International Journal of Medical Informatics 88 (2016) 58–61

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International Journal of Medical Informatics

journal homepage: www.ijmijournal.com

Design and implementation of a national public health surveillance

system in Jordan
Sami Adel Sheikhali a , Mohammed Abdallat a , Sultan Mabdalla a , Bashir Al Qaseer a ,
Rania Khorma a , Mamunur Malik b , Maria Cristina Profili c , Gunnar Rø c,d , John Haskew c,∗
a
Ministry of Health, Jordan
b
World Health Organization, Cairo, Egypt
c
World Health Organization, Amman, Jordan
d
University of Durham, UK

a r t i c l e i n f o a b s t r a c t

Article history: Understanding and improving the health status of communities depend on effective public health surveil-
Received 14 September 2015 lance. Adoption of new technologies, standardised case definitions and clinical guidelines for accurate
Received in revised form 12 January 2016 diagnosis, and access to timely and reliable data, remains a challenge for public health surveillance sys-
Accepted 12 January 2016
tems however and existing public health surveillance systems are often fragmented, disease specific,
inconsistent and of poor quality. We describe the application of an enterprise architecture approach
Keywords:
to the design, planning and implementation of a national public health surveillance system in Jordan.
Public health surveillance
This enabled a well planned and collaboratively supported system to be built and implemented using
Information and communication
technology
consistent standards for data collection, management, reporting and use. The system is case-based and
International classification of disease integrated and employs mobile information technology to aid collection of real-time, standardised data
Clinical diagnostic algorithms to inform and improve decision-making at different levels of the health system.
© 2016 The Authors. Published by Elsevier Ireland Ltd. This is an open access article under the CC BY
license (http://creativecommons.org/licenses/by/4.0/).

1. Introduction
Public health surveillance is the ongoing, systematic assess-
ment of the health of a community [1] and a national public
health surveillance system plays an important role in ensuring that
reliable and timely health information is available to inform opera-
tional and strategic decision making at different levels of the health
system. Despite its importance for evidence-based decisions, pub-
lic health surveillance in many countries is weak, fragmented and
often focused on disease-specific program areas. Surveillance pro-
grams often rely on multiple layers of reporting structure from
the facility to central level, which can result in delays in release
of data and substantial human and time resources may be spent
on data cleaning and analysis before they can be released and
interpreted correctly [2]. Data sharing may also be impeded if stan-
dardised approaches are not used for coding and formatting of data.
For example, aggregated data may be collected and reported from
disease registers for which there is no quality control over the
case definition used. Furthermore, aggregated data can limit the
ability to link epidemiological data to laboratory confirmation of
∗ Corresponding author.
E-mail address: john.haskew@gmail.com (J. Haskew).
diagnosis and the ability to undertake contact tracing and follow-up
of suspected notifiable diseases.
Technological and analytical innovations within public health
surveillance systems, including the use of information and commu-
nication technology, may help in enabling standardised data to be
collected in real-time, and several advantages have been discussed
that could help to inform and improve decision-making [3,4]. Elec-
tronic information can be collected in a structured, coded manner
and, if the tool is used within the consultation, skip-logic algo-
rithms can be used to provide clinical decision support in support
of diagnosis and management of disease [5]. Mobile information
technology also enables other data sources, including population
and mapping data, and other tools for data visualisation, including
Google Maps [6], to be more readily integrated into the process of
data collection, reporting and analysis [7,8].
2. Development of a public health surveillance framework
in Jordan
An innovative national program of public health surveillance
is being implemented across Jordan, in partnership with the Min-
istry of Health and World Health Organization (WHO), that uses
mobile tools and an online framework for collection, analysis and

