Public Health Surveillance

Edited by

William Halperin, M.D., M.p.H.

Edward L. Baker, Jr., M.D.
Consulting Editor

Richard R. Monsoo, M.D., Sc.D.

NewYork

'

JOHN WILEY & SONS,INC.

Chicheste. weinheim . Brisbane . singapore
-1

Toronto

Surveillance in
Developing Countnes
Michael D. Malison

Surveillance systerns provide essential information for designing, implementing, and evaluating disease prevention and control activities. In the
develofing world, surveillance data are often untimely, incomplete, unreP
resentitivl, and generally of such poor quality that confidence in the entire
systern is undermined. The process is cyclical-poor-quality data are not
in demand, and the lack of demand further reduces incentives to improve
quatity, The cycle continues until some state of equilibrium is reached
at which supply equals demand. In many instances, this equilibrium is
determined by the demand set, not by program managers or decision
rnakers, but by the archivists whose primary goal is to compile data for
the annual statistical yearbook.
what factors affect the quality of surveillance data in the developing
world? More specifically, given the resource constraints that all developing
countries face, are there ways to increase both the supply of and demand
for surveillance data? To answer these questions, let us review some of
the attributes shared by many surveillance systems in the developing

world.
one of the most prevalent characteristics of surveillance systems in the
devetoping world is that they attempt to collect too much information
about too many diseases and conditions- As the list of reportable diseases
grows longer and the number of questions on each report form multiplies,
the goal of surveillance grows more and more obscure- Highly endemic
diseases or conditions can also overburden the system if reporting lacks
specificity. For example, surveillance for gastroenteritis and malaria,
rather than overwbelming the system, could be focused more specifically
on the targets of prevention programs such as diarrhea with dehydration

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Surveillance in Developing Countries

orcerebralmalaria.Inadditiontothevolumeofdatasurveillancesystems
iltaracteristic of surveillance systems in the
are asked to collect, u*tft"t
and the complexity of forms and
L;;;i;g *ortd is the lackof uniformity
pro..dui;t,h^t are required to report. This often results in
to report what' on which form' and to
"ir-#i.i,iu"
confusion about who is supposed
also have
il;;:;;;at nedth r*iiit/ttun in moit developing countries
littleornoideaorno*su.ueillancedataareusedandgenerallydonotsee
managerial or progftlmmatic needs.
;;"ilI;;as meeting ;ny of their
world are usually aggregated
Lastly, surveillance i"r" iri the developing
or interpreted for the specific
and tabulated, but u." ,"ioor analyzid
public health practice. While
purpose of extractinginfo'ution n.id"d for
a w^orst-case scenario, it itlustrates
the above description frobably depicts
irru.t thataffect the quality of surveillance
the range and comple*i,v
"r
now look at the process of surveillance
data in the developing **fO' Let us
to make the system
uiJ io"ntirv whic,h components can be strengthened
more efficient and useful'

DATA COLLECTION

important to have an
To improve the quality of data collection' it is
understandingor*no'"po,t.,*hu'skillsarerequiredtoreport,andwhat
motivates individuals to report'

Responsibilitvro'r"po'tingindevelopingcountriesisoftenvagueand

diffuse.Physiciansort.nr""ritshouldbethenurseswhoreport,and
to make an official
nurses complain tnui tt *v oo not have the authority

may actuJiugnori.. The reluctance to accept responsibility for reporting personal

limit
to
ally indicat" u *or" iundamental ptobl"tt the need
synonymous
iiuLifir' for reporting in cultures where responsibility is often
to solve'
time
with culpabilitv' Such problems are deeprooted and take
the
clarifying
of
it,. ir"p"r,uni poini-lo get across is thlt the purpose
considis
responsibility for reportiig is simply to ensure that surveillance
b""o*"s part of someone's job description' It
ered a routine activity
^nJ
persons who either report
is not intended to make it easier to identify those
too much or too little.
whether
Once it is clear who reports, the next question to address.is
of this
lack
The
report'
these persons know wtrat, how, and to whom to
underreporting'
of
cause
specific information is perhaps the most common
b" expensive' disruptive' and misused as a
Such training, hor,r"ve.,
"un
persons. A.simpler and
;"d;i;tr; ;ulring in ihe training oiinappropriate
as a job-aid' If the
itself
form
iess'costly alternative is to use ihe report
essential, and
thatare
those
to
only
list of reportable diseases is restricted
possible
is
often
it
case,
each
aboui
only essential information is requested

