DHIS2 - Transforming Health IT Standards in the Developing World (Part 2)

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

Julie M. Smyth A Rwandan district hospital data manager made the 6-8 hour drive to Kigali with a USB drive loaded with export files for the Rwandan Ministry of Health's main server. When Andrew Muhire, then tasked with receiving all export files, checked the flash drive, he found nothing on it. The data manager then returned to his own district to reload the files and drove again to Kigali, unsure if the flash drive would work or if it had perhaps been infected with a virus that might cause it to fail again. That was before the District Health Information Software 2 (DHIS2) rollout in Rwanda.

"[Before DHIS2] we had a system that was really not working," said Muhire, who is now the Sector M&E , HMIS, and Report Lead Specialist for the Rwandan Ministry of Health. "It was hard to share information between health facilities... The Ministry was very eager to change."

Rwanda's 2012 implementation of DHIS2 is one of at least 16 completed national rollouts of this free and open source health data management. A total of 54 countries are deploying DHIS2 on a national scale, 30 of which are in the pilot stage or early phase in their rollouts. Since DHIS2's release in 2006, NGOs and national governments in 60 countries have deployed DHIS2 for health-related projects, including patient health monitoring, improving disease surveillance and pinpointing outbreaks, and speeding up health data access.

DHIS2 is an open source software developed by the Health Information Systems Program (HISP) and supported by the University of Oslo's Department of Informatics. Although HISP initially focused on grassroots health committees and Community Information Systems in South African health districts, DHIS was quickly adopted for national implementation by South Africa and other African countries as was the web-based version, DHIS2, after its development in 2005-2006.

While not all implementing countries have deployed DHIS2 at the district level yet, Muhire said that Rwanda has successfully put DHIS2 into service in district hospitals and health facilities, which are now able to report health data directly through DHIS2 using the Internet rather than being forced to aggregate data at the district level and then submitting it to a central server. Rwanda's Ministry of Health now tracks both aggregate and individual data through DHIS2 and is using the system to improve health data analysis.

Muhire said that Rwanda's DHIS2 rollout's success is due in part to the groundwork laid by the Rwandan government in the years before adopting the platform. Between 2008 and 2010, Rwanda invested in building the infrastructure that contributed to an easy DHIS2 implementation. Some of those investments including improving the country's Internet and building human resources, which included placing data managers in each health facility. He added that while Rwanda's previous health information systems made it difficult to share, track, and backup data, DHIS2 has provided Rwanda with workable solutions for each of these problems.

"[DHIS2 has] really simplified our life," Muhire told Open Health News. "The way it is built, it is a really good system that I can recommend."

Andrew Muhire Health Systems Then and Now

In the 1990s, before the widespread deployment of DHIS and DHIS2, consultants paid by international organizations traveled to developing countries like Uganda and developed their own small-scale hospital systems for district governments. Uwe Wahser, a German student then working on his master's degree in Medical Informatics, was one of them.

When Wahser traveled to a health district in Uganda to set up a computer-based data system for hospitals during the 1990s, Uganda did not have a national IT solution for data management and DHIS was still limited to the South African health system.

Uganda's early reliance on paper records allowed the same patient to have numerous records in different health facilities. For example, a patient might have an outpatient record for the flu in one location and a separate maternal health record for pregnancy. These records would then need to be compiled into one district report, a process that could take up to two or three days, according to Wahser.

"It was very time-consuming for the doctors and nurses," Wahser said."[Ugandan health officials] started looking at how they could use computers to get better data."

With help from international consultants, health districts in Uganda and other developing countries implemented localized data solutions, but because the systems were each developed separately they typically weren't interoperable, Wahser said. At that time, if the consulting developers discontinued support for their systems, health districts would be left to manage virtually on their own.

"This has changed drastically now," Wahser told Open Health News. "DHIS2 has a very stable developer community. [If you have a problem], you are going to get help from someone. It's a very vivid community."

Roughly a decade after Wahser finished his assignment in Uganda, DHIS2's release provided health ministries in developing countries with a single, user-friendly platform for aggregate statistical data collection, validation, analysis, management, and presentation. While the basic source of information is still typically kept on paper somewhere in the health facilities, Wahser said that information is now entered into DHIS2, which serves as a data warehouse and makes health data available across the country's health systems.

"DHIS2 is now a standard for routine health data in developing countries," Wahser said, adding that many health ministries in developing countries are basically relying on DHIS2 now for their data needs.

