Scaling DHIS2 in Sri Lanka: Early Action to Track and Prevent COVID-19

In this case study, we describe the implementation story of DHIS2 in Sri Lanka and its adaptation during COVID-19. At end, there is an assessment of performance against the MAPS framework.

When the COVID-19 outbreak began to spread throughout Asia at the beginning of 2020, Sri Lanka’s health authorities moved quickly to keep it from spreading to their country. The Ministry of Health already used DHIS2 as its primary health information system to track and manage health data; within just a few days, partners from HISP Sri Lanka—a global network including independent HISP groups, universities, ministries of health, nongovernmental organizations, and global policy makers—developed and implemented new DHIS2 modules specifically for COVID-19 surveillance.

The first module developed enabled Sri Lanka to monitor its borders by screening travelers for COVID-19 at ports of entry, then maintaining active disease surveillance for the entire 14-day incubation period.¹ Within 5 days, the module had been deployed at the Colombo International Airport because it was the only port of entry in the early days of the COVID-19 pandemic, with the initial user training completed in 2 days. In part because of this effective port-of-entry tracking, Sri Lanka reported no cases of COVID-19 between May 2020 and October 2020.

This innovation also triggered work on the development of a global DHIS2 COVID-19 surveillance package. As of September 2020, more than 50 countries had implemented, or were in the process of implementing, one or more digital tools to detect and contain the novel coronavirus.¹ In addition to developing the foundation for the global package, the HISP Sri Lanka team directly supported Timor-Leste, Solomon Islands, and Vanuatu in configuring their DHIS2 for immunization registry for COVID-19. Additionally, the team is supporting Guinea in using the contact mapping application for the latest Ebola outbreak.

DHIS2 in Sri Lanka Before COVID-19

More than a decade of investment in digital health infrastructure in Sri Lanka made it possible for policy makers to quickly assess their needs in response to the emergence of COVID-19 in 2020, and to identify the digital tools that could meet them, define their requirements, and mobilize support for their execution.

In 2011, some departments in the country’s Ministry of Health implemented DHIS2 pilot programs to serve as the primary health information system for the country. DHIS2 is a web-based software platform for data collection, management, and analysis. Today, DHIS2 is the world’s largest health management information system platform, in use by ministries of health in 73 lower- and middle-income countries. Within Sri Lanka, DHIS2 is being used as the national information system by many preventive health care institutes in the Ministry of Health. These are national-level implementations. Therefore, the country has developed capacity at the district and field level to use DHIS2 to capture both aggregate and case-based data.

DHIS2 already had a few custom instances operating at scale in Sri Lanka, including the Electronic Reproductive Health Management Information System (eRHMIS). The eRHMIS is a DHIS2-based health information management system that was developed and implemented to manage data from reproductive, maternal, newborn, child, adolescent, and youth health programs in Sri Lanka since 2017. According to HISP Sri Lanka, “eRHMIS captures nearly 1,860 data elements in 25 data sets from 38,194 organization units. Around 100,000 data values are currently being recorded per day and nearly 3,000 users are registered in the system. Nearly 600 maternal and child health indicators are generated in the system.” ²

While Sri Lanka developed DHIS2 infrastructure, the country also focused on strengthening health information expertise; health authorities invested in a community of developers they could quickly mobilize to help meet emerging digital health challenges. In 2009, with support from Norway, the Sri Lankan government developed a master’s in health informatics program to train local health care workers to operate DHIS2 systems. More than 200 doctors have completed the program and returned to work at the Ministry of Health at the national and district levels.

As the COVID-19 pandemic was beginning in early 2020, DHIS2 already had a strong foothold in Sri Lanka—including an HISP team based in Colombo that provides support and resources for the design and customization, development, implementation, and training of the DHIS2 platform, with the support of the University of Oslo and the global HISP network that managed the existing DHIS2 infrastructure and new developments. The Ministry of Health, Information and Communication Technology Agency (ICTA) and HISP collaborated closely and frequently exchanged information to enable rapid decision making.

