Developing Nations Improving Health Communication Through the Use of DHIS2

This article is Part 1 in a series of articles about DHIS2 by Open Health News and is part of Open Health New's ongoing coverage of DHIS2. To read more about DHIS2, you can start here.

Julie M. SmythDHIS2 implementations are spreading steadily among national health services in developing countries as well as among international non-governmental organizations (NGOs) working to improving health in the developing world through the use of health information technology. As an open source solution, DHIS2 offers developing countries the advantage of adopting a cost-effective and flexible solution for aggregate statistical data collection, validation, analysis, management, and presentation as well as for data sharing between healthcare professionals and facilities. The use of DHIS2 has become so prevalent that organizations and individuals who work with humanitarian software solutions will need to know what DHIS2 is, how it works, and how it might be implemented by national health services and other health-related projects across the globe.

District Health Information Software 2 (DHIS2) is an open source health management data platform used by multiple international organizations, including the European Union (EU) and the World Health Organization (WHO), as well as by national governments worldwide. The platform is being used in 60 countries, including national-scale deployments in 54 countries and pilot programs in 33 countries. This completely web-based health IT platform boasts visualization features and the ability to create analysis from live data in seconds.

Countries deploying DHIS 2

  • Complete national implementation - Bangladesh, Burkina Faso, Ghana, India (Bihar, Orissa, Maharashtra, Kerala, Punjab, Haryana, H Pradesh), Kenya, Liberia, Mozambique, Nigeria, Rwanda, Sierra Leone, Tanzania, The Gambia, Uganda, Zambia, Zanzibar, and Zimbabwe
  • Adoption via programs or partial national roll-out - Algeria, Bhutan, Burundi, Colombia, DRC, Laos, Malawi, Solomon Islands, South Africa, Sri Lanka, Tajikistan, and Vietnam
  • Pilot stage or early phase in roll-out - Afghanistan, Benin, Congo Brazzaville, Cote d'Ivoire, Guinea Bissau, Mexico, Myanmar, Namibia, Nepal, Niger, North Korea, Samoa, Senegal, South Sudan, Sudan, Timor Leste, and Vanuatu

DHIS2 development has roots in post-apartheid South Africa. DHIS, the predecessor to web-based version DHIS2, sprang from a collaboration between South African public health activists and Scandinavian-based information system developers and eventually led to the development of DHIS2 in the mid-2000's. DHIS2 is currently supported by Norad, the Research Council of Norway, PEPFAR, and The Global Fund.

Health Information Systems Program (HISP). HISP coordinates DHIS2 development, which is an open process with developers in Norway, India, Vietnam, Tanzania, Ireland, and the United States. HISP, based at the University of Oslo (UiO) in Norway, is one of the leading organizations in the movement to design, implement, sustain, and strengthen health information systems in developing countries and focuses on supporting local management of health care deliver and information flows in these countries, particularly through promoting their DHIS2 software as a global public good.

As chairman and founder of eSHIFT Partner Network / HISP Geneva Steven Uggowitzer puts it, the team in Oslo's goal is to help small countries help themselves improve their health information systems. The sheer number of completed and piloted implementations, the growth of the DHIS2 community, and improved data sharing between health care professionals as reported by in-country DHIS2 experts suggest that small countries are accepting DHIS2 as a viable tool for health data management.

"The specification, design and implementation of information technology helps people really understand their data collection, organization dissemination, and management needs," Uggowitzer said. "Generally, [ministries of health in developing countries] see this as a chance to organize themselves and their data in more modern ways that actually optimizes information management and data aggregation, but also ensures data use in decision making."

The extent to which DHIS2 implementation can be credited to helping improve actual health outcomes is unclear. While the experts I talked to typically agreed that DHIS2 is improving the functionality and efficiency of national health IT systems, they were reluctant to credit DHIS2 with specific improvements in health. Those I interviewed were more likely to credit DHIS2 with improving communication between health professionals and building confidence in countries' health information systems, thus helping health ministries and professionals to fulfill their duties more efficiently.

