Streamlining donor reporting by sending indicator data directly from DHIS2
The Global Fund and the HISP network have helped countries like Mozambique reduce their manual reporting burden–and improve data quality–through DHIS2 aggregate data exchange.
While low- and middle-income countries (LMICs) have gradually increased their spending on public health in recent decades, as of 2024, 36% of health sector spending in low-income countries was covered by development assistance, compared to 26% from national governments (source). The Global Fund to Fight AIDS, Tuberculosis and Malaria is one of the largest multilateral funding mechanisms for public health programs in LMICs, with 15.7 billion dollars in contributions from 2024-2026. At the country-level, these funds are distributed in the form of grants that support Ministry of Health priorities for HIV, TB, and malaria programs, as well as health system strengthening overall. In many countries, these grants have supported the rollout and scale-up of DHIS2-based Health Management Information Systems (HMIS) that have helped countries improve health program monitoring, analysis, and planning. This funding has had an impact: Since it was founded in 2002, health programs supported by the Global Fund have increased coverage of key treatment and prevention interventions for HIV, TB and malaria, ultimately saving 65 million lives.
Effective management of this global effort requires good data. At the central level, the Global Fund uses their own DHIS2 system to monitor and evaluate the performance of the programs that they fund around the world. Countries receiving financial support are required to report on key indicators for HIV, TB and malaria programs each quarter. In the past, this has been a largely manual process. Starting in 2023, the Global Fund has worked with the core DHIS2 team at HISP UiO and the local groups in the HISP network to streamline and automate this reporting process with the DHIS2 Data Exchange app and a standardized metadata package for the Global Fund reporting format, making it possible for countries to send key indicators directly from their national HMIS to the central Global Fund repository.
As of the end of 2024, Global Fund Aggregate Data Exchange (ADEx) reporting has been rolled out in 12 countries. The results have been positive. Using ADEx has reduced the amount of time countries spend on preparing reports, made it easier to identify and correct data quality issues, and helped to identify data gaps in national HMIS systems that several countries are now working to address.
“We use less time reporting now. Before, we were going into SISMA (the national DHIS2 system) and selecting the data, and then each program (HIV, TB, and malaria) would use maybe 2-3 days to clean and revise the data before sending it to PMU. Now, they can do this process in just one day. So it is faster than before.”
— Ivone Rungo, Monitoring & Evaluation Officer, Program Management Unit (PMU), Ministry of Health Mozambique
Developing a new approach for more efficient national data reporting
In the standard manual process for quarterly reporting to the Global Fund, Ministries of Health extract data from their own systems, do data cleaning, calculations, and transformations in Excel to produce the required programmatic indicators, then send the resulting file to the Global Fund where it is manually imported into the central database. There are several downsides with this system. The export, cleaning, and import process is labor- and time-intensive. It also encourages health programs to do their data quality checks and corrections outside of the HMIS, which means that in most cases the cleaned data does not make it back into the country’s DHIS2 system, which creates both a missed opportunity to improve HMIS data quality and results in data discrepancies between national and Global Fund systems.
The push to create a more streamlined reporting system came during the COVID pandemic. The Global Fund received a sudden influx of contributions to support pandemic response in LMICs, but this also created a need for rapid reporting from countries to monitor COVID cases and commodities so that the Global Fund could effectively allocate and disburse funds quickly. The DHIS2 core team helped implement an initial approach to allow country data to be sent to the Global Fund using the DHIS2 API. This was later developed into the Data Exchange app, allowing Global Fund teams and their Ministry of Health counterparts the ability to configure data exchanges directly through the DHIS2 user interface. A metadata package was also developed that includes standard indicators for HIV, TB, and malaria programs, which individual countries can install in national HMIS systems and use to easily select the specific indicators they want to report through ADEx.
Once configured, ADEx allows countries to create their Global Fund reports, and do data quality review and cleaning, directly in DHIS2. This reduces the time required for manual reporting and allows national health program officers to spend more time on improving the quality of the data itself before the report is submitted. It also eliminates the need for countries to produce customized indicator calculations, as the Global Fund’s system is able to ingest the data and do the transformations and calculations automatically.
“The core of the (ADEx project) is how do we make programmatic decisions faster, while simultaneously strengthening data quality.”
— Nicola Hobby, Technical Advisor & Implementation Lead, The Global Fund
Locally implemented with support from HISP and the Global Fund
The first live implementation of the ADEx reporting system took place in September 2023 in Uganda, with Mozambique following shortly after. By the end of 2023, 7 countries had implemented ADEx and began using it to submit data for Q1 2024. Another 5 countries came online in 2024.
At the country-level, ADEx implementation is quite straightforward. Nicola Hobby, the technical lead for the project at the Global Fund, describes it as “the easiest project I have implemented so far when it comes to in-country setup.” Local HISP groups are contracted to provide technical support, including pre-configuration steps like upgrading the DHIS2 software version of the HMIS to v2.39 or higher to enable the use of the Data Exchange app, installing the app and metadata package, and supporting an HMIS data quality assessment if needed.
The Global Fund team then supports the MoH with ADEx setup, which typically takes around one week to complete. This involves working in-person with local MoH program and HMIS staff to define numerators and denominators and map them to exchange indicators. The mapping process usually takes around one day per health program, plus one more day to set up the exchange for all programs together. The Global Fund team is always looking for ways to make this process more efficient. In one specific case, they were able to get a country up and running with ADEx for one health program by providing mapping support remotely. Once the configuration is complete, the MoH team validates it before it is put into production on the national server. Once the ADEx system is active, when the country HMIS focal person hits the “submit” button for the reporting period, their data is populated in the Global Fund Partner Portal within two hours or less.
