SPECIAL STUDY 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
03 December 2021
Mott MacDonald Mott MacDonald House 8 10 Sydenham Road Croydon CR0 2EE United Kingdom
T +44 (0)20 8774 2000 mottmac.com mottmac.com
Mott MacDonald International Limited.
Registered in England and Wales no. 2064414.
Registered office: Mott MacDonald House, 8 10 Sydenham Road, Croydon CR0 2EE, United Kingdom
Document reference: Information class: Standard
This document is issued for the party which commissioned it and for specific purposes connected with the above captioned project only. It should not be relied upon by any other party or used for any other purpose.
We accept no responsibility for the consequences of this document being relied upon by any other party, or being used for any other purpose, or containing any error or omission which is due to an error or omission in data supplied to us by other parties.
This document contains confidential information and proprietary intellectual property. It should not be shown to other parties without consent from us and from the party which commissioned it.
MwakilamaHenrietta Wells Ruth Pratt FinalFigure
Mott MacDonald | Kuunika Evaluation
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
Figure 11: Training Attendance by System Users 29
Figure 12: Duration of Training on OHSP 29
Figure 13: User Overall Satisfaction with OHSP Deployment 30
Figure 14: Assessment of User Friendliness of the OHSP System 30
Figure 15: Rating of OHSP System’s User Friendliness 31
Figure 16: Functionality of OHSP System 31
Figure 17: Connectivity Availability 32
Figure 18: Source of Data Bundle for OHSP System 32
Figure 19: Responsibility for OHSP mobile devices 37
Figure 20: WHO Epidemic Alert and Response Checklist 2005 41
Figure 21: Global Digital Health Index 42
Figure 22: Evaluation team's reconstructed theory of change 50
Figure 23: Evaluation team's reconstruction of the Kuunika causal pathways 51
Table 1: OHSP users interviewed at district, health facility and ports of entry levels 15
Table 2: Analytical Framework 1 WHO Epidemic Alert and Response 2005 Checklist 17
Table 3: Partners and Support Provided 28
Table 4: Distribution of OHSP Mobile Devices in Sampled Districts 34
Table 5: Use of OHSP versus Paper/ WhatsApp 35
Table 6: Summary of Issues for not using OHSP 36
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
BMGF Bill and Melinda Gates Foundation
CDC Centers for Disease Control and Prevention [USA]
CMED Central Monitoring and Evaluation Division
CS Cooper / Smith
DDE Demographics Data Exchange
DHA Department of HIV & AIDS
DHD Digital Health Division
DHIS2 District Health Information System 2
DHMT District Health Management Team
DHO District Health Officer
DHSS Directors of Health and Social Services
EGPAF Elizabeth Glaser Paediatric AIDS Foundation
EHR Electronic Health Record
EMR Electronic Medical Record
EOC Emergency Operations Centre
GoM Government of Malawi
GWAN Government Wide Area Network
HIE Health Information Exchange
HMIS Health management information system
HSA Health surveillance assistant
ICT Information Communication Technology
IDSR Integrated Disease Surveillance and Response
IT Information Technology
KII Key Informant Interview
LIN Luke International, Norway
LMIS Logistic Management Information System
M&E Monitoring and evaluation
MoH Ministry of Health
MM Mott MacDonald
NLMIS National Laboratory Management Information System
OHSP One Health Surveillance Platform
PHIM Public Health Institute of Malawi
STEM Science, technology, engineering and mathematics
TNM Telekoms Network Malawi
UNDP United Nations Development Programme
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
UTAUT Unified Theory of Acceptance and Use of Technology
WHO World Health Organization
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
The Kuunika programme (2016 2021), with funding from the Bill and Melinda Gates Foundation (BMGF), aims to improve data supply, data use, and data governance in the health sector in Malawi. Technological innovations and products have been at the centre of the work of Kuunika to improve efficiency and enable evidence based decision making at all levels in the health sector. Although the first ‘use case’ focused on HIV/AIDS, the programme responded to the pandemic in 2020 to include monitoring of COVID-19 and the Integrated Disease Surveillance and Response (IDSR)
This study is the first of a small series of ‘deep dive’ special studies conducted in 2021 as part of the Mott MacDonald independent evaluation into the implementation and impact of Kuunika1. It seeks to describe how the programme engaged with the Government of Malawi’s pandemic response as the latter evolved.
The study methodology comprised of a desk review, key informant interviews and a briefing discussion with the Kuunika team. A total of 36 interviews were conducted across a range of stakeholders. Two existing conceptual frameworks developed by international health and digital agencies were referenced to determine potential impacts of Kuunika: WHO Epidemic Alert and Response 2005 Checklist (retrospective) and the Global Digital Health Index 7 part framework (prospective). Two other theoretical frameworks related to digital acceptance are also referred to.
1. Evidence for a permanent, COVID 19 pandemic driven ‘surge’ in demand for digital data in the Malawi health sector and its use in decision making.
The first cases of COVID-19 in Malawi were registered towards the end of March 2020, and the government were swift to introduce lockdowns The subsequent surge in the use of digital technologies across all sectors led to mobile phone and internet service providers introducing specific data bundles for different categories of customers. The Ministry of Health (MoH) formed a Presidential Task Force (PTF) and instructed the relatively new Digital Health Division (DHD) to develop models for the spread of COVID 19 in Malawi and tools with which to track and monitor its spread Using the WHO Epidemic Alert and Response Checklist, the DHD built a DHIS2 mobile based tool for recording and reporting disease surveillance data, using a holistic approach on top of UNICEF’s draft One Health Surveillance Platform (OHSP) In addition to the OHSP, an impressive suite of digital tools were developed, including internal dashboards, interactive epidemiological models, a Public Health Emergency Operations Centre (EOC), COVID-19 website, incident management system and Community Applications. The OHSP has been a significant source of information used by health workersin health facilities, districts and ports of entry across the country, whereas the Community Applications have been widely used by members of the public. Within the MoH and PTF, OHSP has been the primary provider of data for daily situation updates of COVID-19 The latter is demanded by the general public on a daily basis, particularly during each new wave of the pandemic.
The response has demonstrated the potential power of digital technologies on managing public health and emergencies Key informants felt that the Kuunika innovations OHSP, e vaccine certificates and others
1 The special studies are part of an evaluation design which also includes a baseline (3 surveys iterated twice) and a mid term programme review. The in country fieldwork for the evaluation was approved by the National Committee on Research in the Social Sciences and Humanities (NCRSH) in May 2017.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
have helped position Malawi as one of the leading countries in sub Saharan Africa in the use of digital solutions in response to the pandemic.
2. Role of Kuunika in responding to and sustaining a digital surge.
The Kuunika Programme supported the establishment and ongoing functioning of the DHD, the key department to which the government turned for COVID data. Kuunika responded rapidly with a ‘project pivot’ towards the urgent new requirements. The development and rollout of the OHSP was relatively rapid, leveraging the success of existing digital architecture. Community applications developed using WhatsApp, Android Mobile Applications and SMS achieved functionality and interoperability with OHSP The COVID website was accessed repeatedly from all over the world
On questioning in mid 2021, key informants stated that 95% of OHSP system users have been trained, with 89% of these reporting that the system is user friendly However, there are significant gaps and challenges with digital rollout and uptake across the health sector. 61% of key informants indicated that the system is not functional all the time and 71% use their personal money to purchase data bundles for the OHSP system. Usage of OHSP and access to data in the system is limited to designated cadres at health facilities, ports of entry and district offices, as well as officials with access to various tools at national level. The majority of health facility staff can only access summaries and reports as end products e.g. on the Public Health Institute of Malawi (PHIM) website or through the social media channels accessed by the general public. Most health facilities and districts continue to use paper systems and WhatsApp either in parallel or as an alternative for submitting data to central level.
Despite defining a clear business and data architecture prior to development, the urgency of the situation perhaps inevitably led to some sacrifices e.g. in following best practice of user led design and in focussing exclusively on the immediate issue. Training of OHSP users was limited to COVID 19 monitoring forms and did not include IDSR until November 2021. In addition, there are sentiments within MoH that OHSP is not yet complete until animal and environmental components are incorporated Nevertheless, the central role of Kuunika’s digital solutions in assisting the Malawi Government in planning, monitoring and responding to the Covid 19 pandemic is evident. Kuunika managed to deliver the requested solutions on time despite facing other challenges during implementation, including limited resources and time. Evidence of the extent and levels of involvement of health workers, district management and national level officials in the sector leads to the conclusion that Kuunika contributed towards an increase in digitalization but more needs to be done for it to become a sustained ‘digital ‘surge’.
Kuunika’s capacity to swiftly pivot direction was key in the MoH and PTF’s decision to put DHD in charge of managing key digital health interventions related to COVID 19. The quick response of the DHD to the MoH requests provided a huge reputational boost to the programme and the department. The project had already shown this adaptability in previous ‘pivots’ in response to the changing landscape in which the project was operating. It was significant that the UNICEF initiated OHSP had been designed by Luke International Norway (LIN), by 2020 the sole implementing partner in Kuunika. Through DHD, Kuunika also worked hard to align and coordinate efforts and resources from development partners towards the national effort Inevitably, some competitive and politically motivated initiatives occurred within the digital health space at the time as some stakeholders sought to promote personal products and agendas over the national directive, but the government showed strong leadership in supporting OHSP from the start.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
Locating OHSP on DHIS2/national digital health architecture continues the core Kuunika aim of an interoperable central platform linked to NLMIS, community applications and OpenLMIS, etc using the interoperability layer. A rare example of co operation between digital partners in actual implementation of common infrastructure and deployment needs is an important achievement and example in donor co ordination and can be built on.
4. Non Kuunika contextual determinants promoting or limiting a digital surge and its sustainability, post COVID 19, in Malawi’s health sector.
• Political will and support from Government. From the outset the government recognized science and digital data as key to providing evidence for decision making in monitoring and responding to the pandemic.
• Accepted use of open source software when developing digital products over ‘for profit’ software.
• Use of local consultants, developers and technicians has promoted the development of local expertise to support the interventions.
• Demand created for and reliance on digital data, easily accessible e.g. DHIS2
• Improved capacity of health workers on data supply and use, and officials on analysis and use for decision making.
• Issues with ICT infrastructure in the health sector and the whole country e.g. aging infrastructure, connectivity issues etc.
• Data quality issues due to user failure to enter complete data e.g. digital vaccine certificates.
• No apparent financial commitment from Government making digital health implementations to be largely donor dependent.
• Missed opportunities such as involvement of e Government to leverage human resources in districts and the national ICT infrastructure, including a Government Wide Area Network (GWAN).
• Prohibitive cost of data bundles and digital technologies.
• Health workers reluctance to adopt new methodologies
5. Lessons and recommendations for the design and sequencing of new digital health sector programmes that can build on and embed any ‘digital surge’ into national health systems.
