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Faculty of Mathematics and Natural SciencesInstitute of Geography

DFG-Project: Blueprint for an Effective Urban Health Monitoring System for the city of Pune

Principal investigator: Prof. Dr. Frauke Kraas, Dr. Carsten Butsch, University of Cologne

Research partners in Pune

Project core team

  • Dr. Mareike Kroll - University of Cologne (associate principal investigator); did her PhD on health disparities (differences in exposure to health determining factors and disease burden in different socioeconomic groups) in Pune (2008-2012). Her fields of expertise include geographies of health, urban health, social epidemiology, infectious and non-communicable diseases.
  • Dr. Revati Phalkey - University of Cologne (postdoctoral fellow); submitted her PhD on the assessment of the Integrated Disease Surveillance Project (IDSP) in Maharashtra (2008-2013). Her fields of expertise include Public Health particularly health service systems research, infectious disease surveillance with focus on outbreak investigations, health in emergencies especially natural disasters. Contact: email: rphalkeySpamProtectiongmail.com, phone +49-221-470-7055 / +49-6221-5636158
  • Dr. Carsten Butsch - University of Cologne (postdoctoral fellow); did his PhD on access to health care in Pune (2007-2011). His fields of expertise include geographies of health, urban health and health systems research. Contact: email: butschcSpamProtectionuni-koeln.de, phone +49-221-470-4142
  • Ms. Sayani Dutta - BVIEER Pune (PhD candidate and Programme Officer in Pune); has done her Masters in Environmental Science from Bharati Vidyapeeth Institute of Environmental Education & Research, Pune. She was actively involved in the project “Environmental Health in the emerging megacity of Pune” funded by DFG (2011-2012). Her fields of expertise include Microbiology, Environmental Science and water borne diseases.

Project duration: 01.09.2012 – 30.04.2016

Keywords: Health management information system / disease surveillance / health governance

Research discipline: Urban Health, Geography of Health and Health Care, Development Studies, Public Health 

Project rationale

Like most other lower-middle income countries, India has to brave its path through the daunting triple burden of communicable diseases, chronic non-communicable diseases and weak overburdened health care system largely incapable of combating the two simultaneously. Maharashtra is amongst the most rapidly urbanizing state with over 45% population living in urban areas. Steep socioeconomic gradients within cities expose urban population subgroups (especially economic migrants and the urban poor) to unique health risks. Notable amongst them are emerging co-morbidity patterns like the high incidence of type-2 diabetes and tuberculosis. Further, inaccessibility of public health care facilities as well as the questionable quality of health care available particularly to the economically marginalized in cities jeopardizes patient outcomes. In the backdrop of these infrastructural and socioeconomic vulnerabilities, private health care sector has gained increasing importance in urban health care service provision in the state. Over 80% of all outpatient care and about 60% of all inpatient care in India is provided by the private sector predominantly located in urban areas. Private physicians are preferred first contact in over 70% patients and hence more likely to detect early warning signs of emerging disease patterns and epidemics especially in urban poor.Effective disease surveillance is a crucial step in monitoring disease burden. It is key to informing researchers, health care providers, decision makers as well as the population about current disease distribution and the changes over time. Surveillance also forms the essential evidence base for planning and delivering timely curative and preventive measures. Prior to 1998, outbreak control measures in India, like in several other low and middle income countries, involved efforts within centrally planned vertical single disease control programs mandatorily implemented in all states. The heavily centralized, mandatorily implemented, yet strong and well established vertical disease control programs for tuberculosis,  HIV/AIDS, six vector borne diseases, leprosy and poliomyelitis in the meantime continued to operate albeit in improvised formats. In the absence of case based reporting, diseases not covered under these programs were largely neglected hampering the development of a long term and effective nation-wide routine surveillance system.It was around the same time (2002) that the WHO-SEARO recommended the integrated disease surveillance strategy and the Government of India adopted it in 2003 through the Integrated Disease Surveillance Project (IDSP). It is a three-tier decentralized state based system, covering 13 mandatory diseases and syndromes with a focus on the districts. Active data collection began in 2006. Currently, this is the only nationwide structured surveillance effort in Maharashtra state (as in the country) and therefore indispensable. However, a recent evaluation of the IDSP in Maharashtra revealed that the deadly triple combination of excluded private practitioners and labs, poor urban surveillance and non-inclusion of alternate medicine units is the back drop of gross under reporting especially in cities. Further, the curremt system also does not include non-communicable diseases for routine surveillance. 

Objectives of the research project

The DFG knowledge transfer project is based on knowledge gained from the previous DFG-funded research project on health disparities in Pune and will be implemented together with an application partner, the Bharati Medical Foundation in Pune.

The main objective of the current project is to develop and implement a prototype surveillance system which addresses the gaps identified in urban disease surveillance in India - namely weak private practitioner participation and exclusion of non-communicable diseases from routine surveillance. The aim is to design a generic “blueprint” for effective urban health monitoring which can then be extrapolated to other cities in India. The system will be designed in a way that it does not duplicate existing programmes but rather supplements them. A pilot test will be conducted within selected health care facilities in three pre-identified areas in Pune.

