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World Health Organization . Country Office - India. Framework for implementation of revised IHR 2005 in India. Dr Sampath K Krishnan Coordinator CDS & IHR Contact Point. World Health Organization . Country Office - India. Presentation. Health Legislation & Governance

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framework for implementation of revised ihr 2005 in india

World Health

Organization

Country Office - India

Framework for implementation of revised IHR 2005 in India

Dr Sampath K Krishnan

Coordinator CDS & IHR Contact Point

presentation

World Health

Organization

Country Office - India

Presentation
  • Health Legislation & Governance
  • Disease surveillance
    • NSPCD
    • IDSP
  • Plan of action for implementation of IHR in India
constitutional allocation of government powers

World Health

Organization

Country Office - India

Constitutional allocation of Government powers
  • Federal structure - Health is a state subject in the main
  • Central (Union) list, State list & Concurrent list
  • Central list has more of public health legislations whereas state list also has legislations for health emergencies
  • Concurrent list also contains important areas concerning public health which can be taken up by state or centre.
  • Pandemic diseases could be declared as Public health disasters and centre could take control-e.g. SARS, Avian Flu, Pandemic Flu
constitutional protections

World Health

Organization

Country Office - India

Constitutional protections
  • Constitution of India guarantees right to life (Article 21). Right to health as a pre-requisite recognized by the Supreme Court.
  • Under Directive Principles of the State, health care is the responsibility of the State (Nation)
  • Public health can override individual rights
  • E.g. in Avian influenza-social isolation and limited quarantine were introduced in affected areas
    • Poultry farmers supported culling operations.
    • Protests could occur even if legislations are in place
constitutional procedural requirements

World Health

Organization

Country Office - India

Constitutional procedural requirements
  • Enactments/ amendments would be required for effective implementation of IHR
  • But presently, could be implemented under existing health/other legislations (even though some are quite old)
  • Other legislations also may be used when necessary
    • E.g. Criminal Procedure Code (CrPC) in MP and Police Act in Maharashtra imposed during avian influenza outbreak (under maintenance of public law and order)
federal system

World Health

Organization

Country Office - India

Federal system
  • Health is a state subject in the main hence states usually enact their own health legislations
  • States usually have their own surveillance systems in place. Were earlier reporting on a monthly basis to Central Bureau of Health Intelligence for about 30 diseases of PH importance
  • NSPCD programme ensured that the 101 districts in these states reported outbreaks directly to Centre (NICD)
  • States sometimes report late to Centre due to various reasons including awaiting lab confirmation of diagnosis
  • States obtain significant funding from centre for
    • All sub-centres
    • PHC/CHC- Temporary staff, drugs, lab equipment
    • Anganwadis –ICDS (creche)
role of centre in control of important diseases of public health importance

World Health

Organization

Country Office - India

Role of centre in control of important diseases of public health importance
  • Detailing of central teams for assisting investigation and response
  • Capacity building and laboratory support
  • Project mode-IDSP, NACP, RNTCP, NPSP. These then become National Health Programmes (may have some component of external funding)
  • Emergencies (SARS, Avian Influenza)
  • States can also directly obtain external funding for health but centre has to give clearance
slide8
Malaria

Filariasis

Kala azar

Leprosy

Tuberculosis

Poliomyelitis

HIV/AIDS

Vaccine preventable diseases

RCH

Cancer control

Blindness

Mental Health

Iodine deficiency

Water supply

Total Sanitation

World Health

Organization

Country Office - India

National Health ProgrammesSignificant surveillance componentDisease specific and vertical in approach
statutory and administrative law issues

