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HISP WCA: Supporting digitalization with DHIS2 across West & Central Africa

In this interview, Dr. Edem Kossi of HISP West & Central Africa reflects on his work with HISP and DHIS2 since 2007. A key takeaway: the importance of users in designing, adopting & sustaining local systems

This interview is part of a series of articles on HISP history and impact, published as part of a yearlong celebration of the 30th anniversary of HISP

Could you tell us about HISP WCA’s work in West and Central Africa?

Edem Kossi: The first country HISP West and Central Africa (WCA) supported with DHIS2 implementation was Sierra Leone in 2007. Since then, thanks to country interest and partner investment, we have grown to 23 countries in total. Our work has involved supporting assessments and strategic planning of Health Management Information Systems (HMIS), as well as DHIS2 implementation through various activities like designing the system together with the local stakeholders and providing capacity building through in-country trainings and regional DHIS2 Academies. In addition to that, we also support regional organizations like the West African Health Organization (WAHO), with whom we have worked together to develop a regional digital platform that collects data from all 15 ECOWAS member countries, including programmatic data like HIV, malaria, nutrition, which provides an overview of the public health status in those countries. At the continental level, we also work with WHO AFRO in collaboration with the other HISP groups in Africa as a joint effort to support the AFRO regional DHIS2 platform.

In addition to country and regional support, we also contribute to global efforts in the DHIS2 community. For instance, we are in charge of the French-language documentation for the community, such as user guides. We also develop custom apps, some of which are published and available to the community to use through the App Hub, and we contribute to global capacity building efforts and DHIS2 Academy material development.

How have things changed over time as a result of your work?

I would say that what started back in 2007 in Sierra Leone has seriously impacted the HMIS ecosystem, both at the country level and the level of the individual people who make up the system. At the country level, when we began this work, many countries were using a variety of different paper and electronic systems for HMIS data. But very quickly everyone saw that the Sierra Leone case was different, that suddenly–for the first time–everyone could have access to the data. It was no longer sitting on a single person’s computer, and they were also able to bring data from various sources into a single system. It was no longer a case of one system for malaria, another one for HIV, and so forth. Previously, health workers had to navigate through all these different systems–immunization, maternal health, malaria, etc.–to capture data, but DHIS2 allowed them to bring it all together in one place. So that was quite impressive for people. It was a big success.

The news quickly spread to other countries. People started hearing stories about how there was something happening in Sierra Leone where now people have access to data. The Gambia was the second country in our region that requested DHIS2, and then suddenly the Gambia and Sierra Leone were talking about DHIS2 in WAHO meetings, sharing their experiences with the system, and other countries said, “Wow! That’s interesting. Let’s see what this is.” So that’s how what we started in Sierra Leone and the Gambia sparked a regional change, and other countries started implementing DHIS2. Everyone started realizing that now, at the central level, health programs and other stakeholders can leverage the fact that data from various sources are combined, so they can do cross analysis and they don’t have to go begging for access to their own data, and that they can work in coordination. And even at the regional and district level, people were suddenly able to analyze and compare the data themselves, and see how they were performing compared to their peers. That was quite an achievement and it was a really a giant step forward for those countries.

This has also had an impact at an individual level. I remember when we first started working on DHIS2, I was conducting an assessment in Guinea and someone there told me that the HMIS division is usually where they send people they want to punish, for being stubborn or not following the rules. Or if they think you are not up to the job you have, then they will send you to the HMIS. So HMIS was like a punishment duty, or a “garage” where they would just pack away people they didn’t want anywhere else. But when we started with DHIS2, the HMIS suddenly became very sexy, because people are now able to demonstrate the value of data, to share data with everybody. Then suddenly everyone realized that data is very important. You can have access to data, we have access to nice graphs, maps… and so it became an attractive area to work in. As of today, people actually want to be appointed into the HMIS team.

Being an HMIS officer is now a matter of pride for people. People are really proud to be the HMS Officer at a regional or district level. It’s something we as a community don’t recognize often, but I think is that important to say, because that feeling of pride, of having the moral satisfaction to say “I’m contributing to something. I’m being valued.” – I think it’s something that the DHIS2 movement has brought to countries and to HMIS officers in particular. So helping change the perception of HMIS from being a punishment to something that is very attractive, I think it’s quite an achievement at the personal and professional level.

How has HISP supported building capacity for digitalization in the region?

When we go to each country, we always try to work in a participatory way with users and stakeholders, and we always try to empower people. This reflects the HISP network values. Bearing that in mind, we usually start by forming coordination bodies and what we call the DHIS2 core team. These are the key people, including the admin, trainers and others who we work with in DHIS2 implementation. We start by building their capacity first. Also, we always try to not just jump into digitizing existing tools, but to bring forward the idea of using the opportunity of digitization to improve processes, to make things easier for people, and to be more efficient. So that’s why we always try to discuss approaches collaboratively and see what needs to be changed, how to approach the customization of DHIS2, what are the existing practices, and what the impact of making certain changes would be. And together we assess the situation as we move forward.

