Abstract

Background: A quarter of a century after its launch, the Integrated Disease Surveillance and Response (IDSR) strategy remains at the heart of Africa’s efforts to build a public health system capable of detecting, analysing and remediating epidemic threats, as well as responding quickly to them. Objective: The objective of this systematic review is to review and document the achievements and challenges regarding the implementation of the integrated epidemiological surveillance system in the WHO African Region and to facilitate the identification of common obstacles to anticipate future health events. Method: In accordance with PRISMA recommendations, we conducted a peer-reviewed literature review that was published over the period from January 2010 to January 2026 on Google Scholar and PubMed verifying the predefined inclusion criteria. The Mendeley software allowed us to eliminate duplicates, while Excel 2021 was helpful for data extraction and analysis. Results: Of the 51 articles that were included, 09 focused on the entire WHO Africa region, while 42 focused on specific countries in the region. About 70% (n = 35) of these were published over the period 2015-2019 and 53% (n = 28) linked several diseases to the implementation of the IDSR strategy. The IDSR has made significant progress in Africa, with improved timeliness and completeness of data, increased efficiency of critical functions, and significant support for polio-related infrastructure to strengthen surveillance of priority diseases. However, the review highlights recurring challenges: insufficient human and financial resources, supply disruptions, low data quality and integration, under-reporting of diseases, lack of training and supervision, as well as coordination and communication problems at all levels of the health system. Conclusion and Perspectives: The IDSR has contributed to strengthening epidemiological surveillance; however, these performances vary by country and remain weakened by persistent structural challenges. Building resilient health systems requires stronger resources, integrated data, digital innovation, and robust governance to sustain gains against emerging and recurrent threats.

Keywords

Integrated Epidemiological Surveillance System, Africa, Performance, Challenges, Prospects

Share and Cite:

1. Introduction

Epidemiological surveillance is the production of continuous epidemiological information on a health problem, to identify appropriate actions to remedy it [1]. Countries in the WHO African Region frequently experience outbreaks of infectious diseases, resulting in widespread morbidity, disability and death. The magnitude of the impact of these health problems is exacerbated by weak surveillance, preparedness and response systems leading to delayed detection and ineffective response to these outbreaks [2]. To this end, the international community has recognized the importance of a solid and functional strategy of Integrated Disease Surveillance and Response (IDSR) [3].

Adopted in 1998 by the World Health Organization African Region (WHO-AFRO), the IDSR was intended to serve as a comprehensive strategy to improve disease surveillance and improve the laboratory and response capacities of WHO member states in Africa [4]. It was developed in response to a range of emerging and re-emerging diseases that have caused the deaths of large numbers of people in the African region [5]-[7]. This strategy targeted nineteen (19) priority communicable diseases, which are divided into four categories: Diseases with epidemic potential, diseases targeted for eradication, diseases targeted for elimination and endemic diseases [4]. The emergence of new diseases, conditions and events has necessitated a rethinking of public health priorities for surveillance and response [2] [8]. To this end, the International Health Regulations (IHR) adopted and revised in 2005 required a revision of the 1998 IDSR strategy in 2010 [9]. This revision proposed a modification of the typology of diseases under surveillance into five categories as follows: epidemic-prone diseases, diseases targeted for eradication or elimination, other major diseases, events or conditions of public health significance, and diseases or events of international concern [9] [10]. As the health situation in the WHO African Region continues to evolve, a third revision of the 2010 IDSR took place in 2019 [11] and which was in line with the guidance of the fifty-sixth session of the WHO Regional Committee for Africa in 2006 [12], the 2016-2020 emergencies (including COVID-19) in the WHO African Region and using the opportunities offered by new information technologies such as mobile phone networks, increased broadband internet connectivity and electronic monitoring systems [13]. Since the Integrated Monitoring and Reporting System (IMSR) and the requirements of the IHR (2005) share common objectives, WHO Member States in the African region have decided to use the strategy IDSR revised 2010 as the basis for the implementation of the IHR (2005) [7]. Especially since the IDSR and IHR frameworks offer low-income countries the opportunity to leverage their limited resources to continuously improve their disease surveillance and response systems [14].