World Health

Organization

Country Office - India

Statutory and administrative law issues
  • Statutory reform
    • Changes to existing legislations at national and state levels is an ongoing process
    • Disease surveillance is not a legal requirement at central level, but some states have it
    • Examples of existing legislations governing key IHR related issues
      • Public Health Act 1925
        • Public Health emergencies Act being processed (Epidemic Diseases Act 1897 being repealed)
      • Prevention of extension of Infectious disease from one state to another (Concurrent list Entry 29)
      • Port quarantine (Union List entry 28, Constitution of India)
      • National Disaster Act 2005
      • Right to Information Act 2005
public health emergencies act under process

World Health

Organization

Country Office - India

Public Health Emergencies Act (under process)
  • To provide for the control and management of public health emergencies (including PHEIC)
  • Scope of the Act:
    • Dangerous epidemic disease (potential to spread rapidly)
    • Epidemic prone diseases (29 diseases + PHEIC when notified by WHO)
    • Bio-terrorism (34 agents + others)
    • Disasters (19 disasters + others)
    • Centre would have powers to direct states
    • Declare area of PHE for 3 months duration at a time
  • Need for a draft (model) PHE Act for countries to adapt
vertical policy coordination and coherence

World Health

Organization

Country Office - India

Vertical policy coordination and coherence
  • Current strategy
    • National Rural Health Mission, NHPs
    • All India Services – Bureaucrats (IAS, IPS), Central Government Health Scheme, etc
    • Regional Offices of Health & Family Welfare (cover all states/UTs) monitor implementation of central health schemes
    • Communications is entirely under Centre
  • Dispute resolution
    • Central Council for Health & Family Welfare
fiscal and budgetary issues

World Health

Organization

Country Office - India

Fiscal and budgetary issues
  • Adequate resources to fulfill the basic obligations of IHR implementation
  • Funds would be required for capacity building at
    • Centre
    • State & districts
    • Public Health Laboratories
    • Border crossings
    • Port and airport health authorities
    • Hospitals for admitting large numbers of patients under isolation
ihr and non governmental actors

World Health

Organization

Country Office - India

IHR and non-governmental actors
  • Municipal Corporations especially large Metros
  • Defence
  • Airlines
  • Railways
  • Shipping
  • Travel & Tourism
  • Exporters
  • Hospitals
  • Media
  • NGOs
media

World Health

Organization

Country Office - India

Media
  • Freedom of press a major factor in frequent reporting of outbreaks
  • Often report ‘mysterious illness/unknown disease’ which does alert international health networks. All disease outbreaks would fall in this category until lab confirmed.
  • 24 hr news channels (repeat the news, does create apprehension and also significant economic impact)
  • Health authorities use it to convey the status report
  • Play a positive role in IEC
public health surveillance and response infrastructure

World Health

Organization

Country Office - India

Public health surveillance and response infrastructure
  • National Surveillance Programme for Communicable Diseases
  • Integrated Disease Surveillance Project (WB supported) for 5 years
  • Budgetary support planned under XI Five-year Plan
  • Laboratory strengthening under IDSP as well as additional funds for Pandemic Flu preparedness
  • Training of Health staff on-going
disease surveillance

World Health

Organization

Country Office - India

Disease surveillance
  • Disease surveillance in India has always been practiced by the states (health being a state subject)
  • Many gaps, differed in degree and quality of surveillance, different priorities in diseases, lack of uniformity
  • Rapid Response Teams (RRTs) functioning but weak
  • Information was made available at National level only at monthly intervals
national surveillance programme for communicable diseases nspcd

World Health

Organization

Country Office - India

National Surveillance Programme for Communicable Diseases (NSPCD)
  • NSPCD was therefore launched by the Centre in 1997-98 in five pilot districts of the country (centrally sponsored scheme) and over the years extended to cover 101 Districts in all 35 states and UTs in the country.
  • In this programme the states were the implementing agencies and NICD Delhi was the Nodal agency for coordinating the activities.
  • This programme was based on outbreak reporting (as and when outbreaks occur) with weekly reporting of epidemic prone diseases directly from Districts (including nil reporting) to the Centre.
main components