"Ultimately the goal is for them [ministries of health] to be able to own, operate, and maintain [DHIS2] without the help of outsiders," Uggowitzer said. He added that "because the [DHIS2] community is so strong and the international community now sees it [DHIS2] as the reference platform, there is confidence to use this tool."

DHIS2 can be used to monitor patient health, improve disease surveillance and pinpoint outbreaks, and speed up health data access for health facilities and government organizations. The user interface of DHIS2 has been fully translated into eight languages: English, Chinese, Spanish, French, Russian, Portuguese, Vietnamese, and Tajik. DHIS2 also allows users to personally translate database content into any number of languages. Users can switch between languages and translate the user interface into new languages.

As a modular web-based software package, DHIS2 was built with the open source Java frameworks and operates under a liberal BSD open source license. Clients can get DHIS2 as software-as-a-service, which includes system backups with safe storage at a remote server, SSL (HTTPS/encryption) use for data security, and stable, high-speed Internet connectivity. The service provider for DHIS2 software-as-a-service in the cloud is BAO Systems. DHIS2 is easily interoperable with third-party clients, including Web portals, Android apps, and other information systems.

DHIS2 offers a number of mobile solutions, including SMS, plain HTML, and Java options for feature phones as well as a Web-based solution with offline support for smartphones. Clients can use their mobile phones for registering cases, events, and personal information, tracking individuals, conducting surveys, and collecting aggregate data.

DHIS2's mobile solutions make it easier to use effectively, particularly in a number of low- and middle- income regions where DHIS2 is currently being deployed. DHIS2 Mobile can be deployed using the web interface to support and integrated HIS system usable by all levels of a health service or as a standalone mobile reporting system. The DHIS2 provides a number of resources for learning about DHIS2 and how it works, including documentation, online demos, tutorials, user stories, infographics, and information about DHIS2 Academies.

DHIS2 Academies

The DHIS2 Academies are offered in several regions throughout the year for anyone who has a strong interest in DHIS2. Since 2011, more than 2,000 participants from 60 countries have been trained in the DHIS2 Academies.

Andrew Muhire, the Sector M&E , HMIS, and Report Lead Specialist for the Rwandan Ministry of Health, remembers being involved in the early DHIS2 Academies. In 2013 he was one of the facilitators training regional implementers of DHIS2. The early academies started with a small group of people; this later grew into a bigger pool of students who were eventually able to train others in turn. Muhire told Open Health News, "It was like training the trainers."

The goal of the DHIS2 Academies is to build regional communities of DHIS2 users and experts, enabling the DHIS2 communities to support each other and the maintain their systems on their own. So, Muhire said,"[DHIS2 Academy facilitators] take the expert team in that region and [then the trainees] become the facilitators."

Users and experts within these communities can share their experiences with DHIS2 deployments and their strategies for national implementations. The attendees of DHIS2 Academies participate in hands-on training, using standardized DHIS2 modules and learning to customize DHIS2, according to Muhire. He noted that in his experience facilitators divided students into groups and gave them assignments, giving the attendees practical experience in using DHIS2.

Two levels of DHIS2 Academies are now available. Level 1 academies include: the DHIS2 Information Use Academy, the DHIS2 Tracker Academy, and the DHIS2 Design & Customization Academy. Level 2 academies cover a range of specialized topics, covering more of the three core topics offered in the Level 1 academies as well as offering additional topics such as app development and disease surveillance. An online course in DHIS2 Fundamentals is also offered by the DHIS2 Online Academy. The DHIS2 community also an annual DHIS2 Conference and the annual DHIS2 Experts Academy, the most recent of which was held in mid-August at the University of Oslo in Norway. You can learn more about these events here.

More information on some DHIS2 deployments

Each of the countries implementing DHIS2 has unique needs, as reflected by some of the DHIS2-based projects adopted by various developing nations. Below are some examples of ways DHIS2 is being used to improve health systems in six African nations.