An effective surveillance system collects, analyzes, and interprets data quickly and accurately, facilitating a rapid response to outbreaks [13]. The effectiveness of such a surveillance system lies in its ability to adequately monitor health events in order to generate quality and timely information that can be used to carry out appropriate public health actions [15] [16]. Regular monitoring ensures the relevance and effectiveness of the system, identifying strengths and weaknesses to enable continuous improvements. Thus, the evaluation of the integrated epidemiological surveillance system is of particular importance [17]. To this end, WHO recommends a regular assessment of the core functions of the revised 2010 IDSR and supporting functions (guidelines, laboratory capacity, supervision, training, resources and coordination) at all levels of the health system [15] [18]. In this momentum, in 2009, Uganda was among the first countries to conduct an evaluation of the IDSR and it documented successes and challenges, including inadequacies and inconsistencies at the national level in the core activities of the IDSR and support functions such as training, support supervision, communication, and feedback [19]. In addition, one of the key requirements of the IDSR strategy is the development and dissemination of information products, including the writing and publication of scientific articles on IDSR, to inform policymakers’ decision-making [3]. Indeed, a review of the published literature, particularly that on recent outbreaks, can help to identify areas where the implementation of the IDSR is working well and those where it remains weak, highlighting areas for research and prioritization [2]. However, peer-reviewed scientific articles as information products on the IDSR are still rare [2].

The objective of this systematic review is to review and document the achievements and challenges in the implementation of the integrated epidemiological surveillance system in the WHO African Region and to facilitate the identification of common barriers to anticipate future health events. This systematic review integrates recent research and health systems strengthening efforts in the Africa region to reinforce the findings of previous studies. We will identify the key factors for good performance that will strengthen the achievements of health surveillance systems in the WHO African Region; It will also be a question of identifying the challenges and recommendations made in terms of the IDSR.

2. Methodology

2.1. Scope of the Study

The present study is restricted to the African region, as it remains the epidemiological focus of most health problems including: cholera, meningitis, measles, poliomyelitis, yellow fever, malaria and several emerging diseases [20]. Moreover, the choice of this zone is linked to the fact that most African countries suffer from comparable health ills and share similar difficulties in terms of epidemiological surveillance. In this study, we consider integrated epidemiological surveillance as a public health strategy that aims to harmonize the collection, analysis and use of data on priority diseases to enable early detection and rapid response [21]. By performance, we mean the ability of integrated epidemiological surveillance to fulfil its missions and produce the expected effects. In this case, we assess the performance of the IDSR strategy, a framework adopted by WHO Africa since the late 1990s to harmonize the epidemiological surveillance system in the region, according to the core functions assigned to it and updated as it is revised. These include case identification, reporting, data analysis and interpretation, investigation and confirmation of cases and possible outbreaks, preparedness, response, information flow and evaluation and improvement of the surveillance system [21]. The absence or weakness of any of these criteria will be seen as a challenge to be overcome in terms of prospects. Also, we will look at the challenges in terms of resources, logistics and coordination.

2.2. Search Strategy

In accordance with the PRISMA 2009 recommendations [22], we conducted a peer-reviewed literature review that was published over the period from January 2010 to January 2026. To this end, Google Scholar and PubMed are the two databases that were consulted. The top search terms included “Integrated Epidemiological Surveillance System”, “Performance”, “Challenges”, “Assessment”, “Challenges” and the English equivalents in the title and abstract of the indexed literature. We have systematically consulted all the scientific work on the subject. To do so, we reviewed titles and abstracts using the inclusion and exclusion criteria described below. Full-text articles of titles and abstracts checking the inclusion criteria were uploaded and reviewed for data collection. In addition, we used the reference lists of included studies. A careful reading of the titles and abstracts of full-text articles was done independently to identify eligible articles in each database. We then made a summary of each database. Finally, we checked and managed duplicates with Mendeley reference citation software.