• Kuunika and the DHD have the potential to be the convening point for the international community including new donors who may now be more willing to support Malawi’s digital plans. It is felt that without Kuunika’s ongoing support the DHD will not yet be able to fulfil this potential alone, warranting a further phase of Kuunika.
• We understand that Kuunika is developing a strategy to systematically address the challenges faced in operating and managing the OHSP at local and national levels, as well as to build capacity at all levels for sustainability. It should contain a clear path of transition and timeframe and the overall government’s commitments, including technical and financial aspects
• Multiple donor-led health programmes and data collection processes at district level are starting to overwhelm health workers and affecting the quality of DHIS2. Better co ordination and standardisation will improve this
• Infrastructure, finance and logistics limitations are still very apparent. These failures are contributing to continued preference for paper systemsand need to be addressed urgently. In order to achieve affordability of IT services, Government should put in place incentives to boost competition in the IT/ telecommunications sector.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
• Data gaps that appear in the OHSP server at PHIM should be addressed at source
• System technical support is limiting usage. E Govt officers at district level could assist in providing first level support and systems troubleshooting by being more immediately if integrated into the Kuunika programme.
• To avoid OHSP users at local level purchasing data bundles using their personal resources, Kuunika/MoH should negotiate with Airtel for provision of free data bundles or to provide a certain amount of data as a start up contribution to all Airtel network users.
• The OHSP/DHIS2 webpage has problems which should be corrected
In summary, key lessons by question area are: Covid-19 Immediate Response
• Reputational boost for Kuunika and DHD in effective rapid response to pandemic, evidenced by direct requests from President for more digital tools
• Demonstration effect to MoH of the potential power of digital continues to foster leadership in DHD
• Kuunika has the potential to be the convening point for international community including new donors who may now be more willing to support Malawi’s digital plans.
• Urgency of covid response drove agreement of a clear business plan and data architecture that built on the existing application architecture prior to development.
• But some corners cut in user centred design principles and training for OHSP due to urgency. Don’t repeat.
• Covid 19 monitoring is yet another silo ed programme multiplying reporting procedures and forms at facility level
• OHSP/DHIS2 webpage has problems which should be corrected
• Locating OHSP on DHIS2 continues core Kuunika aim of an interoperable central platform.
• Act Fast, Fail Fast, Learn Fast: Kuunika must ensure it does the latter to build on lessons learnt during Covid 19
• Infrastructure, finance and logistics limitations still very apparent. These failures may be contributing to continued preference for paper systems.
• System technical support from the centre needs to be improved. Build out from e Govt technicians at district level.
• Too soon to hand over to DHD: Kuunika 2 warranted.
• Increasing donor interest in DHD important to harness but be careful it doesn’t end up in even greater donor dependency.
• Have a clear capacity building and exit plan from the start.
• Multiple donor-led health programmes and data collection processes at district level are overwhelming health workers and affecting the quality of DHIS2. Need more co ordination and standardisation.
Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
This report on Special Study 2 is one of three ‘deep dive’ studies for the final evaluation of the Kuunika Project in Malawi. The study focuses on the how the programme engaged with the Government of Malawi’s pandemic response as the latter evolved.
The Kuunika Project: Data for Action is funded by the Bill & Melinda Gates Foundation (BMGF). It commenced in 2016 and was implemented in partnership with the Government of Malawi (GoM). The Kuunika Project aimed to establish a strong base of high quality, routinely available data and a culture of data use in the health sector, using the HIV/AIDS programme as a first use case. There was a particular focus on addressing the range of technological innovations, knowledge translation, and health system strengthening needs of the Ministry of Health (MoH) in Malawi.
BMGF contracted Mott MacDonald to provide independent evaluation services to the Kuunika Project over the course of programme implementation (2016 2021). These evaluation services have included baseline, midline and endline evaluations. This Special Study (1) is one of three ‘deep dive’ special studies being conducted as part of Mott MacDonald’s final, endline evaluation.
The study set out to assess how Kuunika engaged with the pandemic as it and the Government response evolved, and to explore if it took advantage of the impetus provided by the crisis to promote uptake across a national health system which has proved to be particularly resistant to the digital transition in recent years.2
The specific objectives of the study are:
• to identify and analyse evidence (including quantified evidence, where available) for a permanent, COVID19 pandemic driven ‘surge’ in demand for, and use in decision making of, digital data in the Malawi health sector;
• to explore the role of Kuunika in initiating, directing and sustaining the digital surge;
• to identify which aspects of Kuunika project design, activities and implementation were most important in: supporting the immediate monitoring response (retrospective) and - (potentially) sustaining the digital surge (prospective);
• to identify other (non Kuunika) key contextual determinants promoting or limiting the sustainability of the post Covid digital data surge in Malawi’s health sector; and
• to draw out lessons and recommendations for the design and sequencing of new digital health sector programmes that can sustain and build on the ‘digital surge’ and promote adoption in national health systems that have hitherto been resistant.
This Special Study Report begins with an overview of the Kuunika Project Chapter 3 presents the Covid context a review of key literature and the conceptual frameworks used to determine the potential impacts Kuunika may have had on any digital surge in the health sector Chapter 4describes the studymethodology, including data collection methods. Chapter 5 presents a synthesis of evidence based findings from the study enquiry these findings are presented systematically against each of the study objectives. The final
2 Adoption of Digital Technologies in Health Care During the COVID 19 Pandemic: Systematic Review of Early Scientific Literature PubMed (nih.gov)
Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
chapter of this report (Chapter 6) presents a summary of lessons arising from the study findings, along with our conclusion and recommendations for key stakeholders.
The Annexes to this report provide the analytical frameworks in detail and more background information.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
This section presents an overview of the Kuunika Project and the ‘essentials’ of the how the programme engaged with the government as the pandemic evolved. This, in turn, provides the context for the specific questions underpinning this study enquiry.
The Kuunika Project has aimed to establish a strong base of high-quality, routinely-available data and a culture of data use in the Malawi health sector, using HIV as a first use case. Together with the Government of Malawi (GoM), the Project has sought to strategically and efficiently strengthen the data systems architecture, while simultaneously evaluating targeted methods to increase data use for decision-making at facility, district and central levels.3
Notably, Kuunika has been characterised by an adaptive project design approach from the outset. Delivery of the Kuunika Project was based on a multi phase implementation plan to allow for innovation, evaluation, and iterative responses. Phase I (scheduled for 2016 2019) included formative research and mapping of the ‘enterprise architecture’. This informed the design of a full package of support to five districts including Lilongwe, Blantyre, Zomba,Thyolo and Mangochi and three facilities in Mulanje.It was expected that Phase II would be based on scale up to additional districts and sites, prior to a final phase of sustaining programme gains and translating lessons learned into policy and further roll out.
The Kuunika Project was initially set up to be implemented by a consortium of four organisations: Lighthouse Trust (LHT); Baobab Health Trust (BHT), Luke International, Norway (LIN); and International Training and Education Center for Health (I-TECH); additional technical support has been provided by Cooper Smith.
In practice, Phase I delivery proved slower than expected. The Kuunika team, therefore, agreed with BMGF to undertake a ‘project pivot’ to prioritise activities that would more rapidly ‘unlock defined key capabilities’ in HIV services. From November 2018, this involved a tighter focus on existing sites (rather than rolling out to new ones), accelerated delivery of specific data products to encourage data use, and a revised training approach. There were also new targets for improving the underlying system architecture, including the Health Facility Registry, the Demographic Data Exchange and the interoperability layer. On the back of this project pivot there was a significant reconfiguration of the consortium. This resulted in LIN becoming the sole Implementing Partner (drawing on consultant support from the original consortium partners), with additional technical assistance provided by Cooper Smith.
Annex 1 shows the Kuunika theory of change developed by the evaluation team in 2019 which incorporates the 2018 / 2019 project pivot. This version of theory of change updated the baseline theory of change and shows the priority activities / deliverables agreed at each system level. It shows that key outputs for successful delivery of intended Kuunika outcomes would be the establishment of a Master Health Facility Registry and a Demographic Data Exchange (to support data sharing and patient mobility), contributions to the National Standards Registry through Standard Operating Procedures (SOPs) and approval procedures and inclusion of data quality assessment tools within DHIS2.
The Kuunika programme operates within the Digital Health Division at the Ministry of Health and works with other departments and divisions within the Ministry Department of HIV & AIDS (DHA), Centre for Monitoring & Evaluation Division (CMED), and Public Health Institute of Malawi (PHIM). Kuunika was therefore well placed to mobilise swiftly to support the Government in monitoring and reporting the domestic 3 Kuunika. (2019). Press Statement for the Kuunika Core Package Launch. Retrieved from: https://www.kuunika.org/?p=3340
4
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
course of the coronavirus. Using platforms and structures it had been working on, Kuunika pivoted again in March 2020 towards supporting the centralised COVID 19 Emergency Operations Centre with epidemiological and risk modelling, piloting and installing real time data capture.
Figure 14 below shows a reconstructed timeline of key project milestones relevant to review of Kuunika contributions to digital health governance themes in Malawi since 2016.
Figure 1: Key Kuunika milestones
5
Figure 1 shows that in Phase 1 (2016-2018) there was a focus on formative research, with particular emphasis on opportunities to improve data use for decision making at all system levels. This, in turn, was accompanied by efforts to improve access to timely, quality data through roll out of EMRs, with the HIV programme as the use case.5
As indicated above, in Phase 2 there was a rationalisation and restructuring of the project, initially to refocus efforts on systems strengthening and accelerated delivery of key data products to support data use.
A further significant milestone occurred at the end of Phase 2 when the GoM requested Kuunika to become the lead implementing partner for its new Digital Health Division this ongoing role includes support to some 26 staff inthe Division. A key initial task area was technical assistance for development of the National Digital Health Strategy, 2020 2025. Although a robust Strategy was produced, the period 2019 2020 was associated with two national elections, leadership changes in MoH, and the outbreak of the COVID 19 pandemic all of which have had consequences for operationalising the Strategy.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
Mott MacDonald conducted independent evaluations of the Kuunika Project in 2017 (baseline) and 2019 (midline).
The 2017 baseline evaluation report used a theory based, mixed method approach to generate a baseline for the Kuunika design objectives relating to: core information technology (IT) infrastructure; strengthening and scaling up EMR systems; training, mentoring and incentivising target users; and assisting in the establishment of MoH data governance structures and support use of quality for data driven decision making. The baseline evaluation confirmed the presence of hybrid electronic and paper based systems for collection of HIV data, and highly fragmented and parallel systems for registering and providing HIV (and other primary health care services) at facility level. It was noted that, at baseline, there were mixed stakeholder perceptions of HMIS data quality, and there was little use of electronic data for decision making at each system level
The midline evaluation found that by 2019 paper based data systems continued to predominate. The extent of use of an EMR to enter data had remained largely unchanged at just over one in three (38%) respondents with power and connectivity issues being a key factor in consistent EMR use. There was some evidence of a stronger, more active ‘data culture’ by 2019; however, the enabling environment for using data within the larger health system remained weak. Very few respondents at facility and district levels had knowledge of the key technology deliverables relating to Unique Identifiers, the Health Facility Registry and the Demographics Data Exchange (DDE).