  • Burkina Faso used DHIS2 to improve malaria data accuracy. Using DHIS2, Burkina Faso integrated data from their existing health information management system (HMIS) and from a parallel system designed by the National Malaria Control Program to capture malaria data. The country's 2014 data quality assessment (DQA) reveal data inaccuracies among key indicators as well as issues with reliability, completeness, and timeliness in malaria data reporting. Burkina Faso's DQA 2017 showed that data accuracy had improved since their DHIS2 deployment, increasing data accuracy to 83 percent from the previous 43 percent. Data reliability increased from 67 percent to 87 percent, data completeness increased from 64 percent to 78 percent, and data timeliness increased from 62 percent to 80 percent. You can read more about Burkina Faso's efforts here.
  • Ghana has used DHIS2 nation-wide since April 2012 after delivering a national rollout of DHIS2 in just six months. Ghana Health Service has led this fully online deployment of DHIS2 and won The African Development Bank eHealth competition in 2013 for this implementation of the software. Hospitals in Ghana use the routine aggregate data collected monthly as well as the DHIS2 Tracker module with ICD-10 coded diagnosis to capture case-based data from inpatient admissions and deaths. This use of DHIS2 enables Ghana to collect more accurate morbidity and mortality statistics.
  • Kenya (hiskenya.org) was the first country in Sub-Saharan Africa to deploy a totally online health information system powered by DHIS2, which was completed in September 2011. All the Kenyan districts and selected health facilities involved are connected to DHIS2 national server using Mobile Internet on computers. DHIS2 improves the Kenyan national health system's data analysis capabilities through an extensive facility survey that can now be conducted using the World Health Organization's SARA tool, which was customized through the DHIS2 Tracker. Kenya's online HIS self-registration for personal user accounts and the deployment of DHIS2 has increased the use of collaborative tools and encouraged more feedback from users.
  • Tanzania (dhis.moh.go.tz) completed its nationwide rollout of DHIS2 in 2013. Use of DHIS2 has improved Tanzania's disease surveillance and response through its epidemiology unit's implementation of weekly Electronic System for Disease Surveillance (eIDSR) reporting that uses Mobile USSD to DHIS2. This implementation allows immediate outbreak and weekly summary data to be collected directly from all public, private, and faith-based organization (FBO) health facilities within the country. Another use of DHIS2, the Pay for Performance payout model into the DHIS2 National data warehouse, allows health service providers to fully monitor their performance and payments.
  • Uganda (hmis1.health.go.ug) took advantage of the rapidly improving mobile internet coverage in East Africa to deploy an online DHIS2 implementation in August 2012. Uganda is using the new patient tracking capabilities in DHIS2 to pilot an implementation called the Saving Mothers and Giving Life (SMGL). SMGL tracks mothers and children to improve continuum of care. In the four pilot districts in Western Uganda, SMGL is collecting key indicators on maternal health using mobile phones. Uganda is also exploring different client platforms (such as smart phones, laptops, SMS messaging, and feature phones) for better reaching out to local health works and pregnant mothers. Through SMGL, Village Health Teams (VHTs) submit data directly to the online national DHIS2 system using SMS messaging, making data immediately available for analysis by all online users of all levers throughout Uganda.
  • Zambia (hmis.dhis.co.zm) is currently using DHIS2 for data collection and Malaria eradication. The Zambia national HMIS platform's migration to DHIS2 supports data collection from health facilities across the country. DHIS2 has also been used successfully as a mobile reporting tool by Zambia's Malaria Control Program. This deployment allows community health workers (CHWs) enrolled in the malaria program to use mobile reporting to help track cases of malaria and the health interventions used to treat them.

DHIS2's comparatively low cost of implementation and rapidly-growing network of developers make it a practical option for many developing nations that hope to improve the efficiency and effectiveness of their health systems using health IT. With its notable functionality and ability to work side-by-side with other powerful health IT tools, DHIS2 is rapidly transforming health IT in developing areas of the world.