2.3. Inclusion and Exclusion Criteria

Only articles that met the following criteria were included in this review:

• Have been published in a peer-reviewed scientific journal; and

• Have been peer-reviewed, in full text; or

• Have been published by the World Health Organization; and

• Have been published between January 2010 and January 2026; and

• Have been published in English or French; and

• Focus on countries in the WHO African Region; and

• Be “Open Access”; and

• Address the surveillance system, performance and challenges of implementing the IDSR strategy, or address the surveillance of diseases covered by the IDSR framework.

Thus, the exclusion criteria are as follows:

• Not have been published in a scientific journal (except which published by the WHO); or

• Have been published only as abstracts or presented at conferences without being accompanied by full publications; or

• Be published before the year 2010 or from February 2026; or

• Have been published in a language other than French or English; or

• Relate to a country or region outside WHO-Africa; or

• Require payment to access the full text; or

• Address topics other than the IDSR strategy, or address diseases covered by the IDSR framework but that did not link the surveillance system or their findings to the IDSR strategy.

2.4. Article Selection Procedure

To reduce bias, each included article was independently double read. Indeed, each reading consisted of the one hand of a complete and detailed examination of the article (titles/abstracts and full texts), and on the other hand of the analysis of the content of the article according to the inclusion criteria. In the event of divergent decisions between the two reviewers on the inclusion or exclusion of a reviewed article, in-depth discussions will be reached to reach a consensus. In the event of a lack of consensus, it is sent to a third reading to decide.

2.5. Risk Analysis of Article

A risk assessment of the included articles was carried out to evaluate their quality and the risk of bias associated with their inclusion in the systematic review. For each included article, we used the following indicator to assess this risk:

$\text{Risk}=1-\frac{{\displaystyle {\sum }_{j=1}^5{\text{criteria score}}_j}}{20}$

where ${\text{criteria score}}_j$ is the article’s score for criterion j. Table 1 below presents the said evaluation criteria, as well as the associated reference scores.

A safe article (0%) verifies the inclusion and exclusion criteria for articles for inclusion, was published in 2026 (in the first quarter at the time of submission of the article), uses the IDSR strategy to assess the surveillance system of diseases under epidemiological surveillance in African countries. The risk ranges from 0 (almost zero risk) to 100% (very high risk). Appendix 1 presents the results of the risk assessment of the inclusion of items. On average, the articles included present a 35% (+/− 15%) risk of bias according to the criteria used. Half of them were less than 30% at risk. The riskiest included article had a score of 65% and one article had no risk of inclusion. This analysis shows that the articles included have overall little risk of bias on the review. To further reduce this risk, the articles have been cited according to the geographical area and the diseases they cover.

Table 1. Risk assessment criteria and references scores.

Source: Authors.

2.6. Data Extraction and Analysis

For each of the selected articles, we collected three (03) types of information (variable), namely:

• Performance indicators such as case identification, reporting, data analysis and interpretation, investigation and confirmation of cases and possible disease outbreaks, preparedness, response, information flow, evaluation and improvement of the surveillance system.

• The challenges encountered in terms of human, financial, and logistical resources and coordination.

• The perspectives, which include the reforms, innovations and digital integration proposed by the authors.

To do this, we used a standardised and digitised reading grid using Excel 2021 software. This software was also used for the synthesis and visualization of the results. The data was consolidated using a mixed approach: a narrative analysis to identify recurring themes and a tabular presentation to structure the performance indicators. The results were compared by country and subregion using performance matrices [speed of reporting, completeness, quality of data], to identify convergences and divergences. Finally, a cross-sectional analysis highlighted continental trends and local specificities, based on a thematic classification and standardised quantitative indicators. Appendix 2 presents the results of this work.