Adapting to a New Challenge

As COVID-19 began to spread through Asia—and particularly through countries such as China, whose residents regularly travel to Sri Lanka—health authorities sought to keep it out of the country by screening and tracking visitors from their ports of entry.1 To do this, they sought to adapt the standard DHIS2 tracker model to register data for individual travelers from areas with high rates of COVID-19 as they entered the country and enable health care workers to follow-up with them twice over the course of their mandatory 2-week quarantine.

The standard DHIS2 tracker data model already enables case-based surveillance and contact tracing; however, Sri Lanka’s Ministry of Health also wanted to build visualizations—for public health interventions as well as epidemiological investigations—that could demonstrate the possible spread of disease across a cohort of cases and their contacts. Specifically, the team shared system dashboards with key decision makers including the director general of health services and the National COVID Centre. For example, the additional secretary of public health services checks the dashboards daily and advises district-level staff on progress of vaccination. The National COVID Centre coordinating all COVID-19 activities also has dashboards to track progress. Finally, the dashboards available at vaccination centers and individual health care facilities are used by facility managers for preparing presentations and reports, which otherwise would be a tedious process.

Table: Module components developed as part of the COVID-19 response in Sri Lanka

The new apps (e.g., contacts visualization app, COVID-19 Vaccine Certificate and Citizen portal, etc.) were created to address limitations in standard DHIS2 dissemination. For example, the contact mapping visualization builds a mesh-like map of disease transmission, which is of great value to contact tracers and the national epidemiology team to assess the disease transmission and specific events. Such visualizations were not available in standard distribution. This expands the use of the platform beyond the standard application in reporting scenarios.

Sri Lanka did not have any firsthand experience with pandemic response, but the HISP team had read about how DHIS2 had been used in previous pandemics in Africa; for example, Liberia used a custom module developed for tracking Ebola patients and contacts. Inputs for relationship mapping were obtained from epidemiologists in Sri Lanka based on contact tracing on previous outbreaks. Developers are currently redesigning the contact mapping visualization app for generic use based on inputs of the current Ebola outbreak in Guinea.

At an initial meeting between the Ministry of Health and HISP in late January 2020, officials developed a list of additional requirements for a custom DHIS2 web app for active COVID-19 surveillance. The new module needed to have the capacity to:

• Share COVID-19 data between stakeholders (Ministry of Health and others.
• Operate within a few days of development, without a long procurement procedure.
• Start with a few facilities but rapidly scale up.
• Provide a flexible platform on which other tools could be built, to enable the module to evolve the scope of its requirements over time.
• Ensure data security using fine access controls due to the large number of potential users.
• Operate without a large amount of funding or time for user training.
• Capture mobile data when necessary.
• Integrate with other information systems in and out of the Ministry of Health (e.g., the immigration information system or the third party Supariksha app, which collects community polymerase chain reaction information and laboratory data).

Within days, the new DHIS2 system was operational at the country’s airports with training and support from HISP Sri Lanka. As individual travelers from areas with high rates of COVID-19 entered Sri Lanka, immigration officials collected data on “tracked entity attributes”—names, dates of birth, gender, email addresses, passport numbers, telephone numbers, and a few other sociodemographic factors—as well as any symptoms of COVID-19, contacts in Sri Lanka, and the length of stay in the country. In the second compulsory program stage, health care workers followed up with each traveler during their 14-day quarantine to check for symptoms of COVID-19 and capture data on any action taken during the surveillance process. Finally, health care workers followed up for a third time at the end of the quarantine, marking the conclusion of the surveillance process. All this tracker data could be aggregated for national-level reporting and dashboards, while still protecting the privacy and security of individuals whose data are stored in the system.

The government closed the border in March 2020, and community monitoring became the core focus. The country did not have any reported cases from May through October, so the focus was on people entering the country, including returning citizens. Since the country has implemented mandatory quarantine up to this date, however, the full potential of the port of entry monitoring has not been used since the initial 2 months of the pandemic.

