Dr. Vikram GuptaAssistant Professor,

Community Medicine, Dayanand Medical College & Hospital,

Ludhiana, Punjab (India)

HMISHMIS is defined as a system that provides

up-to-date, reliable , completetimely 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.

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.

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CHC

PHC

Sub Centres

Aim : Primary health careNetwork of Integrated Health

And Family Welfare Delivery System

Rural Health Infrastructure

Community HealthCentre

{80000 to 120000Population}

Primary HealthCentre

{30000 pop.}{20000 in hilly, tribal

& backward area}

Sub centre5000 pop.

{3000 in hilly , tribal& backward area}

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RURAL SET UPRURAL SET UP

HEALTH SYSTEM IN INDIAHEALTH SYSTEM IN INDIA

11

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 and child health, family welfare, nutrition, immunization, diarrhea control 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

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Primary Health Centres (PHCs)

First contact point with Medical Officer.

Envisaged to provide an integrated curative and preventive care

Established and maintained by the State Governments under the Minimum Needs Programme (MNP)

Manned by a Medical Officer supported by 14 paramedical and other 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

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Community Health Centres

Established and maintained by the State Government under MNP/BMS programme .

It is manned by four medical specialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21 paramedical and other staff.

It has 30 in-door beds with one OT, X-ray, Labour Room and Laboratory facilities.

It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and specialist consultations.

As on March, 2007, there are 4045 CHCs functioning.

State Health Organization

HOME-BASED OR CLIENT BASED RECORDS AND INFORMATION

VILLAGE BASED (1000)

SUB CENTRE (5000)

PHC (30000)

CHC (1,00,000)

District (>5lakh)MoHFW

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.

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.

KEY REGISTERS AT SUB CENTRE LEVEL

Survey registersSub centre village information Household informationEligible couple and children information

Continuous care registersFamily welfare servicesMaternal care servicesChild care and immunization servicesTuberculosis and leprosy controlMalaria and blood smear and treatment

Other registersHome visit diaryClinic registersStock and issue registersBirth and death registersAccounts of untied funds and JSY(Janani

Surakasha Yojna)

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.

REPORTSThe 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.

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.

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 achievementsImmunization report.National child survival and safe motherhood

programme report.

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.

PART A: REPRODUCTIVE & CHILD HEALTH

M1: Antenatal Care ServicesM2: DeliveriesM3: Pregnancy Outcomes and detail of

NewbornM4: Post-Natal careM5: Family PlanningM6: Child ImmunizationM7: Number of Vitamin A DosesM8: Number of Cases of Childhood diseases

reported during the month (0-5 years)

PART : HEALTH FACILITIES SERVICES

M9: Patient ServicesM10: Laboratory Testing

PART C: LINE LISTING OF DEATHS

S. No. 34- Mortality Details

HMIS- MAJOR SOURCESRoutine 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.

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.

COMMON PROBLEMS WITH ROUTINE 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.

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.

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.

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,

INNOVATIONSHome-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 introducedNational Information Centre ( NIC) has been

set upGeographic 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.

SUGGESTIONSRole of Supervisors and team leaders must be

supportive and not fault findingAWC & 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 valuable information with each home.

USES OF HMISTo 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.

To monitor programme operations.

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.

Launched in November, 2004

Hon’ble Prof. Laxmi Kanta Chawla launching the project formally at BhawaniGarh (Distt. Sangrur) in 2007.

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.

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.

Key Elements of a Surveillance SystemDetection 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

Important Information in Disease Surveillance- 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?

Components of Surveillance Activity

Collection of data

Compilation of data

Analysis and

interpretation

Follow up action

Feed back- IDSP ALERT

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

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

Objectives of the IDSPTo 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.

MAJOR PROJECT COMPONENTSIntegration 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.

HIGH SPEED BROADBANDThe 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

Types of Surveillance in IDSPSyndromic: 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.

DATA COLLECTIONUnder 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.

