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Disease surveillance has not typically made headlines or secured high billing on priority global health agendas but, with the ongoing COVID-19 pandemic, phrases like ‘track and treat’ have crept into common parlance and with them, a more universal recognition of the importance of surveillance in tackling diseases. We sit down with Arantxa Roca-Feltrer, Head of Surveillance, Monitoring and Evaluation at Malaria Consortium to hear why more effective disease surveillance and response is the bedrock of resilient health systems.

Why do we need better disease surveillance?
In simple terms, surveillance is considered the eyes and ears of public health. It refers to the systematic and ongoing collection, collation, analysis and interpretation of health-related data, as well as the timely dissemination of that information to those who really need to know, so that action can be taken. A disease surveillance system comprises a number of aspects – people, procedures, tools and the structures necessary to generate information around disease morbidity and mortality. Since surveillance directly measures what is going on within a given population, it is essential in helping to develop targeted, context-specific responses and understanding how these interventions are actually performing. Strengthening surveillance is therefore fundamental to programme planning and implementation, and in the case of malaria, it’s a crucial contributor to accelerating disease burden reduction to elimination.

What would stronger surveillance systems mean for health outcomes in low- and middle-income countries (LMICs)?
Data and surveillance are critical components of building resilient and responsive health systems that are able to ensure the sustained and accelerated reduction of disease burden. Strengthening health management information systems means governments and other stakeholders can make evidence-based decisions so that all people are able to access high quality health services, when and where they need them. LMICs typically have some of the highest burdens of endemic disease and limited resources to tackle them. A strong surveillance system – able to identify weaknesses in a health system and demonstrate the most effective interventions to a specific area or group of people – can be optimised for better health outcomes. Surveillance can make tangible differences to improved health outcomes even in small ways. For example, in malaria endemic countries, a critical element for a timely malaria response is ensuring appropriate and sufficient commodities are in place. If community health workers (CHWs) or staff at a health facility are reporting a lack of stock, including antimalarial drugs and other commodities, and they are able to report this information into a central system, an alert mechanism can be triggered to notify that new stock is required in that particular health facility and made available in a timely way. An effective surveillance system is able to flag such issues to ensure a continuum of care, especially in remote populations where access to basic health services is already challenging.

What are the biggest barriers to achieving this?
There are many barriers and they are not universal but if we talk specifically of malaria surveillance systems, they are usually weakest in countries with the highest burden of the disease, particularly in LMICs in sub-Saharan Africa. This is mostly due to a lack of good quality data relating to malaria morbidity and mortality trends. To improve the quality of data, it’s important to identify the key issues, whether the surveillance system is performing appropriately, and what components need strengthening. Education on the importance and value of surveillance is needed. Embedding a data culture at government level, right down to communities, is essential in creating an enabling environment that allows everyone to be empowered to effectively use relevant data to inform the necessary decisions at each level. We also need to acknowledge that too much data can be overwhelming if there is no clear pathway as to what it means and how it can be used. Data visualisation is key to overcoming this, as is collaboration across stakeholders where surveillance and data quality approaches and tools are standardised and the tracking of progress follows a clear and harmonised approach.

How can fragmented surveillance systems come together?
Bringing different disease surveillance together means you can get a much better picture of what people are experiencing holistically and a pathway to improving broader health outcomes, rather than only responding to health needs in a siloed way. Stronger, well established surveillance infrastructure for one disease can help build capacity to better understand and respond to other diseases. Integrating often fragmented and disease-specific surveillance systems brings cost efficiencies by minimising resource needs for example, at a given health facility one single digital tablet can be used to report all targeted diseases and avoid the not unknown scenario of the same health facility personnel having to use different tablets or reporting tools for each vertical disease-specific reporting mechanism. Integration can also support sustainability and health resilience efforts by combining training activities and empowering health staff through integrated supervision packages. Digital technology has enabled surveillance systems to be capable of faster aggregation and reporting. It has improved data quality and the visualisation of data in a much more user-friendly way through tools like dashboards. This has brought malaria intelligence to life but it does not come without challenges. One such challenge is ensuring that every single data user or malaria-related staff member is actively engaged as a key player in interpreting and using data for action at their corresponding administrative level. Taking this a step further would mean informing the community and ensuring that everyone is fully engaged in what is happening and the progress that is being made.

What has the COVID-19 pandemic taught us about surveillance?
One of the key lessons learned from the COVID-19 pandemic has been the importance of community level surveillance and the reliance on trusted community health workers to adapt to rapidly evolving circumstances, deliver key messages and to continue supporting the delivery of basic health services. This network of frontline workers, when supported by digital technology, can potentially provide the perfect solution for receiving training modules (adapted to a new context), delivering case management, and informing on syndromic and disease specific surveillance when other more traditional approaches are not available due to travel restrictions and social distancing, for example.

We demonstrated this recently in a project in Mozambique where we adapted an existing platform called upSCALE (a digital health platform), through upgrades, to include the integration of a COVID-19 algorithm that helps CHWs to respond more effectively to the pandemic. upSCALE has proved to be hugely successful in helping to overcome limited access to primary healthcare for rural populations and poor linkages between CHWs and the national health information system. These linkages are essential in sharing information across different levels of the health system, even more so in situations like the current COVID-19 pandemic, and we recently undertook some research to look at the knowledge, attitudes and practices of CHWs around COVID-19 to see how access to a digital information resource impacted their ability to support the pandemic response. In practice, a smartphone and tablet app assists CHWs with patient registration, diagnosis and advice on treatment and referrals. It also allows supervisors to monitor CHWs performance and stock levels of drugs and equipment. Data entered through the app is captured in the District Health Information System at district, provincial and national level and the ability to analyse local disease-specific trends in near real-time improves resource allocation. Mozambique’s Ministry of Health began a country-wide rollout of the app in 2019 – the first of its kind on this scale.

Where is your focus for 2021 to achieve these aims?
One exciting initiative I am supporting is the use of mHealth applications, through mobile phones, to strengthen disease and mortality surveillance systems. This is because mHealth can link the community health worker or health facility staff who are treating a patient with the wider health information system – thereby providing accurate, complete and timely malaria data to inform planning at a national, regional and district level. Transforming and integrating community level surveillance into key information outputs in order to drive decisions and optimise resource allocation is a particular area of focus for me this year. Myself and my team are also working with the RBM Partnership Surveillance, Monitoring, and Evaluation Reference Group (SMERG) which seeks to strengthen routine surveillance and improve in-country data use by convening and aligning those working in this field, tracking global progress in strengthening routine surveillance systems, improving implementation partner coordination, increasing visibility on new tools, and providing an effective mechanism to ensure national malaria control Program (NMCP) priorities are raised and addressed.

To find out more about Malaria Consortium’s expertise in malaria surveillance, read our capacity statement.

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