2.7. Ethical Considerations

The drafting of this review required constant ethical vigilance. We have made the effort to respect academic integrity through correct citation and faithful presentation of the work, while ensuring transparency in the choice of sources. We have also placed particular emphasis on equity and representativeness of perspectives, integrating a variety of research. Finally, the communication of the results was done in an honest and balanced manner, recognizing the limitations and uncertainties of the existing literature.

2.8. Limitations of the Study

For the purposes of this review, the search was limited to studies conducted in the WHO-Africa area, potentially excluding relevant data from countries outside WHO-Africa and outside the continent that have implemented national surveillance aligned with the IDSR. In addition, the research was limited to English and French studies, which may have reduced the sample size and introduced language bias. Also, relevant articles that are not “open source” have escaped the scope of this review. Despite these limitations, the results remain valuable for applications in Africa and similar contexts to identify strategies to overcome barriers and strengthen facilitators to improve the implementation of the IDSR.

3. Results

3.1. Description of Selected Articles

Without specifying a study period, we consulted a total of 172 articles, of which 56% (97 articles) on PubMed and 44% (75 articles) on Google Scholar. Of these articles, only 68% (117 articles) met the study period criterion (January 2010 to January 2026), including 66 articles on PubMed and 51 articles on Google Scholar. After reading the titles and abstracts of each article, 66 articles (including 54 on PubMed and 12 on Google Sholar) were retained in the two databases. Subsequently, 12 articles were excluded because they did not meet the criteria of the IDSR and 03 articles were duplicated (duplicated). Thus, a total of 51 articles were included in this systematic review. Of the 51 studies that were included, we noted that 09 covered the entire WHO Africa region, while 42 focused on specific countries in the region.

Figure 1. Distribution of included items by WHO Africa country. Source: Authors, Excel 2021.

Figure 1 above shows the distribution of the items included by WHO Africa Country. Almost half (43%) of the selected articles focused on West African countries, with most of the work focusing on Nigeria (07 articles) i.e. 32% of the articles selected. Then the most represented articles were about Uganda and Ghana with 05 items each; and after Liberia (03 articles), Kenya (02 articles), Zimbabwe (02 articles), Sierra Leone (02 articles), Ethiopia (02 articles) and DR Congo (02 articles). The other countries had only one article represented. It is South Africa; Cameroon; Malawi; Tanzania; Zambia; Madagascar; Botswana; Mali; Niger; Guinea; Burkina Faso and Benin.

The analysis of the evolution of the number of articles included over time (Figure 2 below), shows that about 70% (n = 35) were published between the years 2015 and 2019. The spike in publication over this period can be explained by the publication of the IDSR evaluation criteria in 2015, which served as the basis for evaluation studies in individual countries and in the region. Since 2019, the pace of publication on the IDSR strategy has dropped, probably due to the focus of studies on the Covid 19 pandemic.

Figure 2. Evolution of the number of articles published (included) between 2010 and 2026. Source: Authors, Excel 2021.

Figure 3 below shows the distribution of the included items according to the priority diseases they treat. Of these articles, 53% (n = 28) or just over half link several diseases to the implementation of the IDSR strategy; 11% (n = 06) relate exclusively to Ebola virus disease; 8% (n = 04) on malaria; 6% (03) on poliomyelitis and cholera respectively; 2% on co-infection of Ebola virus disease (n = 01), Lassa fever (n = 01), rubella (n = 01), neonatal tetanus (n = 01), measles (n = 01), tuberculosis (n = 01), influenza (n = 01), vaccines (n = 01), maternal mortality (n = 01) and peripheral diseases (n = 01) respectively.