The pilot test can help to gain important insights about the integration of chronic diseases into diseases surveillance at the one side, and on opportunities and barriers of the integration of private health care facilities into disease surveillance at the other side in the Indian context. Based on the data analysis and the process evaluation of the pilot, recommendations will be provided on how the design of the health monitoring system can be extrapolated to the whole city or how components of the design might be integrated into existing governmental surveillance structures. Further, it will be discussed in how far the model can be transferred to other Indian cities.

The project consists of six phases:

I. Inventory

The first phase consist of two steps for a comprehensive inventory of the local structures in Pune and the state of the art in disease surveillance:

A systematic literature review will be conducted to get an in-depth understanding on the current state of disease surveillance with specific focus on private sector involvement in disease surveillance, chronic disease surveillance and environmental disease surveillance. Further, documents and reports from existing disease surveillance programmes (state and central government programmes, data collection mechanisms from Pune Municipal Corporation (PMC) as urban administrative body) will be examined in order to analyse existing structures and mechanisms of data compilation and processing in Pune.

The second step focuses on the medical infrastructure in the three selected research areas in Pune. The research areas represent different spatial structures within the city namely inner-urban, suburban and peri-urban. Since not all medical facilities are registered with the PMC, relevant priavte health care facilities will be mapped in order to generate a profound database. Based on this map, facilities will be selected by random sampling for a semi-structured survey. Objective of the survey is to analyse opportunities and barriers for private practitioner involvement into disease surveillance. This involves also a discussion about incentives which could facilitate private providers’ participation in disease surveillance.

II. Design of a health monitoring system

Based on the results of the inventory the reporting format for the health monitoring system will be designed. The pilot test will focus on selected chronic and environment related diseases. Further, spatial and socioeconomic variables will be included in the format. These are of special importance for designing targeted interventions in urban areas where socioeconomic disparities are large and are among the major determinants of the health status of the population. The tool will be designed in a way that allows for application in both private and public health care facilities.

III. Pilot test

In phase three, the design of the health monitoring system will be tested in a pilot with the reporting facilities in the three selected areas. During this phase, all collected data will be entered into a database.

IV. Data analysis

The data analysis involves quality checks and data cleaning, followed by descriptive and multivariate analysis and interpretation.

V. Project evaluation

The project will be evaluated according to the following pre-set criteria: (a) data quality (consistency and completeness of reporting) (b) methodology (methodological and structural problems and opportunities for disease surveillance, esp. in the private sector), (c) development potentials: possibilities and challenges for improving health monitoring systems, (d) model character (transferability and generalizability of the design to other cities in India, inclusion into existing surveillance structures), and (e) analysis of the morbidity patterns according to geographic area, age, sex, socioeconomic status and seasonality to derive conclusions for health care provision and disease prevention.

Project outcome: The project results and recommendations based on the evaluation will be disseminated and discussed with all stakeholder groups in a final workshop at the end of the project. Results will be documented for institutional learning in a final report and key findings published in international journals with joint authorships. 

Publications

Kroll, M., Phalkey, R., Dutta, S., Bharucha, E., Butsch, C., Kraas, F., 2017. Urban health challenges in India – lessons learned from a surveillance study in Pune. Die Erde 148 (1): 75-88.

Kroll, M., Phalkey, R., Dutta, S., Shukla, S., Butsch, C., Bharucha, E., Kraas, F. 2016. Involving private practitioners in an urban NCD sentinel surveillance system: lessons learned from Pune, India. Global Health Action 9: 32635.

Kroll, M., Kraas. F. 2016. Non-communicable diseases in urban India - Challenges for public health. UGEC Viewpoints July 19, 2016.

Kroll, M., Phalkey, R., Kraas, F. 2015. Challenges to the surveillance of non-communicable diseases – a review of selected approaches. BMC Public Health 15: 1243.

Phalkey, R., Kroll, M., Dutta, S., Shukla, S., Butsch, C., Bharucha, E., Kraas, F., 2015. Knowledge, attitude, and practices with respect to disease surveillance among urban private practitioners in Pune, India. Global Health Action 8: 28413.

Kroll, M. 2015. Evidenzbasierte Daten zur Kontrolle nicht-übertragbarer Erkrankungen in Indien - eine Pilotstudie zu Gesundheitsberichterstattung im privaten Gesundheitssektor in Pune. In: Poerting, J, Keck, M. (Ed.): Aktuelle Forschungsbeiträge zu Südasien. Band 3. Heidelberg: 17-20.

Butsch, C., Kroll, M., Kraas, F., Bharucha, E., 2015. How does rapid urbanization in India affect human health? Findings from a case study in Pune. Asien 134: 73-93.

Kroll, M., Bharucha, E., Kraas, F., 2014. Does rapid urbanization aggravate health disparities? Reflections on the epidemiological transition in Pune, India. Global Health Action 7: 23447.

Kroll, M., Butsch, C., Phalkey, R., Bharucha, E., 2013. Challenges for urban disease surveillance in India - case study of Pune. In: Lennartz, T. et al. (Ed.): Aktuelle Forschungsbeiträge zu Südasien. Heidelberg: 41-44.