Based on the findings from the baseline and midline evaluations, and a preliminary desk review for the endline evaluation, the evaluators have identified a number of topics for ‘deep dive’ special studies. The topics and the specific questions for enquiry have been agreed with BMGF, GoM and the Kuunika leadership. They are informed by the Kuunika team’s own progress review in December 20206 key points from this review are summarised in Figure 2 below.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
Figure 2: Summary of Kuunika's progress review (Dec 2020)
Special Study 1 seeks to describe how the programme engaged with the Government of Malawi’s COVID 19 pandemic response as it evolved. It will look for evidence of the hypothesised permanent increased use of digital systems during the pandemic and explore how Kuunika and the Malawian government can build on that impetus.
The specific aims of this study are:
• to identify and analyse evidence (including quantified evidence, where available) for a permanent, COVID 19 pandemic driven ‘surge’ in demand for digital data in the Malawi health sector and its use in decision making;
• to explore the role of Kuunika in responding to and sustaining that digital surge;
• to identify which aspects of Kuunika project design, activities and implementation were most important in a) supporting the immediate monitoring response and b) sustaining a step change in digital data use thereafter.
• to identify other (non Kuunika) key contextual determinants promoting or limiting a digital surge and its sustainability, post COVID 19, in Malawi’s health sector.
• to draw out lessons and recommendations for the design and sequencing of new digital health sector programmes that can build on and embed any ‘digital surge’ into national health systems.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
Almost all countries in Sub Saharan Africa (including Malawi) have either mobile or fixed telecommunications network, or both. However, the terrain of telecommunication services varies significantly from country to country, as well as among regions. Within countries some localities are well covered with broadband or fibre optic connectivity, which can be reliable or not, while others have no coverage at all. With the advent of the pandemic, some governments re-directed priorities to address this infrastructure gap, enabling digital technologies to help firms and individuals to continue to operate while observing COVID 19 restrictions. In Malawi, 30.8 percent of the population now lives within 10kms and nearly all of the population lives within 50km of fibre nodes; 88 percent of people have access to either 3G or 4G signals7
“
In the wake of the COVID 19 pandemic, we saw technology accelerate to a breakneck pace…. Using big data and analytics has always been on a steady growth trajectory and then COVID 19 exploded and made the need for data even greater”.8
This quote summarises the sense amongst many that COVID 19 has created the ‘perfect storm’ 9 10 that is accelerating the process of digitizing data to new speed and scale. Globally, governments have set aside US $1.5 trillion towards digitalization to make sure that it supports the economy through improved connectivity, enhanced data infrastructure and other necessary aspects11
Some of the digital technologies developed and used in Africa during this period accounted for about 13% of all innovations designed and used worldwide, and these include WhatsApp chatbots (South Africa), selfdiagnostic tools (Angola), contact tracing (Ghana), mobile health information tools (Nigeria), and robots supporting medical staff and mass screenings for fever at the airport (Rwanda) 12
In Africa, as elsewhere, the health sector in particular witnessed swift digital and innovation transformation during the pandemic. Digital technology based solutions were developed, tested and adopted to help governments to effectively respond to COVID 19 pandemic.
In the years preceding the emergence of the COVID 19 virus, health care systems worldwide had a relatively poor track record in adopting digital technologies at scale. Many of the technologies employed during the pandemic (eg, to allow health care to be delivered when physical contact is not possible) were already well established but not widely implemented13 In responding to the emergency, health systems in many countries rapidly reinvigorated existing tools or implemented new ones Governments and international partners came to realize the “central role of data in tracking and tracing outbreaks of infection generating unprecedented activity in the search for and development of suitable technology”14 .
7 http://documents.worldbank.org/curated/en/131501624458623473/Malawi Economic Monitor Investing in Digital Transformation
8 The Top 10 Digital Transformation Trends Of 2020: A Post COVID 19 Assessment (forbes.com)
9 Biomedicine Hub 2020, Vol. 5, No. 3 Karger Publishers
10 Impact of digital surge during COVID 19 pandemic: A viewpoint on research and practice (nih.gov)
11 World Bank (2021). World Development Report 2021: Data for Better Lives. Washington DC: World Bank
12 The World Bank. 2020_Ibid. p.5
13 Adoption of Digital Technologies in Health Care During the COVID 19 Pandemic: Systematic Review of Early Scientific Literature PubMed (nih.gov)
14 Horgan, D. et al. 2020. P.2
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
Depending on the maturity of the technology, the provision of health care through remote consultation came to be much more prevalent much more quickly, and as a result, the approach to digital tools in health systems appears to be undergoing a substantial and rapid shift. The global pandemic, plus the situation of much of the technology, appears to have effectively promoted the uptake of digital systems even in those national health systems which have proved to be particularly resistant to the digital transition 1516
Most of these digital solutions and innovative technologies have been specifically proposed for the diagnosis of COVID 19 . Fewer address lifestyle empowerment or patient engagement17 Alsunaidi, S. et al. (2021) argues that controlling this kind of a pandemic requires understanding of several aspects and behaviour, which can only be done by collecting, analyzing and interpreting related big data.18
The digital solutions have become crucial tools for healthcare workers and policy makers in the sector as they seek to be on top of an evolving situation and effectively monitor and respond to the pandemic. Digital technologies have enabled authorities and stakeholders in the health sector to realize the importance of availability and sharing of comprehensive health data to effectively address the pandemic.19 There is generally a hope that ‘the Recovery will be Digital’ enabling the process of digitizing health data to proceed post COVID at a new speed and scale.20
The previous 10 years before COVID saw a plethora of digital legislation, policies and strategies in Malawi, and the presence of many international donors and NGOs both supported and necessitated this. Kuunika’s focus on supporting one dedicated digital department within the MoH and maintaining the principle of interoperability in all digital developments had been important in promoting a culture of government-led standardised systems within the health sector. As outlined above, the Kuunika Project initially aimed to establish a strong base of high quality, routinely available data and a culture of data use in the Malawi health sector, using HIV as a first use case. Through the MoH, the Project has sought to strengthen the data systems architecture, while simultaneously evaluating targeted methods to increase data use for decision-making at facility, district and central levels.21
When COVID struck, Kuunika had made significant progress but was also experiencing challenges, both internal and external. Achievements included the set up and functioning of the Digital Health Division, contributions to the National Digital Health Strategy and the Digital Health Sustainability Paper, and aid effectiveness e.g. through the joint HIS Investment Fund, several Data Use initiatives and the Master Health Facility Register. Challenges included a fragmented digital health investment environment, lack of joint planning between MoH and partners, and IT infrastructure issues across the country. Nevertheless, although progress in the early years was slow, it did provide the Kuunika team with a firm foundation of operational experience and lessons. These, in turn, enabled the significant contributions to the digital response to COVID.
15 The digital revolution | The King's Fund 16 Adoption of Digital Technologies in Health Care During the COVID 19 Pandemic: Systematic Review of Early Scientific Literature PubMed (nih.gov) 17 ibid 18 Alsunaidi, S. et al. 2021. P.1 19 Horgan, D. et al. Ibid, p.2
20 The next normal the recovery will be digital.pdf (mckinsey.com)
21 Kuunika. (2019). Press Statement for the Kuunika Core Package Launch. Retrieved from: https://www.kuunika.org/?p=3340
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
Following the advent of COVID 19 into Malawi, the government, through the Presidential Task Force on COVID 19 (PTF), introduced a series of containment measures to curb the spread of the virus. On 23rd March, 2020, all schools in the country were closed, meaning that almost 6 million school going children had to stay at home22 Some primary, secondary and tertiary institutions, especially those privately run, introduced online learning to keep their students busy and remain on track with their academic programmes, particularly those whose students sit for international examinations. Around the same period, the majority of offices and businesses closed and their staff mostly worked from home. Online platforms, such as Zoom, Microsoft Teams, Skype and Google Meet, were utilized to transact office business, including holding meetings, and this significantly increased demand for digital technologies and solutions to meet people’s needs. This mirrors experiences elsewhere in the world where some countries and localities saw an increase in usage of information systems and technologies from 40 100% when compared with the pre lockdown period23
The Reserve Bank of Malawi also made its contribution by engaging commercial banks to reduce online transaction fees. In April 2020 commercial banks reduced by 40% all fees and charges on mobile payments, internet banking, ATM transactions and other services24. The PTF encouraged people to utilize the online platforms in order to minimize travel to and contact in banking halls amid the pandemic. Businesses too encouraged their customers to utilize this opportunity to minimize use of cash and visits to the bank for deposits. Online platforms were also used by businesses, especially small to medium scale, to market and sell their products.
Furthermore, the period saw a huge increase in the use of social media by the general public. This was a way for people to stay in touch with their family and friends. Social media was also used as a tool for tracking COVID 19 trends, latest developments and following newly instituted guidelines and directives by Government. It also became a convenient tool via which people provided psycho social support to affected individuals, families and friends.
Mobile phone and internet service providers introduced services for various categories of customers. For example, TNM,Airtel and other service providers introduced special and subsidized data bundles to support the education sector, free data bundles to support COVID 19 reporting and response, and other data bundles and options for other sections of the public The period also saw a soaring demand for gadgets supporting this digitalization e.g. tablets, laptops, computers and wifi routers.
The country’s rapid increase in digital demand was not universal, however, with large sectors of society excluded, primarily the urban poor and more remote rural areas. On the education front, public primary and secondary schools could not run online classes to the same level as private schools. Access to digital technologies, data bundles and even reliable power was restricted for the poor and rural populations. 22 UNICEF 2020. Coping with school closures during the Covid 19 pandemic 23 De R. et al, 2020; p.1 24 African News, 2020
MacDonald | Kuunika Evaluation
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
As indicated in previous sections, this study aims to describe how the Kuunika programme engaged with the Government of Malawi’s pandemic response as it evolved through 2020, look for evidence of the hypothesised permanent increased use of digital systems during the pandemic and explore how Kuunika can build on that impetus. Consistent with the framework adopted by the study, the evaluation sought to draw out key lessons on Covid-19 responsiveness; sustainability and aid effectiveness.
These retrospective and contextual enquiries required a qualitative study, complemented by some quantitative analysis, using the following methods;
I. Project document/public media review
II. Rapid literature review
III. Quantitative Analysis where available (e.g. DHIS2 use metrics)
IV. Key informant interviews a total of 36 interviews were conducted.
Two existing conceptual frameworks developed by international health and digital agencies were used as reference to determine potential impacts of Kuunika: WHO Epidemic Alert and Response 2005 Checklist (retrospective) and the Global Digital Health Index 7-part framework (prospective)25. Other theoretical frameworks related to digital acceptance are also referred to.