World Health

Organization

Country Office - India

Main components

To establish Early Warning System (EWS) so as to institute appropriate and timely response for prevention & control of outbreaks

  • Every state/UT and all the 101 districts had a trained multi-disciplinary Rapid Response Team
  • Rapid communications (through e-mails & fax)
  • Strengthening of state and district laboratories for rapid confirmation of diagnosis
  • Capacity development of health staff in the districts
  • IEC (information, education and communication)
slide19

World Health

Organization

Country Office - India

Districts covered under NSPCD

1997-98 (25 districts)

1998-99 (20 districts)

2000-01(35 districts)

2001- 02 (20+1 districts*)

* The district of Shimla taken as a special case during 2002-03

diseases pathogens covered

World Health

Organization

Country Office - India

Diseases/pathogens covered
  • Epidemic prone communicable diseases- acute diarrhoeal diseases including cholera, viral hepatitis, dengue, Japanese encephalitis, meningitis, measles, viral haemorrhagic fevers, leptospirosis, others
  • Pathogens with bioterrorism potential
  • Drug resistant pathogens
expected outcome

World Health

Organization

Country Office - India

Expected outcome
  • Early detection of outbreaks
  • Early institution of containment measures
  • Reduction in morbidity & mortality
  • Minimize economic loss
nspcd

World Health

Organization

Country Office - India

NSPCD

NSPCD has significantly improved the capacity of these districts and states to detect investigate and respond to outbreaks, yet

  • It was not case based reporting and did not give a complete picture of disease burden in the country especially in respect of epidemic prone diseases
  • GoI not convinced to expand this programme to all 600 districts in the country
integrated disease surveillance project idsp

World Health

Organization

Country Office - India

Integrated Disease Surveillance Project (IDSP)
  • Integrated Disease Surveillance Project (IDSP) was conceptualized and the Govt of India approached the World Bank for the necessary funding (US $ 68 M over five yrs)
  • Objectives:
    • To establish a decentralized system of disease surveillance for timely and effective public health action
    • To improve the efficiency of disease surveillance for use in health planning, management and evaluating control strategies
target diseases in idsp
Malaria

ADD (Cholera)

Typhoid

Tuberculosis

Measles

Polio

Plague

Unusual Syndromes

State Specific Diseases

HIV, HBV, HCV

Accidents

Water Quality

Outdoor Air Quality

World Health

Organization

Country Office - India

Target diseases in IDSP

Sentinel Surveillance

Regular Weekly Surveillance

Community-based Surveys

  • NCD Risk factors
slide26

Phasing of Integrated Disease Surveillance Project

World Health

Organization

Country Office - India

Phase-I (04-05)

Phase II (05-06)

Phase III (06-07)

organizational structure

World Health

Organization

Country Office - India

Organizational structure

National Surveillance Committee

Central Surveillance Unit

State Surveillance Committee

State Surveillance Unit

District Surveillance Committee

District Surveillance Unit

information flow

World Health

Organization

Country Office - India

Information flow

C.S.U.

Weekly Surveillance System

Sub-Centres

Programme

Officers

S.S.U.

P.H.C.s

C.H.C.s

D.S.U.

Pvt. Practitioners

Dist.Hosp.

Nursing Homes

Private Hospitals

Med.Col.

Private Labs.

P.H.Lab.

Other Hospitals:

ESI, Municipal

Rly., Army etc.

Corporate

Hospitals

linkages at central level

World Health

Organization

Country Office - India

Linkages at Central level

Outbreak Investigation

& Rapid Response

W.H.O.

E.M.R.