The Path to Scale and Sustainability

Typically, new digital tools of this kind incorporate a 2- to 3-month pilot period for user feedback, testing impact, and bug fixes and improvements. In this case, however, developers did not have time to test the Port of Entry module before rolling it out. Instead, the team received feedback on its prototypes from champions in a few different regions who had an implementation background and familiarity with DHIS2. The team released an initial version of the solution to pilot in a few hospitals and then quickly scaled to a rollout at the national, province, district, and medical health officer levels, with separate access controls and dashboards for each level.

HISP Sri Lanka also provided capacity-building support via a simple, clear set of standard operating procedures, user guides, and trainings for operators of the Port of Entry module across the country.

The initial trainings took place on-site and in-person in the last week of January and first few weeks of February 2020. As the year went on, HISP Sri Lanka moved all trainings online to comply with social distancing guidelines. HISP also simplified the usual training manual, developing one-page training guides on logging in and entering data at the follow-up surveillance checks, and used remote-disrupt solutions to support troubleshooting. Today, even routine maternal, newborn, and child health module trainings are delivered via videoconferencing platforms.

In March 2020, Sri Lanka’s ICTA coordinated a hackathon with the Ministry of Health, HISP, and volunteer developers from around the world to further develop the new COVID-19 module. ICTA set up a messaging platform channel for all of the developers involved, with different channels for different projects based on expertise. University of Oslo headquarters used that channel to support the local team as well as a designated developer.

As a result of the hackathon, and with help from the University of Oslo, the team developed a contact tracing app and shared it on the DHIS2 community platform so any country could use it.

So far, by integrating DHIS2 data with Sri Lanka’s immigration system, location data from cell towers, and additional local health apps, developers have built ten interoperable modules for the DHIS2 COVID-19 Response Package to track and manage other critical health system components, such as ICU bed availability.¹ Many of these were led by the Sri Lanka HISP team (Port of Entry Tracking, Quarantine Persons Module, Inward Persons module, Laboratory Reporting module) and a few were developed through the hackathon, including the Contacts Visualization app.

Global support for the DHIS2 platform enabled developers to consider the potential for global adoption as they built the platform—the work done in Sri Lanka also triggered work on the development of a global digital health package for COVID-19. Recognizing the potential for worldwide deployment, DHIS2 core developers worked with HISP Sri Lanka to produce a version of their app that could be released for global adoption. They shared the details and source code of their initial application (and subsequent modules) on the Community of Practice site, where any country using DHIS2 for COVID-19 surveillance could benefit from their work. Likewise, HISP Sri Lanka shared the technical details of their implementation and their user guides with the global DHIS2 COVID-19 response team, and it has been used as a model for some of the generic training material now available for worldwide use. As of September 2020, more than 50 countries have implemented, or are in the process of implementing, one or more components of the DHIS2 COVID-19 surveillance package.¹

Developing and scaling the various modules in Sri Lanka has required multiagency collaboration and creativity. The implementation costs of the various modules have been supported by the Ministry of Health, but the development of custom applications was achieved through contributions from developers who worked on a volunteer basis. Additionally, maintenance of the system was performed mostly by the Health Information Unit of the Ministry of Health. Finally, the University of Oslo, through the Norwegian Agency for Development Cooperation, provided financial support for capacity building of the HISP Sri Lanka team. As the team continues to adapt to the challenges of the pandemic and improve upon what has been built, the focus is on scaling up infrastructure, capacity building, and data use to both ensure the sustainability of the implementation and stabilize the digital transformation of the country.

Impact

Sri Lanka’s web-based DHIS2 Port of Entry module that captures information on high-risk passengers entering the country from at-risk countries for active COVID-19 surveillance has now been adopted by multiple countries worldwide. Additionally, Sri Lanka’s COVID-19 vaccine delivery system has already been deployed at all vaccination centers around the country, including those run by security forces.¹ While the future of the modules after the pandemic is uncertain, the immunization tracker and laboratory components may be used in the long term.

What Were the Key Drivers of Scale?