The study commenced mid July, 2021 with preliminary study protocols, followed by data collection between August and October 2021. The final report was completed in November, 2021.
A purposive sampling technique was followed, in addition to ‘snowballing’ whereby because those who were interviewed used their position to make referrals to their recommended informants. Participants in the study were drawn from national and international health sector actors and commentators. Care was taken to ensure a geographical as well as a hierarchical perspective was included:
Table 1 shows the range of OHSP users interviewed at district, health facility and ports of entry levels.
Table 1: OHSP users interviewed at district, health facility and ports of entry levels
Designation No.
Public Health Institute of Malawi (PHIM), Ministry of Health (MoH) 2 CMED, MoH 1 PHIM, MoH/ e Government Department 1 Kuunika/ DHD, MoH 4
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
Luke International Norway (LIN)/ Kuunika 2 Independent Consultant/IT expert 2 Telekom Networks Malawi (TNM) 1 Balaka DHO 2 Zomba DHO 2 Machinga DHO 2 Health Centres, Balaka 4 Mission Hospital, Zomba 1 Health Centre, Zomba 1 Health Centre, Blantyre 3 Health Centre, Machinga 3 Border Posts 2 International Airports 2
The target sample size of the study was 40 key informants, and despite challenges on the ground a total of 36 interviews were conducted. This has enabled achievement of saturation and provision of sufficient ‘information power’.
One to one interviews were conducted where possible using a semi structured topic guide (Annex 2). These primarily covered national level stakeholders. Following this, a questionnaire was administered to OHSP system users in districts, health facilities and ports of entry
Secondary data was collected using a standardized rapid literature review template developed for the purpose. Sources used included:
Kuunika programme documents
Written information on the products developed relevant to the study
Local and international literature on COVID 19, digitalization and related aspects
In addition to the empirics, the study also looked at appropriate theoretical frameworks to guide the study (see below).
Interview notes were recorded by the interviewer using a coded notes template. The notes were then transferred to an Excel spreadsheet matrix organised around key sub themes, framework of analysis and the agreed report outline. This allowed a simple thematic analysis, as well as a searchable record during writing up. Each interview questionnaire and record underwent a data cleaning process to eliminate any errors. Qualitative data were analyzed using a content analysis technique, while quantitative was analyzed
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
by generating tables, graphs and other figures conducive to clear interpretation. All respondents were assured of confidentiality. In keeping with the study consent form, no respondent was cited or quoted without prior permission.
Interview records were managed in line with Mott MacDonald/ Microsoft Teams data privacy and protection protocols. In keeping with Mott MacDonald procedures, a Data Protection Impact Assessment26will be completed before contract closure to ensure compliance with Mott MacDonald’s Privacy and Data Protection Group Policy Statement27 and the Group’s General Data Protection Regulation (GDPR) Framework guidance. 28
The study utilized three analytical frameworks considered relevant to our understanding of the subjects of epidemic, pandemic, digitalization and sustainability in health. The frameworks assist in assessing Kuunika possible impact regarding a ‘digital surge’. The first is retrospective supporting the immediate response to the pandemic that uses the WHO Epidemic Alert and Response 2005 Checklist. It is suitable for assessing whether Kuunika had an impact on the Ministry of Health and the wider health sector in its immediate actions in the COVID 19 pandemic.
Table 2: Analytical Framework 1 WHO Epidemic Alert and Response 2005 Checklist Domain
1. Preparation for an emergency a) Getting started, b) Command and control, c) Risk assessment, d) Communication, e) Legal and ethical issues, and f) Response plan by pandemic phase.
2. Surveillance a) Inter pandemic surveillance (general and early warning), b) Enhanced surveillance, and c) Pandemic surveillance.
3. Case investigations and treatment a) Diagnostic capacity (local laboratory capacity, and reference laboratory availability), b) Epidemiological investigation and contact management, and c) Clinical management
4. Preventing spread of the disease in the community a) Public health measures, b) Vaccination programmes, and c) Antiviral use as a prevention method.
5. Maintaining essential services a) Health services, b) Other essential services, and c) Recovery.
6. Research and evaluation
7. Implementation, testing and revision of the national plan
The second is a prospective framework focusing on ‘sustaining the surge’, for which the study used the Global Digital Health Index 7 part framework29. This is used to analyze and identify where implementation of Kuunika and the programmatic pivots may support maintaining the surge at new higher levels. This framework allows for exploration of the influence of other contextual factors.
Figure 3: Global Digital Health Index
Lastly, the study also utilizes digital or technology related frameworks by Corver and Elkhuizen (2014)30 , and Venkatesh et al. (2003)31 Corver and Elkhuizen (2014) propound that digital transformation ought to begin and serve the customer first. Its premise is that everything starts with and centres on a customer as a key stakeholder. Thus, a digital transformation process must be tailored towards who the customers are, their needs, and the service(s) that would improve their experience. On his part, Venkatesh et al. (2003) developed the Unified Theory of Acceptance and Use of Technology (UTAUT) which incorporates other theories such as the theory ofplanned behaviour, innovation diffusion theory and the social cognitive theory. The UTAUT theory posits that environmental, social and economic factors are directly linked to individuals’ behavioural changes in how they do things or undertake a particular endeavour. This theory speaks directly to the COVID 19 pandemic which goes beyond a public health problem into an issue that has affected all aspects of life. The framework looks at individuals’ willingness to accept and adopt, or reject, technological innovations introduced to bring about change in their setting or organization. 29 Global Digital Health Index
30 Corver, Q., & Elkhuizen, G. (2014). A Framework for Digital Business Transformation 31 Venkatesh, V., Morris, M. G., Davis, G. B., & Davis, F. D. (2003). User Acceptance of Information Technology: Toward a unified view.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
The study was undertaken following an approved protocol from the National Health Sciences Research Committee. Authorities in all study targeted areas and institutions were informed of the evaluation in advance. The consent statement explained the background and purpose of the study and how findings would be used. All key informants were: a) assured of confidentiality and anonymity unless formally agreed otherwise; b) informed they were under no obligation to answer any question that made them feel uncomfortable; and c) informed they were free to terminate the interview at any time
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
5.1 What evidence is there for a permanent, COVID-19 pandemic-driven ‘surge’ in demand for digital data in the health sector in Malawi
The surge in the use of digital technologies across all sectors led to mobile phone and internet service providers introducing specific data bundles for different categories of customers. Airtel and TNM offered reduced terms for the health sector as a contribution to the efforts to control the spread of the virus. The Ministry of Health (MoH)’s Presidential Task Force (PTF) has led the response, with digital inputs developed through the Digital Health Division (DHD). The DHD’s models and tools developed to track and monitor the spread of COVID 19 in Malawi have become mainstream. The One Health Surveillance Platform (OHSP), built on DHIS2 architecture, became immediately the go to facility for information for the MoH. In addition to the OHSP, internal dashboards, interactive epidemiological models, a public health emergency operations centre, COVID 19 website, incident management system and various Community Applications were developed. The OHSP has become a significant information tool used by health workers in health facilities, districts and ports of entry across the country, whereas the Community Applications have been widely used by members of the public. Within the MoH and PTF, OHSP has been the primary data source for daily situation updates of COVID 19, which are demanded by the general public, particularly during each new wave of the pandemic.
The response has demonstrated the potential power of digital technologies on managing public health and emergencies.
In order to unpack this question, this section firstly lists the different COVID supportive solutions developed by Kuunika, followed by a discussion on Kuunika’s role in response and sustainability based on study findings
As early as February, 2020, before any cases of COVID 19 were reported in Malawi, the Ministry engaged Kuunika and the DHD to discuss best ways of helping it in the fight against the impending pandemic. An agreement was made for Kuunika to help the MoH with data supply in order to make evidence based decisions in its planning, monitoring and response to the pandemic. Kuunika leveraged on existing IDSR paper based reporting forms and the WHO COVID 19 toolkit to standardize forms for all health facilities and ports of entry for tracking, monitoring and reporting of COVID 19 This coincided with the lead Kuunika implementing partner, Luke International Norway, completing the development of the electronic IDSR system, funded by UNICEF. It was therefore agreed that this digital platform be refined to incorporate COVID 19 reporting in additional to the intended purpose of IDSR reporting. This enabled Kuunika to rapidly deliver the One Health Surveillance Platform (OHSP) which catered for both COVID 19 and Integrated Diseases Surveillance and Response’s monitoring and reporting requirements.
In addition to the OHSP, Kuunika delivered a number of other technological solutions adapted for different stakeholders, including the Ministry of Health senior management, the Presidential Task Force on COVID 19, healthcare workers and the general public. The Kuunika innovations (see below) appear to have positioned Malawi as one of the leading countries in sub Saharan Africa in the use of digital solutions in response to the pandemic.
5.2 What was/is Kuunika’s role in responding to and sustaining that surge?
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
5.2.1.1.Public
A national situation room designed to collect, collate and analyze data from multiple sources and package it for use by different stakeholder groups internal and external for their own decision making. Kuunika furnished the Emergency Operations Centre (EOC) and installed TV and computer screens with which staff working in the situation room and any cluster meetings can access live information as streamed by international and local TV stations, as well as data from multiple sources approved by the Ministry of Health.
Figure 4: Emergency Operations Centre at PHIM
Source: Kuunika Data for Action (2020)
Information from local sources is summarized and packaged by the EOC staff in the form of daily situation updates which appear on the internal dashboard and PHIM website, following approval by the Secretary for Health and Minister, who is also Co Chair of the PTF This report is also shared with the general public every evening through media houses and social media platforms such as Facebook and WhatsApp. Figure 5 presents an example of the daily situation report generated by the EOC.
Source: PHIM (2021)
This has become a vital piece of information to the general public, enabling the vast majority of the population to keep up to date with daily COVID 19 trends in the country, and facilitating the public to take the necessary precautionary measures. It became and remains a well known source of current information, sparking discussion during each new wave and particularly at the peak of the pandemic when new COVID 19 cases, admissions into treatment centres and deaths were high.
Since the Public Health Institute of Malawi did not have a website but was suddenly thrust into the public eye, the Kuunika programme developed a simple website for the Institute to act as a platform for disseminating important public health information during phases the pandemic. Figure 6 presents an example of the website landing page:
Mott MacDonald | Kuunika EvaluationFigure 6: Landing page of MoH’s COVID-19 website
Source: MoH COVID-19 Website
This website dashboard shows up to date national information with a more detailed breakdown of COVID 19 information by time and geography, disaggregated right down to district level. PHIM update it on a daily basis and it is used by health personnel (at various levels), partners, researchers and the general public. The website is at https://COVID 19.health.gov.mw/.
