| The absence of a surveillance policy framework and poor governance leads to an ill-defined disease surveillance system | Lack of provincial policy on infectious disease surveillance Lack of laws Lack of surveillance standards Lack of resource planning leading to dysfunctional digital information systems Lack of planning to ensure integrated surveillance of infectious diseases
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| Fragmentation in the healthcare system is a hindrance to a uniform reporting system | Poor coordination between health system stakeholders Lack of integration between different levels of health facilities Lack of defined reporting lines for surveillance data Different organisations managing various levels of health facilities in the district
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| Inadequate resources translate to poor disease surveillance | Inadequate provision of facilities and equipment Lack of dedicated human resource for surveillance Lack of financial support Lack of dedicated line item for surveillance in provincial/district budget
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| In the current system surveillance is predominantly passive | Hospital-based surveillance Surveillance data collected from patients presenting to hospitals Lack of human resource to conduct surveillance in communities Low level of surveillance activities outside hospitals
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| Paper-based reporting is a key determinant of delayed disease reporting | Surveillance data compiled on hard copies Hard copies are delivered from health facilities to the district health office No dedicated human resource to transfer health facility reports to the district health office
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| Surveillance data are underutilised for evidence-based decision making | Monthly report submission by health facilities to the district health office is mandatory No feedback was provided from the district health office to facilities on submitted reports Submitted reports are not reviewed for data errors No one from the district or provincial makes monitoring visits to check the fidelity of reported data
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| Lack of laboratory testing capacity takes a toll on disease surveillance | |
| The lack of integration of the private sector in disease surveillance is a major gap | At the provincial or district level, no measures are taken to bring surveillance data from the private health sector into the mainstream The private health sector does not report surveillance data to the district health office or provincial health department except in case of COVID-19
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