McNabb BMC Public Health 2010, 10(Suppl 1):S3 http://www.biomedcentral.com/1471-2458/10/S1/S3 Page 4 of 7 Table 1. Eight Keys to Comprehensive Health Protection and their Defining Features. Key Politics Policies Priorities Perspectives Procedures Practices Preparation Payers Defining Features public demand; general consensus; mutual interest governance; stewardship; respect for human rights and data ownership; best practices shared vision; acceptance of accountability; embracing strategic and system’s thinking; seeing a common way forward; finding synergy; leveraging existing strengths facility; community; district; regional; national; global review global best practices; assess standard operating procedures; delineate lines of authority; establish channels of communication; intervene and re-evalaute assess existing workflow; evaluate effectiveness and efficiency training; transparency; forthrightness; one size does not fit all local and national governments; global programs practices, preparation, and payers (Table 1). While these eight prerequisites have a loosely sequential nature, there are relationships and interdependencies among them that should be acknowledged because of critical linkages to core competencies of public health surveillance and action (Figure 2). Many challenges (gaps and impediments) exist between the current and end-state described here. They can be disaggregated into technical, logistic, governance, and ﬁnancial domains. Within the technical domain, single (silo) categorical, disease-speciﬁc surveillance systems create the situation where public health practitioners cannot determine relationships between health condi- tions or co-morbidities (e.g., through data linkages). For example, new tuberculosis (TB) cases could be missed because HIV/AIDS data are not cross-matched with the TB registry. In this situation, surveillance becomes ineﬀective, because it is incomplete; events that represent a public health threat or that could inform about a potential public health threat are missed. Many times disease-speciﬁc silos are created and sustained by single funding streams and corresponding program obligations and priorities. They are often then maintained by pro- gram corporate cultures. Secondly, appropriate public health information is often not collected because what needs to be measured is often not known [20,21]. In these circumstances, surveillance systems are not ﬂexible enough to respond to new or unusual presentations of disease, events, or conditions (i.e., not easily adapted to changing information needs). Thirdly, current surveil- lance systems are often not timely (i.e., by the time an event of interest or concern is detected, the opportunity to intervene has passed) [22]. Additionally, some new surveillance systems are neither eﬀective, nor eﬃcient (i.e, the delivery of needed information is dependent on an inordinate number of resources) [23]. The logistic gaps include technical disparities among Member States, such as the cost for internet access and IT infrastructure. Gaps also exist in surveillance practices (e.g., lacking legal or other administrative requirements for mandatory reporting). There is a critical gap in global governance, under which all Member States would agree to function. Countries now collect and communicate public health information within and outside their natural border. The amount and type of information and willingness to collaborate varies from region to region. While there is a justiﬁable need to share important public health infor- mation that might impact neighboring states (and the IHR[2005] provides the legal and technical framework for public health emergencies of international concern), there still exists some uncertainty about what types of public health information are appropriate, how they should be communicated, and how quickly they should be shared. Challenges (or impediments) to bridge the gaps include both the lack of trust and perceived beneﬁt at various levels, the lack of a global governance model to address power and control of public health information, and the lack of focused ﬁnancial support from global partners. Conclusions End-state perspective for global public health surveillance Enhancing global public health surveillance in the 21st century involves empowering and enabling existing public health surveillance systems to interoperate (i.e., one information system to communicate with another syntactically – meaning two or more systems are capable of communicating and exchanging data by using speciﬁed data formats and communication protocols; and semantically – meaning the ability of computer systems to communicate information and have that information properly interpreted by the receiving system in the same sense as intended by the transmitting system). Surveillance systems should also be enjoined (or integrated – meaning streamlining data collection among systems to reduce redundancy of the data collected where it makes sense to do so). These activities will lead