So, first we train people on how to customize DHIS2, but we know that that is not enough. The second step is always to learn by doing. That’s where we work on the customization together with the core team, so that by the end of the process they have mastered how to do DHIS2 customization, but most importantly, they have a good knowledge and understanding of the metadata that is in their system and they will be able to maintain and evolve it over time. Along the way, we also continue to work on capacity building on various topics with them, like analytics, data quality, and data use. This set of capacity building activities is augmented by our DHIS2 Academy offerings, that range from server management to data use, where we bring together DHIS2 users from countries across the region to share experiences and to learn from us and each other.

HISP WCA hosts DHIS2 Academies for the West & Central Africa region

So we do both regional activities and in-country capacity building activities. And with in-country activities, we also go beyond DHIS2, because we’re also talking about the health information system architecture as a whole, and about interoperability. We work with the country stakeholders on interoperability projects and they learn to go beyond DHIS2 and to connect it with other systems.

But most importantly, what we try to do with them is to share the value of empowering people and also of listening to people. Because digitalization is not just about the digitizing tools. It is an opportunity to innovate. And that is one of the key elements that we try to convey. And I think that message has been well received. Today, we see that country DHIS2 core teams are capable of managing their systems themselves. They only call us if they have some very advanced issues that they cannot address, or if there are some new features that they have not mastered yet, and we go there to work with them and train them on those new features.

One recent example of this core team capacity is the introduction of the malaria vaccination campaign in countries like Cameroon and Burkina Faso. They were able to adapt their DHIS2 systems to change their data collection tools to include the collection of malaria vaccination data and to add the necessary indicators to their dashboards. And that is something that the community is proud of, to know that you have good people on the ground who are able to stay on top of everything and keep the country’s system alive and continuously evolving.

Recently, several new groups have joined the HISP network in West and Central Africa. How did that come about, and what are the benefits of that change?

That is related to our history and trajectory. As I said initially, when we started there were not many DHIS2 implementers out there. There were a few of us doing our PhDs at the University of Oslo, but not many others with DHIS2 experience. So, as the number of interested countries grew, we recruited people to be able to support them. Today we have a big team at HISP WCA, but there are also some large countries in the region that have their own challenges and need closer support. Flying our team to them from Togo every day is not a practical solution.

At the same time, across Africa we are seeing a tendency toward self-reliance and independence, where countries want to show that they can do things themselves. While this is a positive trend, we’ve noticed that the MoH are facing some challenges, like retaining trained staff. We decided to gradually create some new HISP groups to get closer to these countries and their challenges and provide better support on the ground. We started with Mali because it’s a big country with its own challenges and the demand for DHIS2 support is there. Gradually we have added other countries like DRC.

So, the creation of new HISP groups is a way to respond to local and country challenges and needs. It is not a straightforward process, it takes time and resources to establish these groups and mentor them and spend time working together with them on projects not only in their countries but also in other countries so that they gain experience. This breadth of experience is important, because to do DHIS2 implementation well you don’t just need technical experience, but also an understanding of the consequences of different kinds of system design decisions, which comes through seeing the system used in different countries and contexts.

Through the process of establishing these HISP groups, we are showing our partners and countries that there is enough DHIS2 expertise in the region and in their countries, so that even if there is a crisis that their technical DHIS2 core team cannot address, then there are HISP people there locally who are also in touch with the larger HISP network and community, and can bring together people to support them. What we have done so far has been appreciated by countries, and is encouraging partners and countries to initiate more projects with DHIS2. For example, in DRC, DHIS2 activities had been a bit limited. But since we started forming HISP DRC around 4 years ago, partners and stakeholders have gradually become confident in initiating DHIS2 activities. For instance, they came to us to request the implementation of DHIS2 for campaigns, wanting to use DHIS2 as a single health campaign management tool. I think having a HISP group there has helped in making sure that if they go with DHIS2, they have people on the ground on a permanent basis that can support these activities.

Edem Kossi and Professor Jørn Braa of the HISP Centre in DRC for DHIS2 training to support Covid-19 vaccination in 2021

How have the HISP shared values played a role in forming these new groups?

Shared values, to me, are what brings us together. These values are part of our identity. That is what makes us unique and trustworthy. It’s in our own interests to keep these values for the safety and sustainability of the community. For instance, when we talk about sharing. We share what we do. Covid was a good example, where a solution that started in Sri Lanka was quickly shared with the community, improved, and shared further to other countries around the world. That made HISP groups in all countries very relevant. HISP groups really proved their value in this crisis – Covid showed that we are there and responding to key demands that are helping governments and society as a whole.

