An Integrated End-to-End Surveillance Platform for COVID-19 Response in Uttar Pradesh, India

The Exemplars in Global Health program would like to thank the Honorable Chief Minister, Government of Uttar Pradesh, the Additional Chief Secretary of Department of Health and Family Welfare and the Department of Medical Education and Training, respectively, as well as state and district officials across both departments for their continued guidance and support to develop this case study.

In this case study, we tell the story of the Unified COVID-19 Data Platform’s development, implementation, and statewide adoption in Uttar Pradesh. At the end, there is an assessment of its performance against the MAPS framework.

As the World Health Organization declared COVID-19 a pandemic in March 2020,¹ the government of India began strengthening health care infrastructure and human resource capacity across the country to prevent the spread of the virus. However, many aspects of public health policy and health care delivery are the province of state governments. Individual states therefore began developing their own pandemic-response initiatives—typically digital tools customized to meet state-specific needs.

Almost immediately, officials in Uttar Pradesh began working closely with the Uttar Pradesh Technical Support Unit (UP TSU) team to conceptualize and develop what would become its Unified COVID-19 Data Platform: a comprehensive, integrated digital tool for all stakeholders to track and manage the state’s COVID-19 response. It was the first digital tool in India that covered the entire continuum of care, and in less than two months, the platform evolved into a modular, end-to-end solution for case reporting and management, contact tracing, workflow integration, data aggregation, stakeholder engagement, and strategic planning. The platform’s architecture is designed to enable clear, immediate, and easy coordination and referral linkages among state and district surveillance teams, field-tracking teams, laboratories and policy makers, and the state’s 235 million inhabitants.²

Key Takeaways

Collaboration between public and private stakeholders drove quick statewide development and adoption of the Unified COVID-19 Data Platform. The medium- to long-term thinking and support from technical support partners such as the Uttar Pradesh Technical Support Unit (UP TSU) enabled the quick development, implementation, adaptation, and rollout of the digital platform. The platform’s modular design integrates the needs of various stakeholders, from tracking teams to testing laboratories to patients in home quarantine. The decision-making dashboard shows policy makers the data they need—such as information on contact tracing, transmission patterns, and clusters of cases—to develop, adapt, and evolve pandemic-response policies and practices. Remote digital trainings for health workers can be adapted for future disease outbreaks as well as for community health workers and other providers of last-mile essential health services.

What Does the Unified COVID-19 Data Platform Do?

The Unified COVID-19 Data Platform is designed to facilitate end-to-end digital case management for health workers and patients. It gives officials a real-time view of the status of the pandemic within or across local districts by collecting and aggregating data from its tracking and contact-tracing modules. It also incorporates information from a COVID-19 Helpline Call Center established to conduct disease surveillance and educate the public on COVID-19 symptoms and prevention. The data platform is Uttar Pradesh’s single and authoritative source of information about the COVID-19 pandemic.

The Unified COVID-19 Data Platform enables comprehensive case management and provides a real-time view of the status of the COVID-19 pandemic across districts via:

• End-to-End Data Visibility: The digital platform makes it possible for data collected from the tracking platform, call center, surveillance teams, and self-quarantine app to flow into the system in near real time. As of July 31, 2021, the platform enabled the State of Uttar Pradesh to track nearly 49.6 million potential cases across the continuum of care and manage 1.7 million positive cases.
• Integrated Modules for Diverse Stakeholders: Key components of the platform include a surveillance module, a facility module, and a lab module, all built on a common backbone. It also includes mobile applications for field tracking, contact tracing, and home isolation. In addition, as protocols evolved over time, a death-audit module and a home isolation module were added.
• Digitally Enabled Decision Making: Information collected via different interfaces and users can be viewed on the Decision-Making Dashboard, the focus for all COVID-19 planning and monitoring. The dashboard includes information on case summaries and overviews, hot spots, contact-tracing status, the availability of trained human resources or infrastructure, and facility preparedness for COVID-19—which equips administrative and departmental officials with the data they need to prioritize their efforts and enables proactive pandemic-response planning.

Because the Unified COVID-19 Data Platform is modular, it accommodates many different use cases and user types. For instance:

• Health workers can refer patients to facilities or providers, view lab results, update case details, and audit patient deaths.
• Officials can leverage the Decision-Making Dashboard to perform dynamic modeling to predict patterns, find outliers, and create heat maps for risk detection.
• Citizens can access their COVID-19 test results and, when necessary, manage their own at-home quarantine or isolation.