Wahser recently returned to the health IT sector after 15 years working for the commercial banking industry and now works on projects for Kenya's National Health Insurance Fund (NHIF) as the Team leader for IT-supported Quality and Process Management for German development agency GIZ's Health Sector Programme. Before NHIF implemented DHIS2, Wahser was working without any kind of budget and with only a two-man team. He told Open Health News that DHIS2's affordability as free and open source software made implementing a usable system on a nonexistent budget possible. Its user-friendliness also made it a good option for his colleagues as NHIF since it allows them to analyze data themselves and does not require a highly-specialized skill set to use. Now NHIF receives free quarterly software updates from Oslo and is getting more consistent and more real-time data through DHIS2.

Uwe WahserWahser said that DHIS2 while has some limits as a more general data warehouse, providing about 60% of the functionality he would expect from a commercial data warehouse, DHIS2 provided all the things that Kenya's national health insurance needed in one package. While NHIF may eventually move to a more sophisticated commercial data warehousing system, Wahser said that "for now we are able to go quite a way with this simple and free system."

Affecting Health Outcomes

Muhire doesn't have to worry about faulty USB drives anymore, at least not for transferring health records between districts. Nor does he have to worry about district hospital data managers traveling to centralized servers to retrieve data if their computers crash; data backups through DHIS2 make it possible to retrieve the information online instead. Now their attention can be focused on other technologies that can help improve their systems and on continuing to improve health outcomes in Rwanda.

Muhire, like many of the experts I talked to, was hesitant to directly credit DHIS2 with improved health outcomes. He did note that Rwandan has been able to reduce maternal and child deaths, saying that a number of factors contributed to the reduction. According to Rwandan Demographic Health Surveys from 2005 and 2014-2015, the mortality rate for children under five years old dropped from 152 deaths per 1,000 live births in 2005 to 50 deaths per 1,000 live births. The maternal mortality ratio (MMR) has also been successfully reduced. The factors Muhire mentioned include greater accessibility to health facilities, community health workers (CHWs), and required death audits in health facilities.

CHWs play a significant role in the Rwandan health system, escorting women to their health appointments and treating childhood diseases such as diarrhea. CHWs use mobile phones to record real-time data using key indicators for maternal, neonatal, and child health collected during the first 1,000 days of life, starting during pregnancy and continuing until the child is two years old. The indicators are recorded using RapidSMS and generate automatic reminders for appointments, delivery, and post-natal care visits. According to Muhire, the components of RapidSMS used in Rwanda allow CHWs to alert doctors and nurses to an emergency and prompt the timely ambulatory response.

In addition to their network of CHWs, Rwanda utilizes required death audits in health facilities. If a child dies, for example, a death audit must be filled out giving the details related to the cause of death and delivery of care leading up to the child's death. This data is automated into DHIS2 Tracker, which allows health professionals can use to analyze the information and identify factors that may have affected the outcome of the case. If problems in care or delayed patient transport are discovered, the data can be used to inform future decisions, adjust policies, and organize additional training for health professionals.

General health data from DHIS2 can help health officials determine what areas or among what populations mosquito net distribution, mosquito spraying, or malaria treatments are most needed. If data shows that the Ministry of Health has been targeting the wrong districts or populations, the Ministry's strategies can be adjusted to reallocate resources to where they are most needed.

"It helps us see the districts we need to focus on," Muhire said. "It helps us to have focused planning."

According to Muhire, DHIS2 provides the Rwandan health system with a robust surveillance system, improved communication between health facilities and professionals, better data backup in case of hardware failures and natural disasters, and improvements to data collection and analysis. But ultimately the improvements to health outcomes are the result of informed changes in the practices of the health professionals, the CHWs, and the Rwandan Ministry of Health.

Advice for Implementers

Normally a system is not "plug and play," Muhire said. "The country needs to prepare itself."

Muhire would know. After Rwanda's DHIS2 rollout, Muhire supported both Sudan and Zambia in their DHIS2 implementations. He also supported Malawi's DHIS2 implementation through his involvement in the DHIS2 Academies. He said that Rwanda's infrastructure investments prior to rolling out DHIS2 made their implementation process much easier. It is also important to prepare the personnel who will be using DHIS2 in order to ensure timely and accurate data reporting.

"If you don't have standard operating procedures [in place], you find that someone in the health facility [who should be reporting data] doesn't know he's supposed to be reporting," Muhire told Open Health News.

Muhire also advised that implementing nations put procedures in place for check data quality and accuracy. Users don't always input valuable information, so the data needs to be linked to carefully-chosen indicators in DHIS2.

"The quality of data depends on how you use the data," Muhire said. "Make sure the information you collect is information you can use; [that] it is not redundant."

Andrew Muhire: Using data to improve health care