NCD Surveillance

MIS & Report

RCH

NACO

NVBDCP

RNTCP

Programme Monitoring

slide30

Network of Reference Laboratories for Surveillance of in India

World Health

Organization

Country Office - India

Kasauli

New Delhi

Delhi

Lucknow

Dibrugarh

Ahmedabad

Kolkata

Mumbai

Proposed BSL-3

under ICMR

Pune

Bangalore

Chennai

L5 labs

Pondicherry

activities planned under national rural health mission

World Health

Organization

Country Office - India

Activities planned under National Rural Health Mission
  • Accredited Social Health Activist (ASHA) to be the community based informant for Disease Surveillance
  • Computerization up to PHC level, establishing connectivity with District Surveillance Unit
  • Setting up Distance Learning Communication Channel using EduSat
  • Strengthen Laboratory Services at PHC level
slide32

ROT

TV/Monitor

Teacher

/Board

Touch Screen

DVD Player

PC/ Web-Camera

PTZ Camera

SIT

WLL

World Health

Organization

Country Office - India

Use of EDUSAT in Distance Learning

& Communication for IDSP/NRHM

EDUSAT

REMOTE CLASSROOMS

TEACHING END

TEACHERS/STUDENTS

RETURN LINK

(Live Voice/ Voice Mail/Text Message)

strengths of idsp

World Health

Organization

Country Office - India

Strengths of IDSP
  • Functional integration of surveillance components of vertical programmes
  • Reporting of suspect, probable and confirmed cases –syndromic reporting from periphery
  • Strong IT component for data analysis
  • Trigger levels for gradated response
  • Action component in the reporting formats
  • Streamlined flow of funds to the districts
slide35

World Health

Organization

Country Office - India

Plan of Action

slide36

World Health

Organization

Country Office - India

National Workshop of all Stakeholders for effective implementation of Revised IHR (2005), 20-21 April 2006
  • To prepare a plan of action and list out the activities for establishing/ strengthening of core capacities for surveillance and response (as per annex – 1A of IHR document) at National/State and District level
  • To prepare a plan of action and list out the activities for establishing/ strengthening of core capacities (as per annex – 1B of IHR document) at Designated airports, Ports, and Ground crossings
  • To suggest a mechanism for:
    • Collaboration between different stakeholders at National / State/ District level and at designated Airports/ Ports/ Ground crossings
    • Addressing the administrative and legal issues related to implementation of IHR 2005
planning for strengthening of core capacities for surveillance and response

World Health

Organization

Country Office - India

Planning forStrengthening of core capacities for surveillance and response
planning for strengthening of core capacities for surveillance and response cont d 2

World Health

Organization

Country Office - India

Planning forStrengthening of core capacities for surveillance and response (cont’d 2)
planning for strengthening of core capacities for surveillance and response cont d 3

World Health

Organization

Country Office - India

Planning forStrengthening of core capacities for surveillance and response (cont’d 3)
planning for strengthening of core capacities for surveillance and response cont d 4

World Health

Organization

Country Office - India

Planning forStrengthening of core capacities for surveillance and response (cont’d 4)
planning for strengthening of core capacities for surveillance and response cont d 5

World Health

Organization

Country Office - India

Planning forStrengthening of core capacities for surveillance and response (cont’d 5)
planning for strengthening of core capacities of ports and ground crossings

World Health

Organization

Country Office - India

Planning forStrengthening of core capacities of ports and ground crossings
planning for strengthening of core capacities of ports and ground crossings cont d 2

World Health

Organization

Country Office - India

Planning forStrengthening of core capacities of ports and ground crossings (cont’d 2)
planning for strengthening of core capacities of ports and ground crossings cont d 3

World Health

Organization

Country Office - India

Planning forStrengthening of core capacities of ports and ground crossings (cont’d 3)
planning for collaborative administrative and legal issues cont d 2

World Health

Organization

Country Office - India

Planning forCollaborative, administrative and legal issues (cont’d 2)
obstacles to implementation

World Health

Organization

Country Office - India

Obstacles to implementation
  • Inter-sectoral coordination (Av Flu)
  • Border crossings (large border and large number of migrants)
  • Frequent large outbreaks (daily 3-5 important outbreaks-presently Chikungunya, Japanese encephalitis, Leptospirosis)