COVID-19 Surveillance in Norway: The first country in Europe using DHIS2

Norway is a highly digitalized country. But when the first cases of COVID-19 arrived in March 2020, it became immediately clear that this Nordic nation lacked a comprehensive data system for monitoring disease outbreaks, and health personnel were stuck using Excel spreadsheets or even pen and paper to track the pandemic’s spread. Doctors and public health officials in Norway needed a digital solution, and they needed it quickly. Because the Norwegian health system is largely decentralized, with responsibility for key aspects of public health response delegated to the municipality level, each of Norway’s 356 kommuner (municipalities) were left to solve this problem on their own.

In northern Norway, Tromsø municipality began their search for a digital solution. One epidemiologist in their health system had previous experience with DHIS2 as a surveillance tool from her previous work with the Norwegian Department of Public Health, where one of her projects had involved supporting the national health system in Palestine — where DHIS2 was first introduced in 2015. She contacted HISP-Oslo directly to assess the possibility of using DHIS2 for COVID-19 response, and helped lead Tromsø’s pilot implementation of the DHIS2 surveillance package, which was the first in Norway. In parallel, Sel, a municipality in the middle of Norway, was also eager to find a robust solution since 1,000 of their 6,000 inhabitants were put in quarantine early on in the crisis, and they also turned to DHIS2.

Meanwhile, several other municipalities in search of a COVID-19 solution had started to contact the Norwegian nationwide organization for municipalities (KS) for help. KS is an umbrella organization that provides various kinds of assistance and support to municipalities across the country, including shared technological solutions. KS immediately saw an opportunity to help develop a solution that would meet the common needs of Norwegian municipalities, while remaining flexible enough to be adapted to the local context, and they contacted the Health Information Systems Programme (HISP) at the University of Oslo (UiO) to propose a collaboration. The HISP-UiO team worked with KS and the Norwegian Institute of Public Health (NIPH) to define the requirements of this system, and to support the launch of pilot programs in five additional municipalities.

The DHIS2 COVID-19 surveillance package was launched worldwide in early March 2020. By June, the Norwegian version was already for deployment through KS. In just a little over three months, Norway went from pen and paper to DHIS2.

FIKS Contact Tracing: A shared DHIS2 system for Norway

Using Tromsø’s work with the standard DHIS2 COVID-19 Surveillance package as a starting point, KS, HISP-UiO and NIPH developed a modified package version that met local requirements and regulations, which was released by KS as FIKS Contact Tracing (“Fiks smittesporing” in Norwegian). The FIKS platform was designed to assist Norwegian municipalities with an overview of local COVID-19 case data and follow-up of people in quarantine and isolation. The platform was configured to allow for quick adaptation to local and national regulations. Additional features of the Norwegian implementation were the translation of the DHIS2 software interface and metadata into Norwegian, and the integration with Norway’s national level sign-on system, so that users could sign in to FIKS using the same method as for other government software platforms. FIKS was designed not only to save time, but also to facilitate standardized workflows and reporting from municipalities to NIPH.

FIKS Contact Tracing was made available to all Norwegian municipalities by KS through their online platform for digital tools. For this project, KS has set up one common instance for all municipalities. This means that each municipality has access to its own data, can assign index cases or contacts to other municipalities (the last will be implemented soon).

FIKS Contact Tracing consists of two modules:

• Registration and follow up of index cases
• Registration of close contacts

In this system, a person with a positive COVID-19 test result is registered with their biographical details, information about their health status, their potential source of infection, their travel history, and other people who they have recently been in contact with. Medical personnel can use the FIKS system to schedule future dates for follow-up with the patient, while contact tracers can use the system to follow up with the infected person’s close contacts to communicate important information to them, including recommending testing or quarantine, depending on the situation and guidelines in their municipality.

“There was a great need for a digital tool that could provide good follow-up of infected and quarantined people. Contact tracing is easier  with the new case registration tool because the contact tracers have a better overview of data and can cooperate, trace, and follow up the infected.”

Bjørn Arild Gram, KS chairman of the board

By November, more than 120 Norwegian municipalities had begun using DHIS2 via the KS FIKS platform. The impact and quick adaptation of the DHIS2 COVID-19 Surveillance package serve as an example of the strength and adaptability of open-source solutions for rapid crisis response. As the FIKS Contract Tracing example has shown, this is not only true for low- and middle-income countries: Wealthy and highly digitalized countries like Norway can also benefit from global digital public goods like DHIS2.

Benefiting from innovation and investment in the Global South

Unlike in Europe, where few countries had digital disease surveillance systems in place before the beginning of the COVID-19 pandemic, in Asia, many countries were already using DHIS2 to collect and analyze health data. This is thanks in part to a decades-long development project led by the Norwegian Agency for Development Cooperation (Norad), which has funded DHIS2 since the beginning in 1994, and in recent years has cooperated with a group of global investors to support DHIS2 adoption and capacity building for health programs in more than 60 countries.

Thanks to local DHIS2 expertise–and the help of the global HISP network–several of these countries were able to use their existing DHIS2 systems to build local solutions that helped them to respond to the spread of COVID-19. This was the case in Sri Lanka, whose early work in developing a customized version of DHIS2 for COVID-19 surveillance served as a model for the global DHIS2 COVID-19 package developed by HISP-UiO that was adopted by countries across Africa, Asia, the Middle East, the Americas, and – finally – Europe. This is a perfect example of how international development projects do not only benefit the countries that receive development aid: global public goods and local innovations, especially when shared in the open-source model and collaborative tradition, can bring benefits to people in donor countries as well.

However, the use of DHIS2 in Norway did raise some ethical questions for HISP-UiO, in particular the question of whether it was acceptable for international development aid donations to subsidize the development of a digital health solution in one of the world’s wealthiest countries. While DHIS2 is free to download and use, there are significant costs to HISP-UiO involved in developing, maintaining and implementing the software. In consultation with KS, it was determined that the FIKS platform should thus be offered to Norwegian municipalities at a nominal cost tied to the number of inhabitants per municipality, that would cover the costs of customizing and deploying the software for the Norwegian system, so that the work on the platform in Norway not come at the expense of HISP-UiO’s support for the Global South.

Competing solutions: DHIS2 serves at the backend for another Norwegian COVID-19 surveillance tool

At the same time that KS was working with DHIS2 to develop FIKS Contact Tracing, another group of developers in Norway — perhaps inspired by coverage of the use of DHIS2 in Sri Lanka in the Norwegian press — had also started experimenting with DHIS2 for COVID-19 response. Rather than deploy a customized version of the DHIS2 interface, this group decided to develop their own front-end app for data entry and analysis, using a DHIS2 database for their backend. This solution, known as ReMin, was made available to Norwegian municipalities for pilot testing in May 2020. As of November, around 150 municipalities had adopted the ReMin system. While HISP-UiO was not involved in the development of ReMin, we are proud that they were also able to leverage the power and flexibility of DHIS2 in their solution, and encourage them to contribute to the open-source DHIS2 community in the future.