Other features of the Unified COVID-19 Data Platform include:

• Telemedicine consultation services staffed by doctors from the Uttar Pradesh State Department.
• Official websites designed to share COVID-19 information with health workers and the public, with the ability to easily share links via SMS.
• A user-friendly self-quarantine app designed for self-reporting of COVID-19 symptoms.
• A simple case-tracking platform for state statistical officers to share with their rapid response teams.

India and Uttar Pradesh before COVID-19

Approximately 235 million people lived in Uttar Pradesh’s 107,000 villages and 75 districts in 2011. Of these, 78 percent lived in rural areas. The state also has more than 5 million migrant workers, a population that is particularly susceptible to infectious diseases. Consequently, last-mile health solutions have been a long-standing challenge in the state.³

Uttar Pradesh’s dispersed rural population is well-suited for digital health solutions which can complement existing health system delivery models, although it had very few digital health interventions achieve scale, before the COVID-19 pandemic. The pandemic provided an opportunity for the government of Uttar Pradesh to build their own solution from the ground up and demonstrate state-wide scaleup successfully.

Adapting to a New Challenge

Under the guidance of the Uttar Pradesh Chief Minister’s office, two departments—the Department of Health and Family Welfare and the Department of Medical Education and Training—together led Uttar Pradesh’s response to COVID-19. In March 2020, as COVID-19 cases in India began to increase, state officials and their partners at the UP TSU initiated development and deployment of the integrated Unified COVID-19 Data Platform.

Over the course of two weeks in March 2020, the UP TSU delivered the following digital initiatives to meet the government’s immediate needs:

• Set up a call center control room with a COVID-19 protocol-based software.
• Supported teleconsultation services with doctors from the State Department.
• Developed and launched a dedicated web page for sharing all COVID-19 information and updates from the government of Uttar Pradesh.
• Developed a self-quarantine app for travelers.
• Developed and launched a website with training materials for doctors, nurses, and auxiliary nurse midwives.
• Developed a simple case-tracking platform for state statistical officers and their rapid response teams.^2, 4

"We could develop this portal and make it successful across the state, with district teams finding it useful, because of clarity of thought at the state level and clear exchange of ideas between State Surveillance Unit and UP TSU. I saved an immense amount of time by using the platform to send out relevant reports from 4–5 hours daily. I was only required to spend 30 minutes per day. Going forward, I believe doctors must be trained into handling such situations in policy making so that more people can come forward to support."

- Dr. Vikasendu Agrawal, State Surveillance Officer, Integrated Disease Surveillance Program, Department of Health and Family Welfare, Uttar Pradesh²  

By the end of March 2020, working in close coordination with the government, the UP TSU had developed an understanding of the surveillance team’s needs and workflows across the entire life cycle of a COVID-19 case. Together they developed a comprehensive vision of a proposed platform that could drive end-to-end case management of COVID-19 cases in Uttar Pradesh. In addition to the surveillance module, it was clear that linkages would need to be established with labs and health facilities across the public and private sectors to achieve three key objectives: (1) ensure timely screening and prompt clinical assistance, (2) drive absolute transparency and accountability across the value chain, and (3) ensure there is a single source of truth available across the entire state for case tracking.

The Unified COVID-19 Data Platform evolved into an end-to-end solution in less than two months. Its guiding principles are illustrated in the figure below.

The platform has three main functions, known as T3: tracking, testing, and treating.  

Tracking meant active surveillance of itinerant populations and the number of active and closed cases in real time. Over time, the platform evolved to identify individual cases across 17 different case types; field teams were assigned to contact tracing duties. Testing also involved understanding the shifting testing landscape across districts in the state. Officials were able to adapt the platform’s algorithms to account for changes in per capita testing levels and adjust to any delays. Treatment was determined depending on whether a case was linked to a facility or home isolation. Treatment protocols were developed to be uniform across the state.

Under the T3 umbrella, the Unified COVID-19 Data Platform evolved to have the following key features:

• Single point of case registration from the state-district helpline, the government of India database, state-specific data, labs, tracking teams, and contact tracing
• Unique case IDs assigned for case management across the system
• Ability to allocate cases in bulk to tracking teams and for testing 
• In-person verification of newly registered cases, daily follow-up, and contact tracing in the field
• Ability to upload test results in bulk and update results in real time at the facility or district level

“Initially we thought it will not work and everybody will not want to use—we were hesitant and we are working on our system so well for 10 years. But when we started using and were able to integrate it across we finally saw value and transparency was created, which saved our time.”