http://dx.doi.org/10.1016/j.ijmedinf.2016.01.003
1386-5056/© 2016 The Authors. Published by Elsevier Ireland Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
 S.A. Sheikhali et al. / International Journal of Medical Informatics 88 (2016) 58–61
Fig. 1. Diagram of public health surveillance system components and data flow.
reporting of surveillance data. Following pilot project implemen-
tation between May to December 2014, national scale-up and
implementation of the public health surveillance system in Jor-
dan took place in a phased manner in April 2015. A total of 269
primary and secondary care facilities are currently included in the
system, using 409 mobile tablets, across all twelve governorates of
the country.
An enterprise architecture approach was applied to iden-
tify the key elements and relationships required to develop
the national public health surveillance system in Jordan. This
approach enabled important interrelationships to be identified and
reduce subsequent risks of fragmentation, duplication and lack of
interoperability. The approach also mitigated the application of
information and communication technology in an unplanned and
unstructured manner. Four domains defined the general model of
enterprise architectal public health surveillance system, each of
which are considered in the following sections.
2.1. Organisational architecture
The organisational architecture of the public health surveillance
system defines the various business functions, process, gover-
nance, policy and resources required for its development and
implementation. The Ministry of Health own and manage the sys-
tem, and multiple departments including communicable disease,
non-communicable disease, mental health, information technol-
ogy and training were involved in its design and implementation.
High level approval from the Minister of Health and Prime Min-
ister was obtained to ensure appropriate policy and resources
could be ensured for effective implementation. A number of
59
consultative meetings with other stakeholders and partners in the
health sector, including military, private sector, other UN agencies
and NGOs, are ongoing who may play a role in any future scale-up
and implementation beyond the national health system.
The system was initially implemented as a pilot across 50 health
facilities between May to December 2014 in northern Jordan, dur-
ing which time technical aspects of implementation could be tested
and refined. This period also enabled extensive consultation to
take place peripherally (among health care workers) and cen-
trally (among management) within the Ministry of Health to better
understand needs and functionality for the system. This afforded
institutional learning and buy-in to take place across the various
departments and levels of Ministry of Health.
The first phase of national scale-up within Ministry of Health
facilities began in April 2015 and the system is now operational
in 269 facilities at primary, secondary and tertiary care level. The
Ministry of Health conducted all training for implementation of the
system, which included facility-level health care workers, gover-
norate level and central health management. Training is continuous
among all levels of the health system and a total of 1738 health
personnel and 48 managers have been trained to date in use of the
system.
2.2. Data architecture
The data architecture of the public health surveillance system
includes the data model, data dictionary and classification of stan-
dards and systems used. Mobile tablets are used by health workers
within the consultation to provide case-based reporting of disease
as well as to introduce electronic modules for prescribing, using the
60 S.A. Sheikhali et al. / International Journal of Medical Informatics 88 (2016) 58–61
WHO Model List of Essential Medicines [9] and clinical diagnostic
algorithms, including the integrated management of childhood ill-
ness (IMCI) [10] and WHO Mental Health Gap Action Programme
(mhGAP) [11]. Disease information is coded in a structured man-
ner according to the International Classification of Disease (ICD-10)
[12].
Reported information is made available within one hour via an
online framework, with support for analysis, mapping and report-
ing that is accessed at all levels of Ministry of Health. Essential
health system indicators are also collected through the system as
defined by the WHO framework for health information systems and
core indicators in the Eastern Mediterranean Region [13].
2.3. Applications architecture
The applications architecture of the public health surveillance
system describes the modality of data collection, management,
analysis and reporting as well as inter-operability of software appli-
cations and interfaces. A case-based reporting form, available in
Arabic and English, was designed in extended mark-up language
(XML) and uploaded to tablets for clinic consultations. The form
is modular in design, collecting individual patient demographic
information as well as relevant clinical, laboratory and prescrib-
ing information depending on user input. Each form is programmed
for the Open Data Kit (ODK; www.opendatakit.org) [14] application
and skip logic algorithms are used. Data are uploaded in real-time
from the clinic tablets to a central server based at the Ministry of
Health. Data are anonymised and aggregated over time and loca-
tion using a custom designed application, based on a PostgreSQL
(www.postgresql.org) database, a python (www.python.org) appli-