Following the need to better present information in a manner in which senior officials in the Ministry and leadership of the PTF can easily understand the COVID 19 situation on the ground and make informed decisions, Kuunika also developed internal dashboards. They provide an overview of all new cases, cumulative confirmed cases, average daily cases and case fatality rate. It also provides general analytics key to inform targeted officials on how the pandemic is spreading and whether prevention and response measures are working or not. The dashboards also present disaggregated data based on location (e.g. districts and cities) and gender (male vs. female) over a given period. Figures 7 and 8 gives examples of some of these internal dashboards.
Figure 7: COVID-19 EOC Home Page
Source: Kuunika (2020)
Figure 8: COVID 19 Case Management Dashboard
Source: Kuunika (2020)
Mott MacDonald | Kuunika Evaluation
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
5.2.1.4
Recognizing that there were gaps in the original IDSR paper based form, and the need for standardization of the reporting forms, Kuunika undertook a review exercise and standardized these forms. The purpose was to ensure uniformity in capturing and reporting for both COVID 19 and IDSR.
5.2.1.5
The OHSP was designed as a tool for collecting data in real time as health personnel interacts with health facilities, travellers and COVID 19 suspected cases at ports of entry into Malawi, and the community. OHSP’s key features are: patient and traveller screening, patient tracking and follow up, contact tracing, case management, laboratory sample tracking, and vaccine delivery. The primary users are health officers at ports of entry to Malawi, district and health facility level surveillance personnel and data entry clerks. Below are examples of the workflows for each:
Port of Entry: An individual entering the country presents himself or herself to health personnel, who fills a portof entry form. At this point,demographics, travelhistory and symptoms are captured.Ifthe individual is not a suspect, they are required to self quarantine at home, while a suspected Covid case follows a case based surveillance workflow, which is explained under case management. A Health Surveillance Assistant follows up on suspected cases and their contacts in the community for up to 14 days checking whether they develop any symptoms of COVID 19
Case Based Surveillance: A suspected case with signs and symptoms of COVID 19 undergoes a clinical diagnosis and examination. This is followed by filling out of a Lab Request Form and administration of the COVID 19 test. When the test result is positive clinical management is triggered and contact tracing also commences, requiring all contacts take their COVID 19 tests.
Contact Tracing: HSAs or assigned health workers create a list of all contacts of the COVID 19 positive case, and makes all necessary follow ups to check for symptoms. All contacts without any symptoms are asked to self-quarantine, while those who have shown symptoms are asked to take a test at a health facility. Clinical management and advice is given when the outcome is positive.
All data captured is synchronized immediately after or later when there is connectivity. The data goes directly from the OHSP mobile device to the server at PHIM Our informants mentioned that often this data is only seen by the designated HSA who collects it at the health facility or point of entry, and the district IDSR focal person. The rest of key stakeholders such as health facility in-charge and members of the District Health Management Team (DHMT) are not privy to the data due to lack of access. Figure# shows information flow of the OHSP.
Another key contribution by Kuunika was the development of an electronic vaccine certificate. This was commissioned following reports that some individuals were making and using fake COVID 19 certificates to use when travelling or if required by their employers to enter office premises. There were growing calls from authorities and the general public to transition from paper based certificates to something credible, which can be trusted beyond the borders.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
People are able to generate their individual e vaccine certificates from the PHIM website using their unique identifier. This works only for individuals whose data was entered electronically during the time of their vaccination However, some individuals are unable to generate the certificates because their data was captured manually and therefore not yet in the database at PHIM. If these individuals return to the centres where they were vaccinated their data can retrospectively be captured electronically. This innovation is recognised to have made Malawi to be far much ahead of other countries in this region (KII N1 1).
Community Applications: WhatsApp Chatbot, USSD Platform and SMS platform, which enabled members of the community and the general public to easily record whenever they suspected themselves to have symptoms of COVID 19 or to report suspected cases.
Mass gathering model, and interactive epidemiological model, which were developed to guide the Ministry’s management and PTF in their planning and response to the pandemic.
Incident Management System, which was set up to assist with receiving, tracking and managing COVID 19 incidences that have been reported.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
5.3 What aspects of Kuunika project design, activities and implementation were most important in a) supporting the immediate monitoring response and b) sustaining a step change in digital data use thereafter.
5.3.1
A review of the approach taken in developing the digital solutions was made to determine the extent to which stakeholders were consulted and the process recorded Compilation and documentation of each and every piece of communication is also critical in system and product development as these are often required in the future as reference points, as well as for maintenance and sustainability.
Using data from a broad range of stakeholders (HSAs, health officers at ports of entry, HMIS officers and District IDSR focal persons), the following two figures illustrate that consultation at different user group levels was extremely restricted:
6% 94%
YES NO
0% 100%
YES NO
N = 18 N = 19
The 94% of original and ongoing OHSP users at District and facility levels that were not consulted on its development felt that this was unfortunate. The Kuunika team initially made sure that consultations with end users were included, to ensure that development mirrored the realities on the ground, but the rapidly changing situation with the pandemic prevented this approach from continuing.
“Kuunika team did come to Mwanza Border for problem analysis, requirements gathering and to appreciate the workflow at the border. But eventually they stopped coming for further interactions. In the end, we just saw them coming to deploy the OHSP.” (KII.M2-1)
Similarly, although at first Kuunika followed the standard approach of documenting the requirements formally and coming up with a Systems Requirements Document part of a standard software development process the urgency and frequent changes that were happening made this approach impossible. Primarily, top officials in the Ministry provided the requirements for the digital solutions, and this continued into the development process. Only meeting and initial product development notes were recorded, including review with MoH officials.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic
The same senior officials in the Ministry reviewed the solutions while in development up to deployment, including OHSP. Prospective users of the OHSP system at district and health facility levels were excluded from this process, with a similar top down approach being used Whilst a user centred approach is certainly best practice, the urgency to deliver the system within a short period, and during a time of frequent change to requirements from the MoH, explains this to some degree.
The OHSP development process was completed in April 2020 and immediately, following guidance from the Ministry and PTF, Kuunika embarked on deployment of the system. A staggered approach was necessary as both funds and mobile devices were limited, and high burden localities, cities and districts were prioritised The Ministry worked in close partnership during this time to maximise funds and procure servers, tablets and smart phones. The Bill & Melinda Gates Foundation, UNICEF, CHAI, WHO, USAID and MSH all provided support in various ways (see Table 3 below) Remarkable cooperation among partners in the health sector was witnessed as they worked towards one goal of investing in infrastructure and deployment needs for effective monitoring and response to the pandemic. This happened at a time when no partner had a specific budget line for this, given the unexpected nature of the situation.
Table 3: Partners and Support Provided Partner some of the Support provided
Bill & Melinda Gates Foundation (Kuunika)
Funding and other resources throughout the entire process
WHO Server procurement and resources for deployment
UNICEF Server procurement and resources for deployment
CHAI Resources for deployment is some districts
MSH/ONSE Tablets and resources for deployment
As of June 2020, Kuunika had deployed 301 mobile devices in 16 districts based on the priority list agreed with MoH and partners.
The study also examined user experiences with the training, deployment and actual use of the One Health Surveillance Platform. In addition to the sampled districts and health facilities, the study included respondents from some ports of entry into Malawi, as they have been a key component in the fight against COVID 19, namely Kamuzu International Airport in Lilongwe, Chileka International Airport in Blantyre, Mwanza Border in Mwanza, and Malaka Border in Nsanje.
The study checked with respondents whether they received formal training on how to use the OHSP. Figure 11 shows the percentage of respondents who were trained by the Kuunika team.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
80%
60%
40%
20%
95% 5% 0%
100% YES NO
N = 19
95% of system users indicated that they were trained by Kuunika on how to use the OHSP system The majority indicated that the duration of the training was 1 to 2 days.
0.5 day 1 day 2 days 3 days 4 days 5 days
0.5 day 1 day 2 days 3 days 4 days 5 days
N = 18
Respondents were asked whether they felt the training was adequate in terms of coverage of all aspects of the OHSP. This is critical as it has a bearing on their ability and confidence to use the system once deployed. Slightly over half of respondents (56%) indicated that they were not satisfied with the training and deployment process as the period was too short. They said this made it impossible for some features and aspects of the system to be covered in detail.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
Figure 13: User Overall Satisfaction with OHSP Deployment
N = 18
5.3.2.2
The study also examined user experiences with actual use of the One Health Surveillance Platform. Respondents were also asked whether the OHSP is user friendly in terms of its design, features and the overall experience .
Figure 14: Assessment of User Friendliness of the OHSP System
N = 18
A majority ofthe users (89%) stated that OHSP is a userfriendly system,with only 11% indicating otherwise. The users were happy with its design, including its capability to capture data in offline mode for a later synchronization. When asked to rate OHSP system’s user friendliness, more than half of respondents (56%) rate it very good and about a quarter of them rate it as excellent
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
Figure
1 = very poor 2 = poor 3 = good 4 = very good 5 = excellent
N = 18
5.3.2.3 Functionality
The study also assessed whether the OHSP was consistently user friendly, and remained operational at all times.
N = 18
Evidence shows that functionality of the system is problematic for most of the system users (61%). They stated that the system is not functional at all times compared to 39% who observe that it is always up and running. The main issue which affected functionality were new updates by Kuunika without prior notice and/ or orientation to system users. Users therefore experience challenges whenever they log in and see new forms appearing in the system without their prior knowledge. This can put off a group of users who are not very familiar with mobile technologies and/ or are technophobic.
Internet connectivity is avery crucial component for anymobile system such asOHSP.It enables the mobile device to receive updates and some system fixes remotely, but more importantly it allows the transmission of data from source to intended destination. Study respondents were asked if connectivity in their area of work is available at all times or not.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
N = 17
In many areas, system users are experiencing problems with internet connectivity. Nearly half of the users (47%) continue to face connectivity issues. This is the case because there are no mobile phone towers covering their areas or they are far and therefore the connection signal is usually weak. This in part explains some of the challenges highlighted by the districts and PHIM with regard to receiving daily reports from health facilities and ports of entry
5.3.2.4
On data for connectivity, Kuunika received an offer for free connection for OHSP mobile devices from Telekom Networks Malawi (TNM) and Airtel Malawi as part of their contribution to the fight against COVID 19. During roll out of the OHSP, however, it was noted that Airtel’s free connection was not functioning properly. As such, Kuunika proceeded with the TNM network for free data, while in areas where there is no TNM network coverage system users were asked to use Airtel paid lines.
Figure
N = 17
Personal Money
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring
The majority of OHSP users (70.6%) use personal money to purchase data bundles for the OHSP system, and obviously this is Airtel network. Only 23.5% of them use free TNM data. This is mainly due to unavailability of TNM coverage of most of the localities in question. This 70.6% is also a clear demonstration of the seriousness and commitment of system users to ensure they get their work done as expected. This is a very critical piece with regard to sustainability of the OHSP system. Some users still feel they need to be receiving a certain amount from Kuunika or the District Health Office., whether as a start up for the month or for the entire period. If it is a start up, then they would be able to supplement data for the rest of the month. This is so because mobile devices were given to individuals and they take care of them as their own asset.