- Dr. Amita Jain, King George’s Medical University, Uttar Pradesh²

“It was extremely tiring to sort every result type manually—negative, indeterminate, and positive—and then sharing timely information around these while also managing samples coming in. For instance, I think we save a 9-hour lag, for instance, earlier if I got the test results for a batch at noon we would upload the final at the end of the day at 9 pm . . . but now because of batch processing we can enter test results at 12:10 pm itself. Since it is the same platform for everyone, now we don’t have to enter all details related to the patient, we can keep the focus on our job.”

- Dr. Vikram, Senior Resident In Charge, Updation Dr. Ram Manohar Lohia Institute of Medical Sciences (RMLIMS) Uttar Pradesh²

• Flexibility for district officers
• Real-time updates of medical records and epidemiological data from health facilities

“COVID-19 data portal is a very good step by the health department and very useful for the district regarding surveillance and monitoring of cases.”

- Dr. Sarfaraj Ansari, Epidemiologist, Auraiya District, Government of Uttar Pradesh²

• Seamless inter-facility referrals
• Efficient case closure and post-discharge management

“This portal helped me discharge a case at midnight. The lab got a negative test result for nine cases and uploaded that information on the portal. We were able to arrange an ambulance (GPS tracked) and ensure the case could be discharged without wasting another day—physically as well as digitally from a reporting perspective.”

- Dr. Yash Agarwal, Nodal Officer for COVID-19, Kaushambi District, Department of Health and Family Welfare, Government of Uttar Pradesh²

• Outcome assigned to each case at the end of its life cycle.

The availability of real-time data on the platform made it possible for the Uttar Pradesh government to manage and adjust its infrastructure requirements according to regional case counts. The state’s total available bed count increased from 2,520 to 152,095 between April and mid-July 2020, and the number of available ventilators increased from 20 to 1,151 over the same period. As the state set up district testing labs, testing capacity dramatically increased as well. The platform incorporated these rapid changes and reflected them in real time.

“The journey has been made smooth—it was a very bumpy ride to begin with—so much time to balance actual lab work and manual data reporting, but UP Portal made it smooth. Thank you for technical support at any time of the day for me and my entire staff. It helped to know that support, which is patiently provided, is just one call away”

- Professor (Dr.) Jyotsna Agarwal, COVID-19 Laboratory In Charge, Head of Microbiology Department at RMLIMS, Lucknow, Uttar Pradesh

The Path to Scale and Sustainability

The Unified COVID-19 Data Platform’s modular, workflow-based systems enabled it to grow and adapt to meet emerging needs for multiple stakeholder groups.

To encourage self-reporting and social responsibility, in July 2020 the government of Uttar Pradesh decided to roll out the UP COVID-19 Home Isolation app for real-time tracking of citizens quarantined or isolated at home. The app captured a user’s travel history, symptoms, and test results. By the end of September 2020 it had tracked more than 50,000 positive cases.

The Uttar Pradesh Chief Minister’s Office launched the Mera COVID Kendra app in December 2020, enabling citizens to find COVID-19 test centers within 5 kilometers of their location. The app provides a map view or list view with essential details such as a testing center’s name, hours, and tests performed; users can also get directions from their location to the test or collection centers.⁵ The app has been rated 4.87 (4 current rating) out of 5 stars on the Google Play Store.

Starting in mid-March 2020, the platform provided remote digital trainings and videos for health workers via the government of India’s Integrated Government Online Training (iGOT) platform—an innovation that can be applied during future disease outbreaks as well as for community health workers and other providers of last-mile essential care. To fill gaps in the iGOT platform, the Department of Health Family Welfare and the UP TSU initiated trainings for health workers and supported the development of a COVID-19 website that made it possible to share customized and easy-to-read training content based on updated guidelines. It also disseminated relevant behavior change communication materials, such as information to help avoid exposure to COVID-19 and monitored training using electronic human resource management system codes to track whether staff members accessed relevant materials. SMS reminders and updates inform users of new content available on the platform, helping officials and health workers across the state to use it more confidently.²

In September 2020, the Chief Minister’s Office launched a common web page (labreports.upcovid19tracks.in)⁶ that allows the public to access COVID-19 test results from RTPCR, CB-NAAT, ANTIGEN, and True-nat tests delivered at public or private laboratories from anywhere using internet-enabled devices. The platform generates a one-time password based on a user’s mobile phone number. More than 4.3 million reports were downloaded between September 2020 and January 2021.