cation programming interface (API) and a password protected
HTML/Javascript website. This website is updated with aggregated
and anonymised data every hour for access and use at all levels
of the Ministry of Health. The custom-designed website displays
demographics and proportional disease morbidity at directorate,
district and health centre level and displays data using tables, charts
and maps. Fig. 1 describes the public health surveillance system
components and data flow.
2.4. Technical architecture
The technical architecture of the public health surveillance sys-
tem describes systems infrastructure and hardware used in its
development and implementation. The system was built using free,
open source software and is implemented as a cloud-based model,
rather than a local clinic model, which removes the need for local
clinic infrastructure. In using the term “cloud-based” we refer to the
fact that the server and data are hosted centrally by the Ministry of
Health and not by the individual clinic.
This approach provides a potentially more cost-effective solu-
tion to implementation (removing the need for local security,
network and computer hardware in each clinic) and also enhances
data access and sharing at different levels of the health system. The
estimated cost of national implementation across 269 sites, and
using 409 tablets, was approximately USD$ 94,000, or USD$ 227
per reporting unit (tablet), which includes the unit cost of tablets,
connection costs and training expenses. Subsequent support and
system costs are approximately USD$ 40,000 per year, or USD$ 96
per reporting unit (tablet) per year.
The system uses a secure network, provided by a mobile phone
operator in Jordan, to which the server and clinic tablets con-
nected exclusively via a Hypertext Transfer Protocol Secure (HTTPS)
connection. Android-based Lenovo IdeaTab 7 A3000 and A3500
tablets are used in each health facility, with built-in mobile data
connection, and are locked so users cannot use the device for
any other function. Only tablets using SIM cards registered by the
Summary points
What was already known on the topic:
• Existing public health surveillance systems are often frag-
mented, disease specific, inconsistent and of poor quality.
• Adoption of new technologies, standardised case definitions
and clinical guidelines for accurate diagnosis, and access to
timely and reliable data, remains a challenge for public health
surveillance systems.
• Technological and analytical innovations within public health
surveillance systems, including the use of information and
communication technology, may help in enabling standard-
ised data to be collected in real-time.
What this study added to our knowledge:
• An enterprise architecture approach was applied to identify
the key elements and relationships required to develop the
national public health surveillance system in Jordan.
• A number of innovative principles of public health surveil-
lance are introduced, including the use of cloud-based,
electronic data collection and management and the use of
case-based reporting within the consultation.
• Several advantages of these features are postulated includ-
ing the use of clinical decision support for disease diagnosis
and management, standardisation and coding of data, pro-
vision of timely and reliable analysis and reporting and
cost-effectiveness of implementation.
project can access the server. Fig. 1 describes the public health
surveillance system components and data flow.
3. Conclusion
An enterprise architecture approach was applied to identify
the key elements and relationships required to develop a national
system of public health surveillance in Jordan and to inform the
introduction of technological innovation. A number of innovative
principles of public health surveillance are introduced, including
the use of cloud-based, electronic data collection and management
and the use of case-based reporting within the consultation. Sev-
eral advantages of these features are postulated including the use
of clinical decision support for disease diagnosis and management,
standardisation and coding of data, provision of timely and reliable
analysis and reporting and cost-effectiveness of implementation.
An evaluation of perceptions of use of the system, as well as
descriptive epidemiological analysis of data collected by the system
will be presented in separate papers. Further work is encouraged
to compare the cloud-based public health surveillance model with
traditional public health surveillance systems, including impact
on cost-effectiveness, data completeness and data sharing and to
consider the scalability of cloud-based models in settings where
data network infrastructure is functional. Further studies are also
encouraged to explore other applications of electronic surveillance,
including the incorporation of clinical decision support to improve
the quality of clinical care.
Authors’ contributions
All authors contributed to the paper. JH conceived and designed
the study. JH, GR, RK, SS designed and implemented the public
health surveillance system. JH, GR, RK, SS, MCP, MM wrote the
paper. All authors reviewed the final draft of the manuscript.
 S.A. Sheikhali et al. / International Journal of Medical Informatics 88 (2016) 58–61
Conflict of interest
No conflicts of interest are declared by the authors. No authors
were paid for writing of the manuscript.
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