• Groundwork – Existing digital health capacity within the Sri Lankan government: The successful development and scaling of a comprehensive set of COVID-19 modules could not have been achieved without in-country health information expertise. Specifically, the team of health informaticians from the Ministry of Health and HISP Sri Lanka (all graduates from the master’s and doctorate program on health informatics from the University of Colombo) were champions who led most of the work, with support and guidance from the higher administration in the Ministry of Health. Due in large part to this existing team, the country already had a robust, up-to-date health information management system (Sri Lanka’s Ministry of Health had updated to DHIS version 2.33 shortly after release) that public health staff were already familiar with.¹
• Partnerships – Interagency collaboration: For example, the Ministry of Health, HISP Sri Lanka, and the ICTA worked closely with the Department of Immigration to integrate and streamline health declaration data entry on immigration forms. This effort significantly minimized manual data entry at ports of entry. Collaborations with different government offices and the private sector ICTA community were also instrumental in producing the suspected-person location tracker from telecommunication tower data. This combination of interagency collaboration and public-private partnerships, which could be less formal than usual because of the urgency of the pandemic, greatly benefited local innovations and effective integrations in Sri Lanka’s efforts to contain COVID-19.
• Operations – Local developer expertise: The government was able to tap into this community of experts to find creative solutions to address a sudden crisis,¹ accelerating the development timeline and reducing the cost of development. For instance, within a few days of the initial meeting in the winter of 2020, the team in Sri Lanka had developed the DHIS2-based Coronavirus Surveillance System that the Ministry of Health used to track travelers from all ports of entry. Likewise, the Sri Lanka HISP team on the ground was able to drive the customization for many of the modules, although some required more complex development. Finally, the connection between HISP Sri Lanka and the DHIS2 core team and global community of DHIS2 experts helped local developers get valuable feedback on their work and made it possible for other countries to benefit from their pioneering innovations.¹

What Implementation and Scaling Challenges Remain?

• Monitoring & Evaluation – Clarifying system requirements as the pandemic evolves: During the initial weeks of the pandemic, the scope of requirements for the COVID-19 response were not clear. The team had to develop the modules with flexibility to adjust as the situation evolved. For example, as cases began to rise in October 2020 in Sri Lanka, the HISP team shifted its focus to enabling connectivity between community-based systems and laboratory testing.
• Groundwork – Lack of a pilot phase: With the goal to scale as rapidly as possible, developers had little time to pilot test and refine the modules, especially for the earlier modules. As such, the team did not have time to adapt the modules to local context and streamline the processes for use. For example, when the Port of Entry module was initially implemented, data entry took a substantial amount of time. To improve this, the volunteer development team worked with the information technology team handling the immigration information system. They designed an integration that decreased the amount of sociodemographic information needed, and in turn, decreased overall data entry time.
• Technology & Architecture – Accommodating the limitations of the DHIS2 platform: Not everything can happen within the DHIS2 platform itself. As new demands arise—for personal health apps, for instance—developers need to consider how to integrate them into the current system. The team was able to circumvent some of these challenges by creating new apps and custom developments.
• Technology & Architecture – Data quality and use: Due to the nature of the COVID-19 pandemic, the team’s focus in the beginning was on agile development and deployment of the DHIS2 modules. As such, there is room for improvement on the data quality and use across the existing modules.

Conclusion

For more than a decade, Sri Lanka has been using District Health Information Software 2 (DHIS2), an open-source digital health management information system platform. Even before the country’s first case of COVID-19 was reported, Sri Lanka’s Ministry of Health commissioned a set of digital tools that would support pandemic prevention, tracking, and response,³ and it took just a few days for developers to implement the country’s first COVID-specific DHIS2 module for port-of entry tracking. In part because of this effective port-of-entry tracking, Sri Lanka reported no cases of COVID-19 between May 2020 and October 2020. In addition, the rapid deployment of Sri Lanka’s DHIS2 COVID-19 modules triggered the development of a global DHIS2 COVID-19 surveillance package. Further into the pandemic, the team continued forward-looking preparation by designing and configuring a system for COVID-19 vaccine delivery by January 2021, before the country received the first stock of the COVISHIELD vaccine.