Mozambique’s experience transitioning to ADEx reporting
Of the 12 countries that have implemented ADEx reporting so far, Mozambique has been one of the most successful. Mozambique first implemented the system in late 2023 in response to a need to report on essential commodities for the country’s COVID response and has since expanded it to include reporting for HIV, TB, and malaria programs. This enables Mozambique to provide granular reports on key programmatic indicators, such as the percentage of people living with HIV who are receiving ART, or the number of confirmed malaria cases who received first-line treatment at public health facilities.
According to Ivone Rungo, Monitoring & Evaluation Officer in the Program Management Unit (PMU) of Mozambique’s Ministry of Health, this has been a good experience. The MoH worked with Saudigitus (HISP Mozambique) to install and configure the Data Exchange app on SISMA, Mozambique’s national DHIS2-based HMIS, and went through the mapping process with two focal points from each program. The MoH was able to produce their report to the Global Fund through ADEx, but observed that there were issues with some of the indicators. They reached out to the Global Fund and Saudigtus and were able to get these quickly resolved.
While there are still some data gaps, such as spectrum population estimates for the HIV program, and there are still some indicators that require manual update from the MoH team following submission to the Global Fund, the process has brought several benefits to the MoH. Implementing ADEx has helped strengthen SISMA, as it has created an impetus for HIV, TB, and malaria MoH teams to have their programs updated in DHIS2, and the use of standardized indicators has enabled teams to set these up as “favorites” in DHIS2, making them easier to find and review. The additional validation steps both in SISMA and in the Global Fund partner portal have helped identify and resolve data issues. It has also helped inform MoH decision making. In addition to sending reports to the Global Fund, the HMIS team shares them with MoH leadership to provide a comprehensive overview of programmatic outcomes so that they can gain insights and make more informed decisions.
“(ADEx reporting) is also helpful in that it promotes collaboration between different stakeholders within the Ministry of Health programs. I think this is an innovative solution.”
— Ivone Rungo, Monitoring & Evaluation Officer, Program Management Unit, Ministry of Health Mozambique
National level results: Reducing reporting burden, improving data quality & identifying data gaps
The feedback the Global Fund team has received from other countries is similar to Mozambique’s experience. In general, countries report that thanks to ADEx they are able to spend less time transcribing data and more time digging into subnational-level results to identify and address data quality issues. Countries see it as a benefit to be able to report this data automatically without the need for manual transformation and external data cleaning.
Because countries themselves can decide which indicators to include in ADEx vs. reporting manually, the system has created added incentives to fix underlying data structure and quality issues so that additional indicators can be included in the report, so that as much data as possible can be reported automatically. While no country has been able to submit all indicators through ADEx from the start, countries like Uganda have achieved 80% HIV reporting through ADEx, as one example, and the Global Fund team expects the trend to continue going up over time.
The use of ADEx to automate reporting has also helped raise the visibility of what data is missing from the national HMIS. Some examples of this are population estimates, such as spectrum surveys which estimate the population of people living with HIV, that are used as denominators in key indicator calculations. Several national MoH teams have identified the potential to add this population data as an annual figure in the HMIS, and at least one country has already taken this step. Some countries like Tanzania, which uses a Tracker program for patient-level HIV monitoring, are also exploring the possibility of aggregating this individual-level data to include in automated Global Fund reports.
Next steps for the Global Fund: Facilitating epidemiological analysis
For the Global Fund, the end goal of ADEx reporting is not just making the reporting process more efficient. Getting access to more granular country data more quickly has also enabled the Global Fund to do more nuanced analysis. These deep dives into country data are not limited to analysis of grant performance but can also involve epidemiological analysis, which has not been possible with traditional reporting that only includes pre-calculated national-level indicators. With additional granularity provided by ADEx reporting, which allows subject matter experts at the Global Fund to see the raw data of the numerators and denominators that these indicators are based on, there is now the potential for these experts to look at the data programmatically, such as performing gap and trend analysis, or overlaying it with other data sets like climate and financing for triangulated analysis.
While the Global Fund team is still developing its approach to working with this data, there have already been some concrete results. For example, after observing that some indicators were being consistently over-reported by one country, an analysis by the Global Fund determined that the HMIS was missing a number of reporting facilities and communicated this to the MoH for resolution. In cases like this, ADEx helps the Global Fund be an active partner to the MoH in using their data to take action.
Future opportunities with ADEx reporting: Additional countries & donors
The Global Fund currently supports HIV, TB, and malaria programs in more than 100 countries. Of these countries, a large percentage of them use DHIS2 for collecting data on these health programs. The Global Fund team hopes that additional countries will prioritize implementing ADEx to streamline their reporting and enable the Global Fund to work with them more closely to improve programmatic outcomes.
ADEx also serves as an example on how utilizing DHIS2 as the source of truth for streamlined reporting can be beneficial for a variety of global health donors and organizations. Currently, each organization has its own reporting requirements, which means that LMICs that get financial support from several different funders for one health program are required to produce separate customized reports for each of them, taking up valuable staff time, and potentially even requiring parallel reporting systems. In some countries, data on the same health program may even be reported into several separate DHIS2 databases to satisfy donor reporting requirements.
The Global Fund has started to have conversations with several key organizations about the potential for indicator alignment and reduction of parallel reporting systems. This is a complex problem, as each organization has specific priorities and data needs, but the hope is that by creating a system that makes it easier for countries to report data automatically based on pre-defined standards, the Global Fund can help inspire a movement toward collaboration and data sharing between donors, further reducing the reporting burden on individual countries and allowing them to focus their limited resources on their core work: improving the health of their people.
Learn more:
- Presentation on ADEx at the 2024 DHIS2 Annual Conference: Watch on YouTube
- Interview with Nicola Hobby, “What does DHIS2 mean to you?”: Watch on YouTube