Disease Conditions under IDSPSurveillance Group of Diseases Examples

Regular Surveillance Vector BorneWater BorneRespiratory DiseasesVaccine Preventable DiseasesDiseases under eradicationOthersOther International commitmentsUnusual clinical syndromes

MalariaAcute Diarrhoeal Disease (Cholera), TyphoidTuberculosisMeaslesPolioRoad Traffic AccidentsPlagueMenigoencephalitis / Respiratory(Causing death / hospitalization)Distress Hemorrhagic fevers, other undiagnosed conditions

Sentinel Surveillance Sexually transmitted diseases/Blood borne:Other Conditions

HIV/HBV, HCVWater Quality, Outdoor Air Quality(Large Urban Centers)

Regular periodic surveys NCD Risk Factors Anthropometry, Physical activity, Blood Pressure, Tobacco, Nutrition, Blindness

Additional State Priorities Each state may identify up to fiveadditional conditions for surveillance

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)

ADMINISTRATIVE ORGANIZATIONCENTRAL 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.

STATE LEVEL1. State surveillance committee: it will be chaired by

health secretary2. 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.

1. Principal Secretary Health & Family Welfare Chairman

2. Director Health Services Co-Chairman

3. Programme Officer of PH, TB, Malaria, HIV, Polio Member

4. Director Research and Medical Education (DRME) -do-

5. Representative from Department of Environment& Home

-do-

6. Coordinating member from State Medical College Surveillance Team

-do-

7. Representative from the state Unit of the Indian Medical Association

-do-

8. NGO representative -do-

9. Head of State Public Health Laboratory -do-

10. State Surveillance Officer Member Secretary

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.

1. Deputy Commissioner of Distt. Chairman

2. Civil Surgeon of Distt. Co-Chairman

3. Programme Officer of PH, TB, Malaria, HIV, Polio

Member

4. Representative of Medical college (if any)

-do-

5. Representative of SSP in District -do-

6. Representative from the Department of Water Supply and Sanitation

-do-

7. NGO representative -do-

8. Chairman Zila Parishad -do-

9. Head of Distt. Public Health Laboratory

-do-

10. The Distt. Surveillance Officer Member Secretary

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.

Development of Software for Disease Surveillance

District Surveillance Network under the IT Network :-

IDSP-STRUCTURAL FRAMEWORK

CSU

SSU

DSU

RURAL SURVEILLANCE URBAN SURVEILLANCE

RURAL SSPS-15

PHC,SUB-CENTERS,INFORMERS

RURAL MEDICAL COLLEGES

DISTRICT HIV/AIDS

DISTRICT TB LAB

DISTRICT HOSP.,

DISPENSARIES

INFORMERS

ESI

RAILWAY HOSP.

WATER DEPT.

CGHS

CORP. HOSP.

POLLUTION CONTROL

ICMR LABSMEDICAL COLLEGES

URBAN SSPS-15POLICE

DISTRICT MALARIA UNIT

STRUCTURAL FRAMEWORK OF IDSP

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.

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 .

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.

Trigger 1:-

Single Case of Measles in a particular Geographical Area.

(a.) Trigger Level I- Suspected Outbreak- local response by HW/MO.

(b.) Trigger Level II- ConfirmedOutbreak/Epid. - local & regional response.

(c.) Trigger Level III- Widespread Epidemic- local , regional &state level response.

ENTOMOLOGICAL SURVEILLANCE ON VECTOR BORNE DISEASESVector 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.

DATA CENTRENational 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 PORTALTRAINING: Completed in 27 states and

partially in 4 states.

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.

L1- Peripheral Labs (PHC/CHC)L2- Distt. LabsL3- State Public Health lab.L4- Focal Laboratory PGI Chd.L5- NICD LabL6- Disease Specific National Labs (National

Virology Lab, Pune, Avian Influenza Lab, Bhopal)

INFECTIOUS DISEASE HOSPITAL SURVEILLANCE NETWORKNew DelhiKolkataChennaiMumbaiBengaluruAhmedabadHyderabad

SWINE FLU & AVIAN INFLUENZAA 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)

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

TOLL FREE NUMBER UNDER IDSPA 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.

Outbreak/Epidemic Investigation under IDSP

Disease Outbreaks detected in last 7 months

Source of data for identification of these outbreaks

Outbreaks investigated by State / District RRT

Distt. Ludhiana- Hepatitis Cases in Kotmangal Singh on 9/03/08 & in Mayapuri on 10/3/08.

Local workers & Health Staff

District RRT

Bareta Mandi (Distt. Mansa) Hepatitis 16/02/08 to 04/04/08

Through SMO District RRT

Fazilka(Distt. Ferozepur)

Hepatitis 02/05/08

Through SMO Distt RRT AND SUB DIV.RRT