“Portal plays a very important role in prevention against COVID-19 given that it is the only portal used across the entire state, with different users being given access. Its user-friendly display and categorization of data fields with a selection menu wherever possible make it easy to operate all functions and helps with prioritization. Since data is line listed it allows helping with disease surveillance for expected seasonal diseases as well.”

- Sanjay Kumar, District Data Manager, Integrated Disease Surveillance Program Unit, Bareilly, Uttar Pradesh²  

Impact

Using the Unified COVID-19 Data Platform, the State has been able to digitally track nearly 49.6 million COVID-19 (potential) cases across the continuum of care, conduct more than 67.1 million tests, and manage 1.7 million positive cases as on July 31, 2021.

The comprehensive, end-to-end Unified COVID-19 Data Platform incorporated multiple dimensions of Uttar Pradesh’s COVID-19 response: supporting government officials, developing digital tools, collecting data at the source, strengthening health workers’ capacities, leveraging technology to manage surveillance and treatment efforts, ensuring actionable visualization via the COVID-19 Dashboard, and providing strategic guidance for future pandemic response efforts.

In particular, the ability to view and analyze case trends in real time is the most important and timely contribution of the statewide rollout of the Unified COVID-19 Data Platform. Real-time data ensured the state could proactively manage changing disease-response strategies and infrastructure requirements, from increasing the number of facilities and availability of beds to earmarking paid facilities and the timely implementation of protocols for home isolation and quarantine.

The digital platform also allows health workers and government officials to compare and track caseloads, map the speed of a disease’s spread, and build and compare epidemic curves—all tools that will likely be useful in the future. For instance:

• The Unified COVID-19 Data Platform enables users to map and analyze the trend of the COVID-19 caseload within a block and district. This tool makes it apparent that the earliest cases in Uttar Pradesh were reported from pockets of major urban centers (such as Gautam Buddha Nagar and Ghaziabad) that experienced a surge of people returning from overseas at the beginning of the pandemic in March 2020. By the middle of May 2020, all districts in Uttar Pradesh had reported at least one case of COVID-19.
• The platform also enables users to compare the epidemic curve across districts in the state as well as across states and countries roughly similar in size and population.

Overall, the platform made it possible to support the Indian Council of Medical Research’s “Track, Test, and Treat” strategy, enabling real-time data updates and analysis across all three areas.

Last-mile health service delivery has traditionally been a challenge for the state of Uttar Pradesh, but with its comprehensive COVID-19 response, the government has successfully developed and scaled an end-to-end digital platform that works across the health care value chain and serves as the authoritative response to this emergency. The state’s ability to engage partners across the public and private sectors to deliver on its ambitious initial vision has clearly demonstrated that even a large state can build, adapt, and adopt digital tools at scale for health care management.

What Were the Key Drivers of Scale?

The quick adoption and scale of the Unified COVID-19 Data Platform in Uttar Pradesh can be attributed to:

• Partnerships—Strong and coordinated support from state government leaders: The Department of Health and Family Welfare and the Department of Medical Education and Training coordinated the state’s COVID-19 response together, under the guidance and leadership of the Chief Minister’s Office. (In some other states, the Disaster Management Authority took responsibility for the health-related response to COVID-19.) Before the COVID-19 pandemic the departments had different data collection platforms, but they quickly moved to adopt a common platform that facilitated data sharing, expedited the development of essential functionalities and tools, and demonstrated value to every user type.
• Groundwork—Technology enabled efficient time management in a crisis: Early in the development process, officials identified and included stakeholders such as laboratories and surveillance and facility teams to ensure that developers-built tools to meet their needs, which resulted in valuable buy-in. State officials also laid the groundwork locally before introducing a statewide technology solution. Rollout of the modular COVID-19 platform helped establish a user-friendly, comprehensive reporting process across the continuum of care for COVID-19. The platform became the single source of information across the state, and data-backed analytics helped officials prioritize key issues and support efforts more effectively.
• Technology and Architecture—Modular development demonstrated value to every user type: The development team “converted” champions for their platform by getting things done as quickly, cleanly, and simply as possible; keeping the end user in mind; and supporting prioritization efforts focused on real-time analysis of immediate needs (e.g., cases, testing, hot spots, and contact tracing) and resource optimization (e.g., tracking the availability of beds and health workers).
• Operations—Strengthening capacity via new training modes drove digital adoption and ensured accurate reporting: Online Zoom training sessions replaced all-day in-person sessions, which enabled faster dissemination of information during a time of when guidelines were changing. Short training or refresher videos posted to YouTube, WhatsApp, and other social media allowed health workers and other viewers the option of learning at their convenience.
• Monitoring and Evaluation—The near real-time data-entry to data-visibility cycle ensured data quality and transparency: The platform’s built-in validation checks (automated basic data quality checks) were crucial because it uses data that comes in multiple formats from different user types. District-level staff took ownership of sensitive health data as they were reported, which also helped ensure transparency and public confidence in data quality.

