from such health threats i.e measles, cholera and COVID-19 is to stop them before they spread to others and cross borders(2). Here comes the role of public health surveillance.
Public health surveillance is the continuous, systematic collection, analysis and interpretation of health-related data(3). An effective disease surveillance system is essential to detecting disease outbreaks quickly before they spread, cost lives and become difficult to control. Public health surveillance provides the scientific and factual database essential to informed decision making and appropriate public health action. Disease surveillance data serves as an early warning system, alerting us early when there might be a disease outbreak that could become a big health problem. It helps us to see how well the things we are doing to stop a disease are working. Surveillance also helps us to understand how diseases are spreading. This information is crucial for deciding what health policies and strategies to adopt.
New developments in information and communication technologies (ICT) – particularly in the area of digital technologies – can significantly improve key functions associated with public health – e.g., the speed, reliability and reach of infectious disease surveillance, prevention and control. Digital technologies can improve the ability to both detect and respond to emerging infectious diseases by providing automatic and real-time mapping, creating new sources of data, and facilitating the discovery of pathogens, while at the same time reducing costs. Digital technologies can also be harnessed to counter some of the risks that such technologies pose for infectious disease prevention and control, for example the rapid dissemination of misinformation on social media(4). This is essential in a situation where more than 70% of the world remains underprepared to prevent, detect, and respond to a public health emergency(5).
Low and middle income countries (LMICs) including Pakistan have fragile health systems therefore the risk of spreading diseases, even beyond their borders, is high. Disease surveillance system in Pakistan has largely been outdated and paper based, frequently leading to delayed detection of measles, cholera and other communicable disease outbreaks. In 2017, Ministry of Health Pakistan, with support of World Health Organization (WHO), launched Integrated Disease Surveillance and Response (IDSR) system(6) which uses electronic health information system (District Health Information System – DHIS-2)(7) as a platform for rapid and near real time reporting for selected diseases. From 2017 to 2022, the new system has been implemented in 52 districts of the country while remaining 104 districts are still using paper based system. The dual existence of different reporting systems presents a unique opportunity for a comparative analysis, allowing for insights into the effectiveness of the digital transition.