Kuunika embedded systems support in its plan for the OHSP system. This support, however, is primarily done remotely Kuunika does not appear to have any technicians operating at local level to provide first level support on site or from the district level. There is also no evidence of Kuunika selecting and empowering OHSP champions who could be providing basic troubleshooting before issues are escalated to the district or national level. The Kuunika team is small and operating from the national level, meaning that there are always outstanding issues in the districts. These are more apparent in Machinga among all the four sampled districts. Besides system champions, it is also clear that Kuunika is missing an opportunity of utilizing government personnel who could perhaps provide support in the districts. Government through the Department of e Government has technicians in district councils providing IT support to government institutions, including District Health Offices. These could be utilized by the projectto provide timely systems support in the districts if there could be involvement of e Government Department in the work of Kuunika The e Government Department is in charge of the Government Wide Area Network (GWAN) and other related infrastructure, which could also benefit the Kuunika programme if there is collaboration.
The details above illustrate that Kuunika was swift and thorough in meeting the digital demands of the Ministry of Health after the recognition that digital data and science would be central to guiding government in its response to the pandemic. The approach taken was to ensure timely capturing and quick submission of data from the source (i.e. community, health facilities and ports of entry). At this level, the OHSP system, as well as standardized COVID 19 paper forms (transmitted mainly via WhatsApp), assisted and continue to assist healthcare workers as they undertake case detection, contacts tracing, follow ups and required reporting across the country. This reporting is done on a daily basis to enable the Ministry’s management and PTF to make informed decisions in a timely manner, but also to keep the general public and other stakeholders informed about the situation of the pandemic on the ground. Alongside this, the same OHSP and standardized paper tools assist the health workers in reporting for IDSR on a weekly and monthly basis. However, when one critically looks at this data supply chain, it becomes clear that the level of digitalization is quite limited to the OHSP users (at community, health facility and port of entry) who received the mobile device or had the application installed on their personal device for reporting with one person at district level (i.e. either DEHO or IDSR Focal Person) designated to oversee and manage district reporting, and the staff at PHIM receiving, consolidating and analyzing these data. Another key group included in this digitalization is that of senior officials in the Ministry of Health and members of the Presidential Task Force on COVID 19 as they have access to internal dashboards and reports. There is no direct involvement or capability of other healthcare workers including health facility in charges, Directors of Health and Social Services (DHSS), District Health Management Teams (DHMT), Hospital Directors, and other key health personnel to see data being collected within their level and access it for review before it is transmitted to the central level. Even when it is submitted to central level, they cannot access the data for their own district until it is
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
processed, and summaries are uploaded on PHIM’s COVID 19 website and other platforms shared with stakeholders and the general public.
Kuunika also helped the Ministry with the establishment and digitalization of the Emergency Operations Centre, a state of the art suite, which acted as an information hub receiving raw data from multiple sources, processed and packaged for various stakeholders involved in the fight against COVID 19. This centre has been key to ensuring that Ministry of Health, the Presidential Task Force and the general public receive daily reports on the pandemic. It also acts as a hub for all other products required by the Ministry and PTF such as production of the e-vaccine certificates, dashboards for internal and external stakeholders, and other deliverables. These components have also driven levels of digitalization within the health sector and beyond. The EOC initiative has enabled the Ministry and PTF to be on top of things through this pandemic. Arguably, without this initiative and all other tools developed by Kuunika there would have been far greater challenges in collating, managing, analyzing and reporting on COVID 19 in the country.
Kuunika products such as the daily COVID 19 update, e vaccine certificate and COVID 19 website have essentially created and satisfied the general public’s demand for digital data. As already alluded to, during each new wave of the pandemic and at the peak, the public seeks to know the COVID 19 situation in the country. These include total daily new cases, hospital admissions and deaths. This enables them to take precautionary measures, especially in localities where cases are purportedly high. As for the production of e vaccine certificate, these have benefitted the general public, employers and travellers. It was introduced to curb the problem of fake COVID 19 vaccine certificates which the country was experiencing at the time when this process was done manually. This is one of the flagships of Kuunika on COVID 19 fight and apparently positioning Malawi ahead of other African countries on this front.
Additionally, in pursuit of one of its core objectives, Kuunika undertook to build capacity of healthcare workers at various levels on data supply, analysis and use. Senior officials in the Ministry also benefited from this, in particular with regard to dashboards that were developed to assist them in their various duties and responsibilities related to fight against the pandemic. Thus, this led to some levels of demand for digital data for use by the cadres and officials for whom the system was developed to support. 5.4 Digital ‘surge’ or a mere digital increase?
This question is difficult to answer at this relatively early stage, but this section examines relevant information gathered from study participants. Firstly, we look at those with direct involvement and/ or use of digital solutions introduced by Kuunika for the fight against COVID 19. As seen below, these have primarily been specific cadres IDSR focal persons, HSAs and DEHOs - in health facilities, ports of entry and districts
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
Health Facilities 22 2 20 20
Balaka DHO 1 6 6 Health Facilities 16 - 16 16
In all health facilities Kuunika distributed one mobile device for OHSP to a designated IDSR focal person or HSA. Since the rest of the healthcare workers did not receive a mobile device, if the person who received the device is away, the work is performed manually and data submitted to district in that manner or entered when the mobile device becomes available. In some main ports of entry such as Mwanza border, Chileka International Airport and Kamuzu International Airport multiple mobile devices were deployed, and at a later stage a deployment of OHSP on static computers was done to facilitate work during busy periods.
In the districts, Kuunika distributed multiple mobile devices to DHMT members such as DHSS, DEHO and IDSR Focal Person in each district. However, our study found that only one person at the district level either DEHO or IDSR focal person uses it for OHSP. The rest simply received the mobile devices but do not use this system, although some study respondents stated that the mobile devices which they received are also used for COVID 19 related work, including sharing updates and reports within the district and to national level via dedicated WhatsApp groups.
There are some health facilities which were excluded completely in the distribution of mobile devices from Kuunika and partners, e.g. 10 facilities in Zomba This was because there were already other projects in these health facilities which deployed mobile devices and computers. Kuunika therefore simply deploys OHSP on these devices to enable them to report on COVID 19 for their facilities and communities.
Beyond receipt of the mobile device, there is the issue of whether these are in use and the OHSP is being used as expected. Table 5 shows the extent of use of the OHSP as well as alternative systems i.e. paper and WhatsApp, when collecting data and reporting to the district and national levels on COVID 19.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
shows 12 health facilities using OHSP against a total of 16. However, no health facility in Blantyre and Machinga are using the OHSP system. Reports from these health facilities are compiled manually and then submitted to the DEHO or District IDSR focal person through either an ambulance vehicle or WhatsApp. This is a major issue and explains gaps in data from these districts in the OHSP server at PHIM. Data which PHIM receives come directly from the district level person mainly through WhatsApp or email. The table further shows that even where OHSP is being used, there is a corresponding use of parallel system paper and WhatsApp.
In addition, various issues have prevented those who do have a mobile device from using it for OHSP:
Table 6: Summary of Issues for not using OHSP
Blantyre DHO Health Facilities 5 5 25
Zomba DHOHealth Facilities Maching a DHO -Health Facilities 22 Balaka DHO Health Facilities 2 2
Both Zomba and Balaka appear to be stable and with very small issues. The latter reported only two cases of faulty mobile devices and two cases of network challenges. However, there are serious problems in Blantyre and Machinga districts. In Machinga, all 22 health facilities do not use OHSP for reporting. Instead these are done at DHO’s office by designated staff DEHO or IDSR focal because the facilities received small phones which do not work with the OHSP. There are some keys and features which cannot be operated using such small phones as opposed to when the system is used on a tablet, computer or large smart phone. Lastly, Blantyre reported the majority of issues ranging from faulty devices through lost devices to not receiving training and data bundles to use for OHSP work.
A final issue relates to clarity over the ownership of the mobile devices. Users are not sure what to do in cases of lost of malfunctioning devices. In addition, since the mobile devices were handed over to individuals who attended OHSP training at the District Health Office, the recipients ended up personalizing them. This restricts usage by other healthcare workers in the health facilities and ports of entry Again, this is one of the explanations of continued use of paper based system on COVID 19 reporting.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
The above issues are clearly relevant to whether the Kuunika/DHD digitisation aims are fulfilled and maintained. It is evident that Kuunika did initiate digitalization in the health sector through its various interventions, particularly OHSP and related products developed to assist government in the fight against the COVID 19 pandemic. But along the chain of targeted users and beneficiaries there have been some shortcomings and exclusion of other key stakeholders primarily at health facility level. The use of alternative system (paper and WhatsApp) remains quite evident. While it has been acknowledged that Kuunika interventions around this pandemic have created and satisfied demand among other external stakeholders, including the general public, there have also been some challenges and exclusion of other stakeholders who are yet to directly access these due to reasons beyond Kuunika e.g. apparent digital divide in the country and techno literacy levels among the general public. Overall the extent of digitalization is limited within certain hierarchies and therefore, at this point is a mere increase in digitalization in the health sector, and not necessarily a digital surge. The sustainability of these interventions is dependent on Kuunika’s strategy and next steps with regard to the shortcomings within its reach and ability to engage with key stakeholders such as government for some of the factors beyond its reach but which are critical These are examined in more detail below.
This section looks at keyfactors, beyond Kuunika (i.e. non Kuunika), which are keyto sustaining the current digital interventions and enable it to maintain any ‘digital surge’ transforming how data is captured, collated, analyzed and used in the health sector in the country.
The following describes the positive factors that have facilitatied and will continue to sustain the digital transformation within the health sector that has been sparked by COVID-19. These can be summarised as political will; demand creation; capacity building; use of local consultants; building on open-source software and an interoperability layer.
The Ministry of Health Management and the Presidential Task Force on COVID 19 opted for digital solutions by Kuunika to enable them to access up to date data on a daily basis from multiple sources for evidence based decision making in their planning, monitoring and response to the pandemic. Requirements and support was provided to the Kuunika team.
Kuunika programme has created demand for digital data at various levels within the health sector and among the general public. Within the health sector, there have been demand for daily updates on COVID-19 by the Ministry’s senior management and the PTF in order for them to be making informed decisions in planning and responding to the pandemic. Other cadres involved in COVID 19 fight also continue to demand digital data as it is quick and easy to access. On top of this, the general public continues to demand daily updates on COVID 19, more so during each new wave and at the peak in order for them to see where things are going and take necessary precautionary measures.
Capacity of staff knowledge, skills and capabilities are key to ensuring continued performance of their functions and improve in ways of doing things. Kuunika recognized the role of capacity building to sustain the OHSP in the health sector. Following this, Kuunika team built the capacity of the Ministry’s staff in districts and health facilities (i.e. DEHOs, district IDSR focal persons, HMIS, port of entry health personnel and HSAs) on the use of the OHSP system including data capturing, synchronizing and use. However, it must be mentioned that there is no evidence of capacity built locally (i.e. districtor health centres) on the technical side of the OHSP at district and national levels.