What Implementation and Scaling Challenges Remain?

• Operations – Short-term capacity to use digital tools: At the state level, there is a need for a dedicated digital team to lead, manage, and support the development of systems and platforms across health programs to sustain capacity for the use of digital tools beyond the COVID-19 crisis. In the absence of such a team, much of the digital efforts were led by the UP TSU itself. The proposed Information Technology (IT) Cell and State Digital Health Mission as part of National Digital Health Mission (NDHM) would be a step in the right direction.
• Technology and Architecture—Limited capacity of platform architecture: Initially, developers chose a local technology vendor to help develop the platform, but it soon became apparent that the vendor could not build the system to its desired scope. A more thorough proactive review of vendors’ capabilities should be viewed as a best practice. New data standards recommended by the National Digital Health Blueprint are now being implemented, and more rigorous data analytics are also being developed.
• Technology and Architecture—Performance issues in the field: During the initial rollout phase, the platform was not mobile responsive and faced system performance issues on the ground. Process-specific concerns included a lack of clarity around the process to rectify errors and duplication in data reporting and overlapping referrals.
• Groundwork—Limited user engagement: More direct communication with the public via social media (e.g., Facebook, WhatsApp, and Telegram) would help improve engagement with local citizens and health workers, while also facilitating two-way communication.

Conclusion

The Unified COVID-19 Data Platform demonstrated the government of Uttar Pradesh’s ability to leverage technology quickly and effectively in a fast-changing pandemic environment. The platform also continues to adapt to a constantly evolving scope and set of user needs and challenges. A dedicated budget could help accelerate the progress of the digital platform and move Uttar Pradesh toward developing electronic health records.

In line with the objectives of the National Digital Health Mission, the government is actively developing a strategy to leverage its learnings from Uttar Pradesh’s recent experience with the COVID-19 digital platform across all health programs. From the perspective of strengthening health systems, key lessons include:

• Digitize citizen-level data at source, which can be shared based on consent, instead of efforts to digitize data at an aggregate level.
• Leverage the principle of data minimalism, capturing data fields to ensure complete electronic health records for each citizen using a unique ID instead of focusing on collection of an exhaustive list of data fields purely from a monitoring point of view.
• The various users have found immense value in modular systems that are customized for their specific workflows. The Unified COVID-19 Data Platform has increased understanding around the importance of leveraging data standards to drive integration and interoperability to ensure a seamless exchange of information across systems.
• Strengthen existing state-level health systems including human resources, supply chain, and data systems.

These lessons will help guide decision making as Uttar Pradesh moves toward developing electronic health records and personal health records and rolling out state-level initiatives led by the National Digital Health Mission.

This is a qualitative assessment based on the mHealth Assessment and Planning for Scale framework. To learn more about the framework, click here.

We would also like to acknowledge the supporting role played by our partner organizations: Suhel Bidani, Dr. Vikas Yadav, and Anaita Singh from the Bill & Melinda Gates Foundation; Dr. Vasanthakumar, Col. Sameer Kanwar, Adi Ranjan, Uday Bhanu Kumar, Vishan Sharma, Som Pal, Mushahid, Ravi Teja, Rishabh Bansal, and Anurag from the Uttar Pradesh Technical Support Unit (supported by University of Manitoba and India Health Action Trust (iHAT)); Suresh Gopalakrishnan, Haritha Reddy, Sai Rahul and Anuranjan Kumar from BeeHyv Software; and Anand and Dipika Verma from Gramener.