It’s the same thing with our ethical values. Because we are promoting a higher standard in terms of ethics, partners can trust us. They know we are always being honest with them. We are not just trying to sell DHIS2 as a product. If we can do something with DHIS2, we say we can do it. If we can’t do it, we tell them the truth. That has also made us very trustworthy partners to the MoH. Because of this, they see us as advisors. Sometimes I get a call from the Ministry in a given country and they say, “I have this problem or an opportunity–what do you think we can do?” And then we discuss ideas together. What we tell them is not always something that goes into DHIS2 directly, sometimes we might suggest subnational capacity building, for example, and then they go and do that activity themselves.

I think these values that we have make us attractive and trustworthy, and that is why our partners from Ministries and governments see that we are reliable and that we are there to stay. Because of the same values that we have, we believe in what we are doing. We believe that we are a development agent. And that’s why we support them even if there are no resources. We do a lot of pro bono work. We really believe that we need to support the Ministry. They realize that, and when they have the opportunity, they thank us. Unfortunately, these acknowledgements are not always visible to the entire community, but we know that they appreciate us, and that is morally rewarding.

What have you done to help ensure that the new groups and team members embrace these values and the HISP approach?

Some of us who have been involved with HISP for many years have had the opportunity to go through a PhD program at UiO, and going through that program helped us to know the history and the development agenda of HISP, and to be exposed to the body of knowledge that guides our information system implementation and research. Being part of this cohort of PhD researchers was helpful for us. But, the community is growing, and not everyone can do – or wants or needs to do – a PhD. However, it is very important for the community that we all know our history, because if you don’t know where you are coming from you cannot know where you are going. So we felt it was very important to bring the new members of the community together and expose them to our history and the body of knowledge related to our work. Most importantly, we also wanted to ensure that these newcomers are not just IT people focused on the IT part, but that they become digitalization experts, meaning that they learn to use IT system implementation as an opportunity to improve organizations and see how organization processes can also improve IT.

So, we invited participants from seven HISP groups; partners from Ministries of Health, Agriculture, and Education from six countries; and researchers from two universities in Lomé to join for a weeklong course on Information Systems Research Fundamentals in 2023, with support from researchers at the HISP Centre. We shared the history of HISP and the key role that our participatory approach has played in our success, discussed information systems theory, and worked through real-world cases that participants had brought with them from their countries. It was very useful for the new HISP group members, and for the Ministry participants it was eye opening. It really helped them see their work with information systems differently, and inspired them to think about how they can do things better. The university participants were also very excited about the course and went back and shared it with their colleagues. We are in touch with these universities and are looking into opportunities for collaboration with them and UiO, potentially a joint Master’s program, if we can get the funding, which would further help to strengthen digitalization capacity in the region.

Looking back, how would you sum up your HISP’s success and impact?

Our approach combined with our values have made us strong and very reliable partners. For instance, if I take a challenging country like the Central African Republic, it was very difficult to start DHIS2 there after so many years of conflict. And that also reminds me of the Sierra Leone case. When we started back in 2007, it was shortly after their civil war, and it surprised everyone when we were able to implement DHIS2 in that context. And today in CAR, as well as in Sierra Leone, the system is working and is run by local teams.

Although the context was challenging in those two countries, I think that we were able to succeed by using our participatory approach, our values, and our belief in empowering people and making people independent and making life easier for people. They were able to maintain, run and operationalize DHIS2 in their countries. It is something that is maybe sometimes difficult for outsiders to grasp, but it is what makes a difference compared to other systems that struggle to scale up in challenging countries. Today in Mali, despite all the security issues in the northern regions, DHIS2 is still working there. People are reporting data and using data in DHIS2.

So there is a lot that we have accomplished. And the credit is not only for the HISP groups, but it’s something that we have done as a collective, together with the government, the Ministry of Health, the HMIS teams, and particularly the health workers on the ground. I think that is something that we were able to co-create. So I want to thank the Ministries – Health, Education, and Culture, and others – and the users on the ground for the opportunity they gave us to work with them, and their dedication despite various challenges. Sometimes they even do their work at the risk of their own lives. I remember back in 2017 or 2018, the HMIS team was going to the northern province to train people on DHIS2, and their car hit a landmine and exploded. Those are the risks that some people are taking in their daily work with the HMIS.

We don’t always have the opportunity to acknowledge these people and thank them for their work, but I want to use this opportunity to say that we do value what they are doing and if their system is successful, and if DHIS2 is successful and is seen as a system that endures in so many countries, it is because of their dedication. And if they are dedicated, it is because they understand the value of the system for the country and they understand the value of data for the development of their community. So I want to thank them for their dedication.

 

Learn more about how the HISP Centre and the HISP groups collaborate to support countries worldwide on the HISP network webpage.