Aim and Objectives
The overarching aim of this research is to conduct a comprehensive evaluation of the infectious disease surveillance system (IDSR), with a specific focus on its electronic component (DHIS-2), to understand their impact on Pakistan's health system.
The following are the specific objectives of this research study;
1. To conduct a comparative analysis of the performance between DHIS-2, an electronic system, and traditional paper-based systems through cross sectional study
• Research question: How do the performance metrics (timeliness, completeness, usefulness, representativeness, and simplicity) of disease surveillance indicators for measles, cholera, and COVID-19 differ between districts utilizing the electronic DHIS-2 system and those employing paper-based systems in Pakistan from 2020 to 2022?
2. To evaluate the effectiveness of the Integrated Disease Surveillance and Response (IDSR) framework and the District Health Information System 2 (DHIS-2) through a comprehensive assessment
• Research question: What is the effectiveness of the Integrated Disease Surveillance and Response (IDSR) and District Health Information System 2 (DHIS-2) initiatives in Pakistan in terms of data quality and outbreak response efficiency for measles, cholera, and COVID-19 during the period from 2020 to 2022?
3. To explore the determinants influencing the adoption of electronic surveillance systems through a mix method study
• Research question: What are the primary determinants affecting the adoption and implementation of electronic disease surveillance system (IDSR) in Pakistan, with a specific focus on technological infrastructure, human resource capacity, and organizational support?
Outcomes
• Identification of key differences in performance metrics (timeliness, completeness, usefulness, representativeness, and simplicity) between DHIS-2 and paper-based systems.
• Insights into the strengths and limitations of both electronic and traditional surveillance systems in Pakistan.
• Assessment of the effectiveness of the IDSR framework and DHIS-2 in improving data quality and enhancing outbreak response efficiency.
• Identification of areas of success and areas needing improvement in the implementation of IDSR and DHIS-2 initiatives.
• Identification of key determinants influencing the adoption and implementation of electronic disease surveillance systems in Pakistan.
• Understanding the role of technological infrastructure, human resource capacity, and organizational support in facilitating or hindering the adoption process.
?
Project feasibility and current status
Led by the Ministry of Health of Pakistan with the support of the World Health Organisation (WHO) and other international partners, the IDSR programme has been rolled out in 52 districts of Pakistan and plans to be implemented in the remaining 104 districts of the country. The local research infrastructure is well-established, with the National Institute of Health (NIH) Pakistan serving as a central data hub for disease surveillance and public health information. The presence of this infrastructure is crucial for the success of the research project, as it provides access to comprehensive and up-to-date data on disease surveillance, outbreaks, and response efforts across Pakistan. The NIH website hosts weekly epidemiological IDSR reports. These reports serve as a rich source of information, forming the foundation for the research and ensuring the reliability and relevance of the data collected. Furthermore, drawing on expertise of my supervisor Professor Pekka Nuorti at Tampere University, will help to enhance the quality and depth of the research findings. Together, these elements of the research infrastructure will contribute to the robustness of the study. The research project is feasible as IDSR implementation, led by Ministry of Health Pakistan, is already in progress with support of WHO. I have five years of practical experience, as a public health expert, in disease surveillance, monitoring, and evaluation with World Health Organisation, US Centers for Disease Control and Prevention (CDC), and UK Health Security Agency. My previous role as the Training Coordinator in the Integrated Disease Surveillance and Response (IDSR) project has been relevant.
Place of Performance
The primary hub for the research study is Tampere University in Finland. Vital collaborative interactions will be sustained through regular meetings with the National Institute of Health (NIH) in Pakistan, ensuring consistent communication and coordination. Given that DHIS-2 is an initiative launched by the University of Oslo, Norway, active collaboration will be cultivated throughout the project's duration.
Ethical Considerations
Institutional Review Board (IRB) approvals will be sought from the Ministry of Health, Pakistan, ensuring compliance with ethical guidelines and standards.
Implementation Plan and Schedule
Phase 1: Preparatory Stage (Apr-Jun 2024)
I will commence the research project with a kickoff meeting, bringing together research supervisors from Tampere University and key stakeholders from the National Institute of Health (NIH) in Pakistan, along with the University of Oslo in Norway. This meeting aims to establish effective coordination and collaboration, outlining respective roles and expectations. Following this, I will undertake a comprehensive review of the literature focusing on the implementation of the Integrated Disease Surveillance and Response (IDSR) programme and digital surveillance technologies. Simultaneously, with the guidance of my supervisors, I will develop a theoretical framework that will serve as a guiding structure for the research. Subsequently, the research proposal will be submitted to Tampere University's Institutional Review Board (IRB) for ethical approvals.
Phase 2: Data Collection Preparation (Jul-Aug 2024)
Moving into the Data Collection Preparation phase, I plan to schedule regular virtual meetings with the NIH in Pakistan and the University of Oslo to maintain ongoing collaboration and receive updates. In addition, I will develop data collection tools, including surveys and interview guides, to ensure their alignment with ethical guidelines. To enhance the efficiency of data collection, training sessions for field personnel in Pakistan will be conducted, focusing on protocols and ethical considerations.
Phase 3: Data Collection (Sep 2024-Feb 2025)
During the Data Collection phase, I will conduct a systematic review and in-depth analysis of published literature, reports, and documented experiences in selected African countries, from 2012-2022, to provide an overview of IDSR implementation. Simultaneously, a comparative analysis between the digital data reporting system (DHIS-2) and the traditional paper-based reporting system in Pakistan will be initiated. Data collection from the official NIH Pakistan website will focus on weekly epidemiological IDSR reports. Qualitative data will be collected through focused group discussions and interviews with stakeholders. Descriptive studies and secondary analysis, examining both training evaluations and weekly data reports, will be carried out to assess how district health personnel training impact the performance of disease surveillance systems.
Phase 4: Data Analysis (Mar-Aug 2025)
Moving forward into the Data Analysis phase, I will analyze the quantitative data from DHIS-2 and paper-based reporting systems, adhering to data surveillance guidelines provided by the US Centers for Disease Control and Prevention (CDC)(8). Simultaneously, qualitative data from interviews and surveys will be analyzed to gain a nuanced understanding of stakeholders' perspectives on the effectiveness of IDSR. The integration of findings will involve synthesizing both quantitative and qualitative results to present a comprehensive evaluation of the IDSR program.
Phase 5: Reporting and Dissemination (Sep-Dec 2025)
I will prepare and publish research papers in peer-reviewed scientific journals, emphasizing key findings, detailed analysis, and recommendations. The research findings will also be presented at relevant international and national conferences, workshops, and seminars, contributing to the wider dissemination of knowledge.
Phase 6: Finalization and Publication (Jan-Jun 2026)
Finally, in the finalization and publication phase, I plan to finalize the dissertation manuscript in collaboration with my supervisors, addressing any feedback provided. The completed dissertation will then be published through Tampere University, Finland. This detailed implementation plan spans 24 months, systematically outlining specific actions for each phase to ensure a thorough evaluation of the IDSR program and DHIS-2, and culminating in the publication of the dissertation.
Significance
1. The study will look at how technology and public health work together, especially by examining the District Health Information System (DHIS-2) and how it can impact infectious disease surveillance. The findings will not only add to what we already know but will also help guide future ideas in public health technology. The results of this research will help us understand how well digital solutions work in monitoring and responding to diseases.
2. In the context of Pakistan, this research will be especially important as it checks how well the IDSR program is performing in the country's health system. The results will provide important information to people who make decisions about health and help them understand what's going well and what needs to be improved in the current surveillance system. This knowledge will help strengthen the country's health system and prepare for health challenges.
3. The significance of this research extends beyond Pakistan to other low- and middle-income countries (LMICs). It may help in development of Pakistan’s national public health emergency preparedness plans and National Action Plans on Health Security, thereby strengthening health systems.?

Research info

Research title
From Data to Action: From Data to Action: Evaluating Infectious Disease Surveillance in Pakistan

Research timeline
1.5.2024 -

Keywords
covid-19 global health security health information system infectious diseases

Region
Asia

Countries
Finland

Institution
Tampere University
Public Health
Tampere, Finland

Head of research
Pekka Nuorti

Partners
National Institute of Health, Islamabad, Pakistan

Contact information

Record last updated
19.12.2024