At national level, Kuunika built capacity of middle level personnel in MoH (i.e. PHIM and DHD) on data analysis and packaging of information for senior officials and PTF members’ use in decision making.
Kuunika uses local developers and consultants in developing its digital solutions of the Ministry. Thus, it would be easy to sustain these since human resources are available locally. In support, the World Bank (2019; and 2020; p.49) states that the presence of people with science, technology, engineering and mathematics (STEM) skills, resulting from right investments in education, is key to supporting and sustaining the technologies and enable further innovations to happen in line with local needs.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
Utilization of open source software (DHIS2 platform) makes the system likely to be sustainable since there is no requirement for license renewals and dependency on owners of the source code. Further, DHIS2 is a familiar platform locally and the main system being used by MoH.
Kuunika has established a platform on which current systems are being maintained and future systems will be built. This foundation includes the interoperability layer which ensures that current and future systems are linked to each other; the Master Health Registry, and other works done around DHIS2.
There are also factors that are precarious to inhibiting the sustainability of this digitalization in the health sector, and could ultimately erode strides already attained. These can be summarised as: Technical know how; internal coordination; financial commitment; lack of infrastructure and user reluctance.
At the moment, there is limited progress towards transitioning and handing over the digital solutions to MoH The technical staff responsible for the development and maintenance of health sector digitization sit within Kuunika, with no technical/ IT team under the Ministry with capacity to take over.
There appears to be no working relationship between Kuunika and the e Government Department, which is in charge of managing all ICT for government Ministries, Departments and Agencies in the country. The department has IT officers in all government Ministries and Departments, including in districts, but there is currently no interface between them and Kuunika.
Although there is political will in government to support digital health, funding is also critical to sustaining these interventions. However, funding for these interventions is currently largely donor dependent. Government is yet to show serious financial commitment to support and sustain these interventions.
The ICT infrastructure in the health sector and at national level requires improvements. Investment is needed urgently in digital infrastructure and service delivery, required to boost connectivity, reliability and affordability of digital technologies and services in the country
Cost of data/ internet in Malawi is one of the highest in the region. This together with the high cost of technologies, including mobile devices, makes implementation and
of a foundation for current and future digital solutions
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
sustenance of digital solutions overly expensive. Some OHSP users are using their own funds to maintain connectivity, whilst others can take advantage of the TNM subsidy. This is clearly not sustainable.
The training provided on OHSP had gaps, with the limited duration impacting on understanding and ultimately usage of the system For instance, e vaccine certificates cannot be produced for individuals whose data was not entered in OHSP following the manual capturing of data at the centre where they took their jabs. Additionally, there has been a lack of follow up, mentorship and regular supervision. Important IDSR training has only just begun.
There is no clear policy on the ownership, responsibility and maintenance of mobile devices. This ambiguity on responsibility over faulty or lost devices makes users and DHMTunsure as who is responsible and/ or how to handle such cases as and when they occur
Despite policy directives and support from Ministry leadership that OHSP should be the primary source of data for COVID 19 from the community, health facilities and ports of entry into Malawi, there remains some resistance from healthcare workers to use it. Inconsistent usage occurs from a preference for the familiar, paper-driven methods, general technophobia or dislike, plus some of the issues mentioned above such as connectivity and cost. As one respondent stated:
“Mindset change is an issue among people who are used to the paper based system.” KII 1 1 This is not helped by the only mobile device available at health centre level being restricted to one person. Consequently, those who do not have access to the OHSP mobile device handle COVID 19 suspects and cases using the paper system. As one respondent indicated:
“it is only one HSA who received and is using the OHSP system; the rest of health workers continue with the paper system.” KII 1 1
There are several partners working with the Ministry of Health in various domains, including in the digital health space. Inevitably some partners tend to promote solutions and tools which are in addition to the existing national systems developed and deployed by DHD through Kuunika. Often, such initiatives come with incentives such as free devices which encourage healthcare workers to prioritize them This is common, for instance, in Blantyre and Lilongwe where some health facilities operate as teaching hospitals. Duplicating systems can be overwhelming and inevitably lead to inefficiency.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
It is evident that Kuunika’s digital solutions played a major role in assisting the Malawi Government in planning, monitoring and responding to the COVID 19 pandemic. Kuunika managed to deliver all products requested by the Ministry of Health and PTF, very close to within the agreed timeframes. The deliverables such as the national daily COVID 19 updates and internal dashboards enabled Ministry management to be up to date and make informed decisions regarding the necessary precautions against this pandemic. This has demonstrated the potential power of digital technologies in managing public health and emergencies. It is worth noting that the Kuunika innovations OHSP, e vaccine certificate and others have positioned Malawi as one of the leading countries in this Sub Saharan Africa region in the use of digital solutions in response to the pandemic. Within Malawi, these innovations have also led to a reputational boost for Kuunika and the Digital Health Division (DHD).
Development of the above digital tools, products and technical assistance to the Ministry was informed by a WHO Epidemic alert and response checklist, which MOH and Kuunika opted to follow at the outset as a reference point and guide (summarised below).
1) 7) Implemen
for an emergenc y
Case investigat ion and treatmen
This framework outlines seven steps, which include preparation for an emergency, surveillance, case investigations, treatment, community prevention and revision of the national plan. Whilst these are far from complete or without many challenges, the principles of the checklist are mirrored in the Kuunika product development process in support of the MoH in managing the pandemic. Realizing the importance of standards and interoperability, Kuunika built its systems on the existing national digital health architecture and leveraged the developing interoperability layer and DHIS2 platform. It also assisted MoH to take a central role in coordinating digital health efforts and coordinate inputs by various partners under the overall leadership and governance framework of the Ministry. Where process standards (e.g. during development of tools) appear to not have been strictly followed, it was primarily due to urgency and the rapid changes in the workflow, requirements and protocols from the Ministry.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
Malawi has not yet been assessed by GDHI, but an examination of the indicators used to determine and track progress is helpful is understanding Kuunika’s role in facilitating the country’s digital health environment. Of the seven categories listed, Kuunika can be seen to have directly contributed to them all, to some extent. The key contribution comes under ‘Leadership and Governance’, where the establishment of a specific MoH department dedicated to digital health (the DHD) is considered a major achievement. Other contributions towards improving the legislative and policy environment also count. Under ‘Standards and Interoperability’, Kuunika’s design ethos is entirely aligned with GDHI best practice. Areas of weakness across all indicator categories include budgetary commitment, integrated curricula and infrastructure maintenance these are advanced goals beyond the possibility of Kuunika, but which indicate the direction to move towards.
Whether the COVID 19 pandemic led to a ‘digital surge’ in the health sector, a trace and review of the data and use chain suggests that indeed it did. However, there were specific gaps in access to the tools and technologies, in particular for healthcare workers in health facilities. Limitations of time and resources impacted on depth of training and number of devices available. Connectivity and data cost issues compounded this, and these issues remain. Other factors affecting sustainability are continued political commitment, coordination of multiple donors involved in e health and changing individuals’ mindset around unfamiliar change, Nevertheless, Kuunika did contribute towards a significant increase in digitalization in the health sector during 2020. To sustain this, there are several obstacles to overcome.
Kuunika has demonstrated the potential to be the convening point for the international community including new donors who are willing to support Malawi’s digital plans in the health sector. It is critical to now tread carefully to avoid donor dependency and to ensure that development is government led. There is need to develop a clear transition plan from Kuunika support to withdrawal. It should include the overall government commitment, including technical and financial aspects. Stakeholders we interviewed did not believe that the Ministry on its own can yet take over and manage these implementations, and strongly encouraged Kuunika Phase 2. This should primarily focus on the areas discussed to prepare and empower the Ministry of Health for takeover and sustainability.
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
• Kuunika and the DHD have the potential to be the convening point for the international community including new donors who may now be more willing to support Malawi’s digital plans. It is felt that without Kuunika’s ongoing support the DHD will not yet be able to fulfil this potential alone, warranting a further phase of Kuunika.
• We understand that Kuunika is developing a strategy to systematically address the challenges faced in operating and managing the OHSP at local and national levels, as well as to build capacity at all levels for sustainability. It should contain a clear path of transition and timeframe and the overall government’s commitments, including technical and financial aspects
• Multiple donor-led health programmes and data collection processes at district level are starting to overwhelm health workers and affecting the quality of DHIS2. Better co ordination and standardisation will improve this.
• Infrastructure, finance and logistics limitations are still very apparent. These failures are contributing to continued preference for paper systemsand need to be addressed urgently. In order to achieve affordability of IT services, Government should put in place incentives to boost competition in the IT/ telecommunications sector.
• Data gaps that appear in the OHSP server at PHIM should be addressed at source
• System technical support is limiting usage. E Govt officers at district level could assist in providing first level support and systems troubleshooting by being more immediately if integrated into the Kuunika programme.
• To avoid OHSP users at local level purchasing data bundles using their personal resources, Kuunika/MoH should negotiate with Airtel for provision of free data bundles or to provide a certain amount of data as a start up contribution to all Airtel network users.
• The OHSP/DHIS2 webpage has problems which should be corrected
In summary, key lessons by question area are:
Covid
• Reputational boost for Kuunika and DHD in effective rapid response to pandemic, evidenced by direct requests from President for more digital tools
• Demonstration effect to MoH of the potential power of digital continues to foster leadership in DHD
• Kuunika has the potential to be the convening point for international community including new donors who
• Locating OHSP on DHIS2 continues core Kuunika aim of an interoperable central platform.
• Act Fast, Fail Fast, Learn Fast: Kuunika must ensure it does the latter to build on lessons learnt during Covid 19
• Infrastructure, finance and logistics limitations still very apparent. These failures may be contributing to continued preference for paper systems.
• Increasing donor interest in DHD important to harness but be careful it doesn’t end up in even greater donor dependency.
• Have a clear capacity building and exit plan from the start.
• Multiple donor led health programmes and data collection processes at district level are overwhelming health workers and affecting the quality of DHIS2. Need more co
In summary, key lessons by question area are: may now be more willing to support Malawi’s digital plans.
• Urgency of covid response drove agreement of a clear business plan and data architecture that built on the existing application architecture prior to development.
• But some corners cut in user centred design principles and training for OHSP due to urgency. Don’t repeat.
• Covid 19 monitoring is yet another silo ed programme multiplying reporting procedures and forms at facility level
• OHSP/DHIS2 webpage has problems which should be corrected
• System technical support from the centre needs to be improved. Build out from eGovt technicians at district level.
• Too soon to hand over to DHD: Kuunika 2 warranted.
ordination and standardisation.
