When a Zambian-based consultant introduced the Akros country director to DHIS2, things took a swing in a different direction. DHIS2, or “District Health Information Software”, is a flexible, open source software platform used in more than 40 countries. With the help of dashboards, charts, pivot tables and maps, DHIS2 makes data aggregation and data visualization very easy to create, understand and share.
Scaling up DHIS2-WASH from 2013 to 2016
In 2013, Akros implemented its first DHIS2 pilot for the WASH project. Thereafter, the electronic WASH surveillance system was scaled to additional districts with a vision of eliminating OD countrywide. Currently the CLTS project has been implemented in 70 districts using the DHIS2 platform.
Stage 1: Champions at the grass roots level
Local stakeholders have played a key role in community level sensitization campaigns that highlight the dangers of OD. With guidance from the Government of Zambia and other partners supporting CLTS, at the village level, volunteers form Sanitation Action Groups (SAGs). These volunteers are equipped with CLTS data collection sheets and collect data on household sanitation, trachoma monitoring, and available access to clean water. Typical survey questions cover areas such as the existence of a latrine in a household and if that latrine is equipped with a lid; access to hand washing and water, soap, or ash; access to bathing shelters; the availability and cleanliness of drinking water, and so forth. SAGs work closely with selected individuals called Community Champions (CCs), who collect data from the SAGs and aggregate and submit the data through their mobile phones to DHIS2.
Stage 2: Reporting
The collected paper-based data is checked by the Community Champions. The data is then submitted via a hand-held device, usually a low-end feature phone that runs a DHIS-J2ME platform, to the next level in the process; the Environmental Health Technicians (EHTs). Thanks to Java technology, the cost of sending data via the DHIS-J2ME platform works out to be ten times cheaper than using standard text messages.
Stage 3: Troubleshooting and verifying data
Once a Community Champion submits aggregated data through their mobile phones, this data is made available to all key stakeholders who receive automated HTML performance reports on a given village. The data is then reported to the next level, the village chief, via an Android DHIS2 app.
Stage 4: Data through the Chief’s eyes
With the help of a Data Viewing Widget on a tablet, referred to as the “Chief App”, the village chief is able to look at the data that his advisors have gathered and make decisions based on what he sees. The chief holds his headmen accountable for any irregularities that could reduce his influence or impinge his reputation. The chief may at times carry out sanctions against underperforming headsmen, or on the contrary, give incentives, typically in the form of mobile phone credit, to high performers.
Stage 5: District monitoring
At the district-level the CLTS Focal Point Person (FPP), logs on to DHIS2 on a monthly basis to monitor ward and village propagation of improved latrines and progression towards ODF status. This person also shares relevant information with the District Commissioner and Town Planner.
Stage 6: Quarterly ward meetings and ODF status
Each ward has a quarterly CLTS meeting to allow representatives from all the villages in the ward to discuss challenges and share successes towards latrine propagation and progress towards achieving ODF status. The event serves to engage the SAGs to continue community sensitization towards achieving ODF status.
On a monthly basis, CCs and EHTs track ODF status of villages in their wards through their mobile phones, and district officials track ODF status of villages through their DHIS2 dashboard. The CC, EHT or district official can select a particular village from a drop-down list, and can see a bar from 0% to 100% indicating the status of that village in working towards 100% ODF.
Once a village achieves ODF and is verified, the District CLTS FPP logs on to DHIS2 and selects “ODF Verified” next to the village’s name, which changes the color of the village name to green.
Working in a tribal context
Zambia is a hierarchical society with strict codes about status. There are roughly 150 chiefdoms. The traditional village chiefs are in charge of all the decisions in the village and very little can be achieved without their approval. They are the custodians of the villagers; ensuring their health and social-economic well-being. Communicating about DHIS2 and obtaining meaningful results required bringing onboard the chiefs within each village. Introducing technology through the means of a tablet was, in some cases, a huge yet surmountable change for certain chiefs.
Maintaining an active interest
As the WASH project got underway, a spirit of competition started to emerge amongst village chiefs. Vying for the best results, the chiefs soon became actively involved in overseeing the implementation and follow up of WASH-related activities within their communities. Thanks to automated DHIS2 data feedback loops such as SMS messages, customized dashboards, PDF reports and the Chief’s data visualization widget that could be interpreted extremely easily, even illiterate participants could access the trends and progress of their community’s efforts.
Choice of phone technology
One of the first challenges that came up was to get participants up to speed using mobile phone technology. Initially, participants were given Galaxy smartphones to work with, but this soon proved to be a bad choice. The design of the menus and complexity of certain applications was completely baffling to some. Even typing with a touchscreen was challenging for certain participants, who had never used a touchscreen phone. Also, due to the sensitivity of the touchscreens, participants would inadvertently change the phone settings, such as the keyboard layout to a different language, and not know how to revert the situation. Applications running in the background would also consume too much of the phone’s resources. In sum, due to their limited battery-life, fragile screens, interface complexity and highly coveted appearance, smartphones had to be replaced. Low-tech yet robust feature phones that could run DHIS2 Java-based applications were introduced. Reporting soon rocketed as a result of this turnaround and the progress of the WASH program instantly improved.