3.2. Twenty-Five Years of Implementation of the IDSR: Major Advances in Africa

After twenty years of implementation, Socé Fall et al. (2019) showed that significant progress had been associated to the IDSR, with 32 countries (68%) reaching

Figure 3. Distribution of included articles by priority diseases. Source: Authors, Excel 2021.

the timeliness and completeness threshold of at least 80% of reporting units [3]. In 2021, Wolfe et al. confirmed effective implementation across all critical and support functions of the IDSR, including priority disease detection, data reporting and analysis, information dissemination, laboratory functionality, and staff training [2]. In addition, Mwengee et al. (2016) showed that in seven countries, polio eradication infrastructure supported surveillance of other priority diseases, with robust data reporting, rapid detection of outbreaks, and strengthened response capacities [23]. Finally, Poy et al. (2014) confirmed that improved in data availability from IST Polio-funded managers were associated to IDSR [24].

The results show that several countries in the WHO Africa region recorded Notable progress in the implementation of the IDSR. In Sierra Leone, the timeliness of the data was reaching 93% in 2016 and 97% in 2017, with suspected outbreak detection of 96% (n = 87) in 2016 and 100% (n = 85) in 2017 [25]. In Zambia, major successes have been noted, including an operational response at all levels, dedicated staff and budgets, and the adoption of WHO technical guidelines adapted to the national context [26]. In Malawi, the completeness of monthly reports reached 73.1% [27]. In Uganda, district reporting has been increased from 49% in 2001 to 85% in 2007, the local analysis of 10% to 47% [p < 0.01], and a decrease in the cholera case fatality rate of 3.2% to 2.1% was observed [19]. In Nigeria, 88.9% of professionals submitted the IDSR002 forms within two days [28]. In Liberia, the use of mobile applications and the AVADAR platform helped maintain performance above the 80% threshold [29], with 65% of structures receiving supervision and 58% providing community feedback (34). Other countries have also shown achievements: in Benin, a good level of performance for the “structure” component and an average level for “processes” and “results” [30]; in Ghana, an increase in monthly completeness (+9%) and on-time performance (+37%), as well as a weekly improvement (+79% and +24%) [31]; in Kenya, 44% of the structures had adequate notification [32]; in Zimbabwe, 79.7% of agents used the data generated and 59.5% found implementation easy [33]; and in Ethiopia, a threefold reduction in malaria-related admissions and deaths between 2005 and 2009 [34]. These studies highlight Concrete progress: improved timeliness and completeness of data, strengthened detection and response, adoption of digital tools, and measurable impacts on mortality, while highlighting differences in performance across countries.

3.3. Twenty-Five Years of Implementation of the IDSR: Persistent Challenges in Africa

In 2019, Fall et al. showed that only 12 countries (26%) had achieved the target of 90% coverage of the IDSR at the peripheral level [3]. Major barriers identified include limited resources, insufficient access to knowledge, and structural constraints, as well as lack of motivation and capacity [35]. Other authors point to specific weaknesses: insufficient training and poor data management, lack of reliable civil registration systems for monitoring mortality, and not giving demographic [36]. As noted by Wolfe et al. (2021), the obstacles concern all the essential functions of the IDSR, from detection to staff training [2]. Finally, Mremi et al. (2021) rewrite data in sub-Saharan African incomplete untimely and of low quality, poorly analyse and misused, with a penny-use of advanced big data analytics technologies, limiting evidence-based decision-making [37].

Country experiences reveal that, despite progress in the implementation of the IDSR in Africa, many challenges remain. In Ethiopia, although 87% of sites have a surveillance officer and 95% a vaccination officer, only 44% have written terms of reference and 17% have conducted independent visits, with 34% facing vaccine stock-outs [38]. In Ghana, studies show a limited role of the community system during the Ebola outbreak, gaps in preparedness (lack of equipment, lack of isolation centres, irregular supervision) and low acceptability of the TB surveillance system [39]. In Zambia, the problems relate to human resources and coordination [26], while in Uganda, funding has fallen sharply and challenges include a lack of trained staff, irregular supervision and a high turnover rate [14]. In Nigeria, under-reporting of priority diseases remains a major problem, compounded by the lack of infrastructure and knowledge of doctors [28] [40].