58

Public Health Surveillance

with
to print the list of reportable diseases directly on the form along
proviare
simple clinical case deiinitions. Surveillance case definitions that
important
an
are
criteria
laboratory
than
rather
sionat and based on clinical
the
to stress in the developing world, where undue concern over
Preadreporting.
"on."p,
impedes
often
diagnosis
and finality of the

"orr""'rn"rt
dressed, franked

forms can also simplify reporting and eliminate confusion

adequate
about how and to whom reports should be sent. Obviously,
approach
for
this
site
reporting
every
at
supplies of forms must be u"uilubl.

to work.
to
In addition to catch-up strategies that provide essential information
also
be
should
surveillance
about
health workers, information
in schools
"*iJing
incorpJrated into preservice training programs, such as those
curricula
the
to
Modifications
public
irlalttr.
oir"ai"in", nurring, and
in
surveillance
on
questions
specific
should be reinforced Uy inlluding
licensure'
professional
for
national
-in" examinations
perhaps the
final question of what motivates persons to report is
used to
approaches
common
most
the
most difficulf to address. One of
comply.
to
failing
for
punishment
,ii,nufu," reporting is the threat of
pubIn many instances, penalties for not reporting are incorporated into
because
ineffective
usually
are
schemes
lic healih laws. In practice, such
ttrey are impossibie to enforce. Far more important are the disincentiu.s for reporting-an unintentional attribute of many surveillance
systems:wtrictr inetuOe the requirement to complete multiple forms for
on
d-ifferent diseases, the request for an excessive amount of information
occurrence
the
for
liable
personally
held
each form, and the fear of being
of those diseases which on" ,"portt. Such disincentives affect both the
quality and quantity of data reported. Ideatly, report forms should be
the
a.raitatte in every facility where large numbers of patients are seen,
minutes
a
few
than
(taking
more
no
io
complete
forms should be simple
per form), and there should be one form for all reportable diseases. The
the
more information the system tries to collect and the more complicated
to
report'
is
there
less
motivation
the
procedures for reporting,
of
Besides minimizing disincentives for reporting, there are a number
to
is
key
The
positive
m9lns-'
more
through
reporting
ways to encourage
surveillance
iOentify ways to make those who report "shareholders" in the
system; in other words, those who initiate reports must realize a tangible
the
benefit for doing so. The more proximate and tangible the benefit,

morelikelypersonsaretoreport.Inthewaningdaysofthesmallpox

to
eradication program, for example, an actual cash reward was offered
impractical
are
incentives
While
such
stimulate r"portr of suspect cases.
on a broad scale, they illustrate the point.
perhaps the best way to develop a strategy to stimulate reporting is

Surveillance in Developing

Countries

59

to capitalize on preexisting local information needs. For example, most

inpatient facilities have a strong interest in knowing how many patients
they see by disease category or service. From their perspective, this
information can be applied to better allocate resources and perhaps justify
reguests for budget increases. By understanding these needs, it should be
possible to design a facility-based data collection system that serves the
needs of both the surveillance system and the local facilities.
Another type of motivational tool for stimulating reporting is the epidemiologic bulletin or newsletter. such publications are vehicles for disseminating information about surveillance, and can also serve as a forum for
providing credit to those who have made an exceptional contribution,
such as reporting an outbreak or finding creative ways to solve difficult
problems. Feedback is an essential part of the surveillance loop and plays
a vital role in motivating persons to report.

