8.3 Moving from multiple tools to a unified system

8.3.1 Before DHIS2

Tanzania Mainland’s first HIS began in the 90s as a paper-based system used at health facilities and district offices. Information was collected and processed with a Microsoft Access database. Without the intervention of external consultants hired by funding agencies, there weren’t any strategies to sustain the system with upgrades or refresher training.

With a surge in demand for a HIS, the MoHSW was being put under strain. Lack of coordination led to fragmented vertical projects running side by side. This caused an unsustainable situation in which efforts were being duplicated as results weren’t being converged.

Around 2007, a plan called the Monitoring and Evaluation Strengthening Initiative was made by the MoSWH, UDSM, UiO and other partners. Its goal was to build a new, integrated HIS to provide reliable data for the ministry and other stakeholders. A new paper-based system combined with DHIS2 was introduced. http://www.dhis2.org

8.3.2 Introducing an integrated HIS in Tanzania

In 2010, the adaptation and implementation of a totally revised HIS began. This process was enabled by a flexible, standard solution and participatory approaches operating across all levels of the national health system. It was important to find a solution that would meet the demands of health managers, implementers, designers and decision-makers.

8.3.3 A gradual, national HIS rollout

In 2011, the coastal region of Pwani was used as a testbed for paper-based data collection tools and DHIS2. Over the next two years, revised systems were rolled out to the remaining 24 regions and associated districts and health facilities of Tanzania Mainland. On completion of this rollout, efforts were directed towards the integration of all major vertical programs such as malaria, TB/leprosy, RCH, HIV/AIDS into DHIS2. Along with the implementation process, training programs were held for implementing partners, district and regional hospital staff, and the MoHSW staff.

Tanzania Mainland DHIS2 rollout phases for 2014

8.3.4 Building a robust HIS

Here are some of the key areas we dedicated time and resources to:

8.3.4.1 Open-source philosophy

The choice to apply open-source tools rather than going through a closed, commercial product ensured that the software remained collaborative with a more diverse and flexible scope of design. Furthermore, the involvement of the many health sector stakeholders and an open source community of developers implied that the system would be geared towards long-term sustainability rather than a short-term lifecycle, dependent on a company’s paid maintenance services.

8.3.4.2 Incremental, flexible, and scalable design

DHIS2 was implemented in an incremental way, rather than in one go. Like that, issues could be tackled directly during the rollout process, and implemented in direct response to user feedback. The most glaring flaws were thus easily spotted and a more stable and efficient system was built.

8.3.4.3 Standards for data collection

We used a set of common data collection standards that covered data collection, reporting, analysis, and quality procedures and tools. All informal tools were removed and the recording of duplicate entries of data declined.

8.3.4.4 Participatory design

A community of users such as managers from the HIS, supporting partners and implementers exchanged emails, spoke on forums, and at workshops about how to make the software more user-friendly. This helped implementers fine-tuned their programs and ensure that DHIS2 was being used optimally.

8.3.4.5 Action-led research

Students enrolled on PhD and MSc degree programs at UiO and UDSM conducted “action-led research” that enabled them to participate in the roll-out of DHIS2 while doing research. By doing so, they learned and documented best practices about system customization, user support, training, and data analysis.

8.3.4.6 Local capacity building

People learned to troubleshoot DHIS2 software, and users were encouraged to assist each other across many different organization levels and roles. By instilling a sense of ownership and self-sufficiency, the gap between implementers and users was thus reduced. Training focused on software usage, data analysis and basic and advanced features of DHIS2 for health and data managers.

8.3.4.7 Using information guidelines and standards

To drive decision-making and to reach national health goals, annual planned targets, and Millennium Development Goals (MDGs), teams created processes on how to generate and use data efficiently.

8.3.4.8 Interoperability of DHIS2 with other systems

Since 2014, DHIS2 has been integrated with other software systems, enabling health workers to cross-cut, analyze and share data across organizations. Here are some examples of systems integrated or made interoperable with DHIS2:

8.3.4.8.1 eIDSR (electronic Integrated Disease Surveillance and Response)

eIDSR was developed from scratch using USSD technology and linked with DHIS2 for the immediate reporting of data on infectious diseases. The tool is designed to improve detection and response time to diseases and is used within all health facilities in Tanzania.

8.3.4.8.2 HRHIS (Human Resources for Health Information Systems)

HRHIS was developed to report health data information from within all Tanzanian health facilities. It has helped to assess HR problems, manage the distribution of HR, and plan and evaluate HR interventions.

8.3.4.8.3 MFL (Master Facility List)

MFL is a health facility register to keep records about health facility profiles.

8.3.4.8.4 eLMIS (Logistics Management Information Systems)

eLMIS is a supply chain system for distributing and stocking of drugs and other commodities.

8.3.4.9 Data use and awareness solutions

Solutions to raise awareness about best practices for data use, data analysis and data dissemination have been embedded within DHIS2. These solutions are:

8.3.4.9.1 Scorecards

Scorecards are used to communicate the status of progress toward key global, regional and national commitments for specific indicators. The representation of visual indicators has the role of stimulating actors to respond to situations rapidly through effective policies and investments.

8.3.4.9.2 HMIS web portal

The HMIS web portal is hosted by the MoHSW and used by health stakeholders. It’s also accessible to the general public. https://hmisportal.moh.go.tz/

8.3.4.9.3 P4P (Pay for Performance)/ RBF (Result Based Finance)

Rewards the delivery of one or more outputs or outcomes by one or more incentives that can be financial or otherwise. The P4P/RBFprogram is integrated within DHIS 2 to enable health service providers to monitor their performance and payments.

8.3.4.9.4 DHP/RHP (District and Region Health Profile)

Provides planning and progress guidance to the district health management team. For example, it offers a summary of district health conditions through priority health indicators that reflect the district health status of the population, status of the health systems and the status of the health services delivery.