Norway has supported the development of the District Health Information Software 2 (DHIS2) to innovate health data management. Thanks to open-source technology, tailoring to partner countries and sustained engagement by development partners, DHIS2 is used in 73 countries. A participatory approach, capacity-building and a timely shift to online and mobile applications were critical for success.
Scaling technology-driven innovation successfully
Abstract
Challenge
Innovations can make a significant difference in the response to development challenges. Many Development Assistance Committee (DAC) members therefore support innovation efforts and leverage innovation capacities that exist in their own countries. However, when innovations are designed in and for high-income countries, transferring them to low- or middle-income countries often leads to suboptimal outcomes, as they often depend on well-developed infrastructure and are designed for users with different behavioural patterns. The traditional North-South technology transfer approach to innovation undervalues local innovation capacities and the potential of grassroots and frugal innovators, with the risk of distorting local innovation ecosystems.
Approach
Since the beginning of the Health Information Systems Programme (HISP) in 1994, in post-apartheid South Africa, Norway’s development co-operation agency Norad has funded a project of the Norwegian University of Oslo and the South African University of the Western Cape to develop the District Health Information Software 2 (DHIS2) to manage health data in developing countries. To increase the likelihood of bringing DHIS to scale, Norway and the project team ensured the following:
High degree of country ownership: An adaptable approach that can complement health ministries’ existing systems in resource constrained contexts. Data ownership rests with each user institution.
Open source: This avoids constraints around licensing and fees, while facilitating learning and improvement with potential contributors from across the globe. An open and well-documented architecture also helps to facilitate interoperability with other national information systems.
Capacity-building: Over 135 DHIS2 “academies” have provided training and support to platform users, building local capacity in each country of deployment, while regional network groups, co-ordinated by the University of Oslo, provide training and implementation support.
Sustained engagement: Norway has supported the DHIS2 for over two decades, contributing to its expansion and continuous improvement through multi-year projects which are renewed upon achievement of predefined objectives. Norway has also advocated for other partners to support the project in order to improve its financial stability, reduce donor-driven development, drive strategic direction, and reduce risk.
Results
The success of the initiative has allowed it to expand and sustain growth over time, attracting substantial funding from large development co-operation partners in the health sector. DHIS2 has become the world’s largest health-information management system, used by 73 low- and middle-income countries in 2021.
Thanks to DHIS2, governments can better plan and co-ordinate their health sector interventions. For example, Sri Lanka used DHIS2 to quickly launch a national COVID-19 tracking system, Malawi uses DHIS2 to monitor stock-out rates and consumption for health supplies, and Afghanistan makes performance-based payments to healthcare providers using DHIS2 dashboards. Accountability actors can also better assess progress, and development co-operation partners can similarly plan and track the effects of their support.
The open and simple architecture as well as the widespread use of DHIS2 software has enabled cross-sector applications, such as in water and sanitation, agriculture, education and other sectors. This is supported by a robust DHIS2 user, implementer and developer community, the growth of which has been facilitated by DHIS2 “academies” and other capacity-building activities.
Lessons learnt
Researchers that participated in DHIS2 have identified a number of success factors:
Design flexibility and modularity enabled customisation to fit various use-case requirements.
The development of DHIS2 was driven by feedback from users and follow-up research. This open and participatory approach contributed to relevance, appropriateness, and innovation.
Learning through hands-on participation has helped build local capacity and contributed to project acceptance at the early stages. Continued DHIS2 training supports long-term success.
Building a network of regional experts, who provide countries with DHIS2 support, has been instrumental in helping countries scale, maintain and adapt their DHIS2 systems to new needs and crises (such as COVID-19).
Flexibility in terms of funding needs meant that the project could advance incrementally.
The project has gradually shifted to online and mobile applications, allowing it to stay relevant.
A platform approach allowed the project team to draw on knowledge and expertise from institutions beyond the project partners, including the World Health Organization (WHO), the private sector and civil society organisations.
A broad user base can lead to standardisation. Wide scale adoption of the technology has influenced others to adopt it, and for WHO to develop normative standards for measurement within the platform.
Further information
University of Oslo, DHIS2 website: https://dhis2.org.
Health Information Systems Programme (HISP) website: http://hisp.uio.no.
Exemplars in Global Health: Scaling DHIS2 in Sri Lanka: Early action to track and prevent COVID-19: https://www.exemplars.health/emerging-topics/epidemic-preparedness-and-response/digital-health-tools/sri-lanka.
Integrating HMIS and eLMIS systems for better decision making in Malawi: https://dhis2.org/malawi-logistics-integration.
DHIS2 as a Data Warehouse in Afghanistan: https://dhis2.org/dhis-data-warehouse-afghanistan.
Ghana: Worldwide Collaboration on Health Information Systems, https://www.youtube.com/watch?v=gFnnNWC55Iw.
The Dynamics of a Global Health Information Systems Research and Implementation Project, https://ep.liu.se/ecp/161/013/ecp19161013.pdf.
PATH, An Interim Review of the Health Information Systems Programme—University of Oslo— with Recommendations for Future Action: https://www.mn.uio.no/ifi/english/research/networks/hisp/hisp-assessment-report.pdf.
Digital Public Goods Alliance, DHIS2 – A Digital Public Goods Case Study: https://digitalpublicgoods.net/blog/launching-dhis2-pathfinding-pilots.
The District Health Information System (DHIS2), A literature review and meta-synthesis of its strengths and operational challenges based on the experiences of 11 countries, Dehnavieh et al (2019): https://www.researchgate.net/publication/325762722_The_District_Health_Information_System_DHIS2_A_literature_review_and_meta-synthesis_of_its_strengths_and_operational_challenges_based_on_the_experiences_of_11_countries.
Factors Influencing District Health Information Software Version 2 Success–A Case of the Greater Bushenyi Districts, Uganda. Muhaise, H., & Ejiri, A. H. (2016): https://asrjetsjournal.org/index.php/American_Scientific_Journal/article/view/1815.
OECD resources
OECD (2019), OECD Development Co-operation Peer Reviews: Norway 2019, OECD Development Co-operation Peer Reviews, OECD Publishing, Paris, https://doi.org/10.1787/75084277-en.
To learn more about Norway’s development co-operation see:
OECD (2021), "Norway", in Development Co-operation Profiles, OECD Publishing, Paris, https://doi.org/10.1787/aaf0304f-en.
