Cross-Country Implementation and Expansion of SORMAS: Key Lessons

Introduction

In 2020, Exemplars in Global Health carried out a short-term research project in low- and lower-middle-income countries (LMICs) on digital tools for COVID-19 response. The aim was to explain the factors that facilitated the scale-up of these tools during the COVID-19 pandemic. One of the tools profiled was the Surveillance Outbreak Response Management and Analysis System (SORMAS) in Nigeria.

SORMAS is an open-source mobile and web software solution that facilitates the collection, organization, and analysis of real-time data for both outbreak response and disease surveillance.^1,2 Operational in high- and low-income settings, it is one of very few applications that can digitally manage all procedures along the disease surveillance and outbreak response pathways, from the initial detection of cases in the community to the management of disease outbreaks.³

While the system was operational only in Ghana and Nigeria before COVID-19, the advantages offered by SORMAS in managing the COVID-19 pandemic sparked a wave of adoptions across high-income countries (HICs) and LMICs including Democratic Republic of Congo, Djibouti, Fiji, France, Germany, Côte d’Ivoire, Kenya, Luxembourg, Nepal, Switzerland, Tanzania, Tunisia, Economic Community of Central African States (CEMAC), and the Intergovernmental Authority on Development (IGAD) region in Eastern Africa.⁴

This rapid wave of adoptions led to the desire to document more comprehensive lessons from implementation across diverse geographies and contexts. The following work is based on desk research and in-depth interviews with stakeholders from three countries (Ghana, Côte d’Ivoire, and Nepal) and the SORMAS Foundation to reflect lessons from different geographies, implementation use cases and phases. The SORMAS Foundation is a nonprofit organization built around the vision of “a world in which all countries are prepared to respond to epidemics and pandemics digitally and collaboratively,” ⁴ with SORMAS as the flagship system.⁵ The SORMAS Foundation aims to support countries with the implementation of SORMAS, to foster exchange between members of the global SORMAS community and to ensure the high standards for the software.

Implementation context, success factors, and challenges

Ghana: Implementation of SORMAS in Ghana started in 2018, well in advance of the COVID-19 pandemic.⁶ The triggers for uptake were an existing desire to digitize disease surveillance; SORMAS advocacy by the German Development Cooperation, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH and the Helmholtz Centre for Infection Research (HZI); and the demonstrated advantages of the tool during learning visits to Nigeria such as modularity, flexibility, and the possibility of some offline use. Initial implementation started in two regions of Ghana but was rapidly expanded nationally ahead of schedule to support COVID-19 surveillance. The identified use cases are routine surveillance of all priority diseases as an electronic Integrated Disease Surveillance and Response tool, and outbreak management. Funding in the pilot phase was through GIZ support, but expansion and ongoing institutionalization have been sustained through a mix of donor and government funds. Some of the identified success factors were the strengths of SORMAS features over competing tools, strong technical leadership within the Ghana Health Service, political commitment especially during the COVID-19 pandemic, a strong public–private partnership with a local IT organization that provided server capacity for data hosting and software development support, a motivated and digital-savvy workforce, and cross-country learning from Nigeria. Unplanned rapid expansion also resulted in implementation challenges, including insufficient server capacity, incomplete data entry for priority diseases other than COVID-19, and unanticipated extra demand for tablets and training resources. Other challenges included limited funds for day-to-day operations, multiple competing tools, persistent lack of in-house software developers due to delays in skills transfer from the private IT partner, and the high cost and reliance on internet access for deployment and synchronization of data. Despite these challenges, SORMAS has been fully adopted as the national routine surveillance digital tool with the capacity to manage any scale of disease outbreak as the need arises.