In other countries, similar difficulties are emerging: in Cameroon, the old case definition of cholera was still used in 2013, with a low capacity for confirmation and a lack of structured analysis [41]; in South Africa, barriers include under-reporting, inconsistent definitions, and weak integration of environmental health [42]; in Liberia, despite post-Ebola investments, delays in sample management and lack of training persist [22] [29]. Infrastructure and communication problems are also noted: in Ethiopia and Botswana, the transmission of malaria data is considered effective [35] [43], but in other countries, such as Malawi, Kenya and Madagascar, challenges include case identification, data quality, lack of technical guidelines and poor procedural skills [28] [33] [44]. Finally, Curran et al. (2015) showed that during the cholera epidemic, only 27% of facilities had rectal swabs and 11% had CaryBlair media, with 34% without reporting forms and 37% without treatment guidelines, highlighting serious coordination and management issues [45].

4. Discussion

The results of this review demonstrate that IDSR has contributed to strengthening epidemiological surveillance, improving data quality and increasing response to outbreaks in the WHO Africa region. Advances in reporting timeliness and completeness, rapid detection of outbreaks, and the adoption of digital tools confirm that the IDSR is a robust platform for integrated surveillance of priority diseases. However, these performances vary across countries and remain weakened by persistent structural challenges.

Problems related to accuracy, incompleteness and delays in reporting are recurrent. In Ghana, for example, the District Health Information Management System II improved the availability of IDSR reports in 2015, but the quality of the data reported remains insufficient and inconsistencies between weekly and monthly data need to be corrected [31]. Njuguna et al. (2020) pointed out that regular data quality assessments can improve their accuracy over time [25]. The under-reporting of certain diseases, documented in several contexts, raises concerns about its impact on health budgets. The inability to provide reporting forms is also a common complaint, while clinicians—patients’ first contact with the health system—play a central role in reporting [3]. As Isere et al. have pointed out, health workers must be aware that they are an essential component of the national surveillance system [46]. The confirmation of cases also requires solid laboratories, but the networks have certainly improved but remain insufficient.

National experiences illustrate these limitations. In Sudan, the EWARN network is working relatively well and has improved detection, reporting and laboratory confirmation, but it requires more resources for communication, transport and regular supervision. More broadly, the response to epidemics requires contingency plans that can reduce the demand for services, optimize the use of existing resources, and mobilize additional resources [47]. However, a rapid and effective response depends on the availability of reliable and timely data, which requires adequate resources and a skilled workforce.

In sum, twenty-five years after its launch, the IDSR has made undeniable progress in Africa, but its sustainability and effectiveness now depend on the ability of countries to close systemic gaps. The strengthening of human and financial resources, the integration of multi-source data, the adoption of digital innovations and the consolidation of governance appear to be essential conditions for transforming the gains into a sustainable system, capable of responding to emerging and recurrent health threats.

5. Conclusion

Twenty-five years after its introduction, the IDSR has established itself as a pillar of epidemiological surveillance in Africa, with tangible advances in timeliness, comprehensiveness and response to outbreaks. Country experiences confirm that the integration of existing infrastructure, the use of digital tools and the strengthening of local capacities have led to measurable impacts on detection and response. However, persistent challenges—insufficient data quality, under-reporting of diseases, supply disruptions, weak laboratories and unstable funding—are a reminder that gains remain fragile. To transform this progress into a sustainable and resilient system, it is imperative to strengthen governance, invest in human and technological resources, and ensure regular and effective supervision. Only such an approach will enable the IDSR to fully respond to emerging and recurrent health threats and strengthen health security in the WHO Africa region.

Acknowledgements

Our thanks go to anyone who contributed in any way to the realization of this study.

Appendices

Appendix 1: Summary of Articles Included and Risk Estimated

Appendix 2: Summary of Results by Problems, Limitations/Difficulties and Suggestions

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

References