ANALYSIS AND INTERPRETATION

once data are collected, they must be analyzed and interpreted in order
to be meaningfully applied to disease prevention and control activities. In
many developing countries, data are tabulated and aggregated by demographic categories, but there the process often ends. Ministries of health
in the developing world are notoriously deficient in manpower with the

basic skills needed to analyze, interpret, and apply the output of the
surveillance system to the practice of public health. Epidemiotogists are
not necessarily in short supply in the developing world, but are most often
employed by universities, not ministries of health. The reasons for this
have to do with incentives; as faculty members, epidemiorogists enjoy
more prestige, are usually better paid, and have more opportunities to do
research and publish than they would as employees of the ministry. The
incentive systems of universities reward those who conduct original research and publish, not those who engage in the practice of public heatth
offering their services to the ministry to analyze and interpretsurveillance
data. The disparity between the products of university-baied research and
the day-to-day needs of ministries of health in the developing world has
grown so apparent in recent years that the world Health organization
(wHo) was recently compelled to pass a resolution cailing for member
countries to develop strategies to expand the use of epidemiology to ensure
that Health for All by the Year 2000 objectives are met.t sut t ow can this
best be achieved? while this question is currently the topic of much
debate, it is worth noting the progress that has been made in this area over
the past decade.
Since 1980, the southeast Asia Regional office (sEARo) of wHo

60

Public Health Surveillance

and the
Centers for Disease Control
i"J"""tiato implement Field Epidemiology
""0 Personnel from these programs are responsr-

has been working with the

governments of Thailand

?;i;;;Pt"grams tpErptj'
ble for analvzing

U'S'

t"*tillance

data and applving

it

to

"J;;;;;;; uciivities. Besides increasing the demand

involved in the feedback
""d'r"ii"i
for surveillan., out",'ti#;iP; ;; adivelv investigations and publishourbreak
loop assisring local Jffl;;Jucring
a view to the future'

disease prevention

fiuilJins' With
ine their findings i" ild;ilJgJ
decision makers, learning firstto-morrow's
tri.nees in today,s dip;;t"
persons and efi;f;;;i;;;, " toot ror motivating
hand the power
Fgtps in three of the six
"f
were
fecting change. By 1990' there
100
'"u*
progra'nt huu" trained more than
WHO regions.a'5 To date, these
their ministries
gE pt'"tniof whom are stiil employed by
epidemiologists,
collaboration
in
undei d"u"loft"nt
of health.5 T*o new Fgfp' ur" no*
are expected
and
(WPRO)
Office
with WHO', W"rtttn F""in" Regional
to become oPerational in 1992'

SUMMARY AND CONCLUSIONS

Surveillancesystemsinthedevelopingworldareoftenoverburdenedby
the
about too many diseases. As
trying to collect ,oo *r"ii-i"rormation
lhe quality
system becomes f..' unJ less efficient'
"f '1" 9,":i -g:teriorates
Factors ihat iontribute to inefficiency
and the goal of ,uru"iilun"" is lost.
for reporting' lack "f !t-t"^1]:1^t:
include poorly O"nt"J ittponsibility
absence of meaningful incenttves'
about what *o no*'io ,"p"ri, and the
s-uruerlla":-1i:i.it lack of
Another factor th"; ;;;;t-t'" o"t""o.ior
epidemiologicmanpowerinmostministriesofheatth'Improvingsurveil.
not impossible' task' one
lance in such settings is a challenging,.but
in u nurU.t of countries is the implemenstrategy that has U.iirr".irtfuf
Field Epidemiology Training
tation of ,"rui""-oii"nted' ministry-based
suroffer an integrated approach to improving

Programs. Sucn programs

data, bv.applvine the
veillance uy in"r"urinilJ;;;Jiotiiett-quuiitv
by
prevention"ani control activities, and
results of analysis to disease
surveilDisease
collection.
providing feeouactrio ihose involued in data
world'
developing
the
in
practical
and
lance is botn necess'ary
and the future of the world'
American Health organization. Epidemiology
Epidemiol Aalf 1990;l l(4):5'

L"t;:"

2.WorldHealthorganization.Fieldepidemiologytrainingprogramme.}V,tly
Epidemiol Rec

l98l; 56{7):49-52'

Surveillance

Developing Countries

6t

World Health Organization. Field epidemiology training for paramedical personnel. W kly Ep i d e m i o I R e c 1987 ;62(36) :265 -268.
4. Malison, M. D., M. M. Dayrit, and K. Limpakarnjanarat. The Field Epidemiology Training hogrammes. Int J Epidemiol 1989; 18(4):995-996.
5. Music, S. I., and M. G. Schultz. Field epidemiology training prograrns-nelv
internat ion af heal th re sour ces. J A M A 1990 ;263 (24):3309- 3 3 I L

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