Côte d’Ivoire: Initiation of SORMAS use in Côte d’Ivoire was triggered by challenges with managing the COVID-19 outbreak using other digital tools, and outreach from HZI proposing the use of SORMAS. It was implemented as a pilot project in two health regions alongside a nationally deployed existing digital health tool for comparison. The original intended use case was COVID-19 contact tracing and contact follow-up, but this was expanded to include routine surveillance for other priority diseases such as cholera, dengue fever, measles, meningitis, and yellow fever. Funding for the pilot phase was through the EU-funded CORESMA (COVID-19-Outbreak Response combining E-health, Serolomics, Modelling, Artificial Intelligence and Implementation Research) project.⁷ Identified success factors were the high user acceptance of SORMAS⁸ and a digital-savvy workforce. Challenges encountered included multiple competing tools, interoperability with the existing information technology landscape, and a lack of in-country server capacity, which significantly delayed initiation of the pilot phase. That said, the pilot phase was deemed successful, motivating a clear desire to continue and expand, although sustainable funding remains a challenge.

Nepal: In Nepal, the decision to adopt SORMAS was based on interdependent factors including the challenges of the existing facility-based sentinel Early Warning Reporting System (e.g. limited event-based surveillance (EBS) capabilities and late detection of outbreaks), the desirable functions and features of SORMAS with regards to EBS, the onset of COVID-19, and advocacy from the HZI. SORMAS was implemented as a pilot project across 183 local-level administrative areas in two of seven provinces in the second half of 2023; transition plans for nationwide expansion are ongoing.⁹ The main use case for SORMAS in Nepal has been to fill the noted gap in EBS. However, there are conversations and long-term aspirations of using it as an integrated surveillance tool for all priority diseases. Funding for the pilot phase was through the EU-funded CORESMA project and other partners, but anticipated funding for expansion would be through a combination of government budget, WHO support, and resources received through the Pandemic Fund in 2023.⁸ Success factors included a motivated workforce, strong technical leadership from within the Epidemiology and Disease Control Division of the Ministry of Health and Population, continued strong advocacy by the government, and partnerships, especially with WHO, that provided support with software development and data hosting capacity. The major challenge encountered was persistent administrative bottlenecks in the process of managing, approving, and releasing funds from the initial grant, which led to more than two years’ delay in pilot phase initiation. Other challenges include lack of clear guidelines on interoperability between SORMAS and the digital technology behind EWARS, insufficient funds availability for expansion, difficulty with clearly defining the different roles of health authorities at the three tiers of government, and added workload on an already burdened workforce.⁸ Despite these challenges, the utility of SORMAS was made clear during the pilot phase, and the country is planning for full scale-up.

Table 1: Background implementation elements across the three countries

Key lessons and conclusion

The key lessons learned for a pre-implementation phase include the following:

• The need to establish a clear vision for SORMAS use cases
• The realization that any health system can successfully implement SORMAS if a proper needs assessment and context-appropriate planning is done
• An accurate and comprehensive resource needs estimation beyond the perceived “free” open-source software to account for cost of hardware and human resources
• A plan for sustainable financing beyond the pilot phase
• An institutional home for SORMAS within the health system as well as a coordinating mechanism for day-to-day implementation
• A clear plan for knowledge and skills transfer, especially where IT knowledge initially lies within a private-sector, nongovernment partner
• The provision of adequate country-specific data hosting server capacity

In the pilot phase, it is imperative to be proactive about knowledge and skills transfer while having a strong learning and evaluation component to inform adjustments for the expansion. The key lessons that span all phases from pre-implementation include the following:

• Needing to maintain political will and buy-in from high political offices to technical leadership through ongoing strong advocacy
• Adopting a multipronged approach to training that includes frontline workers and their managers and supervisors to ensure strong internal advocacy
• Leveraging the role of the SORMAS Foundation as a facilitator of the entire process through software curation, training and accreditation, implementation support, and community building

As SORMAS continues to expand across countries, it will be valuable to continue learning from key implementation lessons in comparable contexts to help achieve the desired and ideal outcomes of a SORMAS deployment.

Table 2: Success factors, challenges, and key lessons across the three countries

* COVID-19 was seen as a facilitator in the accelerated expansion of SORMAS.