MacDonald | Kuunika Evaluation
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
African News. Coronavirus: Malawi banks suspend key payments, reduce digital banking rates 11 April, 2020. Retrieved from: https://www.ghanaweb.com/GhanaHomePage/africa/Coronavirus Malawi banks suspend key payments reduce digital banking rates 921067
Alsunaidi, S. J. et al. 2021. Application of Big Data Analytics to Control COVID 19 Pandemic Sensors. Retrieved from: https://www.mdpi.com/journal/sensors
Catana, S. A. et al. 2021 The Effects of the COVID 19 Pandemic on Teleworking and Education in a Romanian Higher Education Institution: An Internal Stakeholders Perspective. In International Journal of Environmental Research and Public Health. 18, 8180. Retrieved from: https://www.mdpi.com/journal/ijerph
Corver, Q., & Elkhuizen, G. (2014). A Framework for Digital Business Transformation. Cognizant, 1 10. Retrieved from https://www.cognizant.com/InsightsWhitepapers/a-frameworkfor digital business transformation codex 1048.pdf
De, R. et al. 2020. Impact of Digital Surge during COVID-19 Pandemic: A Viewpoint on Research and Practice. In International Journal of Information Management. 55 (2020) 102171. Retrieved from: https://doi.org/10.1016/j.ijinfomgt.2020.102171
European Commission. 2019. Assessing the Impact of Digital Transformation of Health Services. A report of the expert panel on effective ways of investing in health. Retrieved from:https://ec.europa.eu/health/sites/default/files/expert_panel/ocs/022_digitaltransform ation_en.pdf
Giansanti, D. & Veltro, G. 2021 The Digital Divide in the Era of COVID 19: An Investigation into an Important Obstacle to the Access to the mHealth. In Citizen Healthcare, 2021, Vol. 9, No. 371 https://www.mdpi.com/journal/healthcare
Golinelli, D. et al. 2020 Adoption of Digital Technologies in Health Care During the COVID 19 Pandemic: Systemic Review of Early Scientific Literature In Journal of Medical Internet Research. Retrieved from: http://www.jmir.org/2020/11/e22280
Government of Malawi (GoM). 2017. Monitoring, Evaluation and Health Information Systems Strategy (MEHIS) 2017 2022.
GoM. 2020. Digital Health Strategy.
Hutchings, R. 2020 The Impact of COVID 19 on the Use of Digital Technology in the NHS
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
Nuffield Trust Retrieved from: https://www.nuffieldtrust.org.uk/research/the impact of COVID 19 on the use of digital technology in the nhs
Kuunika. Project Implementation Plan Operationalizing Kuunika Sustainability, 2019 2020 July, 2019.
Kuunika. Grant Proposal Narrative, 2020
Kuunika. Progress and Results, February, 2021
Kuunika. Blantye District Monthly Report, April, 2021.
Kuunika and Luke International Norway. District Support Quarterly Report. April to June, 2021
Kuunika and Luke International Norway. Summary Progress Report, April 2021
McKinsey & Company 2020 How COVID 19 has pushed companies over the technology tipping point – and transformed business forever. Retrieved from: https://www.mckinsey.com/business functions/strategy and corporate finance/our insights/how COVID 19 has pushed companies over the technology tipping point and transformed business forever
Nwaiwu, F. 2018 Review and Comparison of Conceptual Frameworks on Digital Business Transformation. In Journal of Competitiveness, Vol. 10, No. 3, pp. 86 – 100.
The World Bank Group. 2021. COVID-19 and the Future of Work in Africa: Emerging Trends in Digital Technology Adoption Africa’s Pulse: An Analysis of Issues Shaping Africa’s Economic Future Vol. 23, April, 2021.
Venkatesh, V., Morris, M. G., Davis, G. B., & Davis, F. D. (2003). User Acceptance of Information Technology: Toward a unified view. MIS Quarterly, 27 (3). 425 478. https://doi.org/10.1017/CBO9781107415324.004
Verina, N. & Titko, J. 2019. Digital Transformation: Conceptual Framework International Scientific Conference on Contemporary Issues in Business, Management and Economic Engineering Retrieved from: https://doi.org/10.3846/cibmee.2019.073
Whitelaw, S. et al. 2020 Application of Digital Technology in COVID 19 Pandemic Planning and Response. In Lancet Digital Health, Vol. 2 August, 2020. Retrieved from: www.thelancet.com/digital-health
UNICEF. 2020. Coping with school closures during the COVID 19 pandemic Retrieved from:
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
https://www.unicef.org/malawi/stories/coping school closures during COVID 19 pandemic
MacDonald | Kuunika
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
Mr. Matchado Epidemiologist and National Coordinator for IDSR
Liz Kadango Mikeka Incident Triage Manager
ORGANIZATION
Public Health Institute of Malawi (PHIM), Ministry of Health (MoH)
PHIM, MoH
Mbongeni Chizonda Systems Analyst/ DHIS2 Trainer CMED, MoH
Penjani Phiri IT Focal for Kuunika Programme PHIM, MoH/ e Government Department
Maganizo Monawe Technical Advisor
Innocent Wowa Data Analyst
Blessings Kamanga DHIS2 Manager
Rajab Billy Software Products Manager
Kuunika/ DHD, MoH
Kuunika/ DHD, MoH
Kuunika/ DHD, MoH
Kuunika/ DHD, MoH
Joseph Wu Technical Advisor Luke International Norway (LIN)/ Kuunika
Rebecca Mtegha Country Representative Luke International Norway (LIN)
Dr. Marlene Chawani Research Fellow/ ICT for Health Expert Independent Consultant
Dr. Rachel Sibande ICT Expert Expert TNM Desk Officer for Kuunika Telekom Networks Malawi (TNM)
Dr. Aisha Katita District Medical Officer Balaka DHO
Dr. Gift Msafiri Senior District Medical Officer Zomba DHO
Vera Maulidi Environmental Health Officer Zomba DHO
Patrick Bonongwe IDSR Coordinator Balaka DHO
William Zuza Environmental Health Officer Machinga DHO
Gift Malizani Statistical Clerk Machinga DHO
Catherine Mwapasa Environmental Health Officer/ IDSR Coordinator Blantyre DHO
Paul Lingani Health Surveillance Assistant (HSA)
Kalembo Health Centre, Balaka
Wenseslous Muhama Senior HSA Namanolo Health Centre, Balaka
Patulani Kasiyamphanje HSA
Chendausiku Health Centre, Balaka
Patrick Lombani Senior HSA Mbera Health Centre, Balaka
Mott MacDonald | Kuunika Evaluation
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
Edith Makupe HSA
Lester Mbalanje Statistical Clerk
St. Lukes Mission Hospital, Zomba
Matawale Health Centre, Zomba
Edna Mwanyopa HSA & IDSR Focal South Lunzu Health Centre, Blantyre
Benedicto Kaunjika HSA Mpemba Health Centre, Blantyre
Gloria Duncan HSA & IDSR Focal
Chilomoni Health Centre, Blantyre
Chiyembekezo Gambatula HSA & IDSR Focal Ntaja, Machinga
Isaac Mponda HSA Namanja, Machinga Ignacious Silla HSA Chikowe Health Centre, Machinga McLean Msandiyang’ane Senior Disease Control Surveillance Assistant Malaka Border Post, Nsanje
Rhoda Chitsulo HSA/ Port Health Officer
Kamuzu International Airport, Lilongwe
Mwanza Border Post, Mwanza Madalitso Nkhata Senior Assistant Environmental Health Officer
Victor Maluwa Port Health Assistant Chileka International Airport
Special Study 1: Kuunika and the COVID-19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
The following version of the Kuunika theory of change is referenced in this Special Study. It was developed by the evaluation team at midline (2019). It updates the baseline theory of change and incorporates the project pivot in 2018. Further updates to this theory of change will be presented in the final evaluation report.
Special Study 1: Kuunika and the COVID-19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
The following diagram shows evaluation team’s 2019 reconstruction of the causal pathways underpinning the Kuunika Project design and theory of change.
Figure 23: Evaluation team's reconstruction of the Kuunika causal pathways
a.InformedConsentStatement
Thank you very much for agreeing to make time to discuss with me today. My name is Shawo Mwakilama and I am conducting a short study for Mott Macdonald in UK. They have been commissioned by the Bill and Melinda Gates Foundation to independently evaluate the Kuunika programme at the Ministry of Health, which they have funded since 2016. What will the Kuunika evaluation do?
The Kuunika evaluation will address the following five simple questions: As a result of the Kuunika interventions…
1. Has data quality improved?
2. Has data use increased?
3. Has decision making improved?
4. Have key HIV service areas improved?
5. What explains the changes (or lack of them)?
What is Kuunika?
It's a project that aims to key barriers to better use of routine data in the health sector; it has been doing that primarily by improving the interoperability and accessibility of the District Health Information System (DHIS). Since March 2020, Kuunika has also been assisting the reporting of the national emergency response to the COVID pandemic.
It is this combination of issues, the support of Kuunika to the pandemic reporting and how that may have unexpectedly helped with its original goal of promoting more and better use of health data, that I’d like to discuss today.
Informed Consent Statement
Our discussion today will take a maximum of 1 hour. I have a guide that lists the key questions I should like to ask you; our discussion will be based on the experience and knowledge that you bring. There are no 'right' or wrong' answers; what is relevant is what each of you as an individual, a health professional, has experienced, what your views are, what you might like to see happen. Your responses will all be anonymous; we shall not identify you by name or location [If, in the course of the interview, it seems appropriate to record the session, I will ask your permission and tell you when recording begins].
Do you have any questions or comments before we begin?
b.Topicguide
Key Informant
Category Question topics
Background
• What are the main objectives of Kuunika program?
• What major activities has Kuunika been implementing over the years?
Kuunika project staff/ partner organizations
Since the advent of Covid 19 in Malawi in early 2020, do you think the country has experienced a surge in demand for digital data in the health sector, and use of it for decision making?
i. General Digital Surge in Malawi
Kuunika
• In your observation, has Malawi experienced any surge in the use of digital technologies since early 2020 when first cases of Covid 19 were report in the country and eventually “lock down” measures implemented by Government?
• What kind of evidence is there to demonstrate this digital surge in Malawi since the advent of Covid 19 in the country?
• What are the key features of this digital surge?
• Has there been a digital surge in the health sector in the country since the emergence of Covid 19 pandemic?
• If so, what evidence is there of a digital surge in the health sector?
• To which program(s) and partner(s) can you attribute this digital surge?
o What did they specifically do, which stimulated this digital surge?
• What kind of digital data was central to authorities in Government for planning and responding to the pandemic?
o What did Kuunika program specifically do on this aspect? Was it successful or not?
To what extent did Kuunika initiate, direct and sustain the digital surge in the country, in general and the health sector, in particular?
• What technological innovations has Kuunika developed and implemented for MoH/ health sector in Malawi which direct relate to Covid 19 pandemic response?
o When were these innovations developed and rolled out?
o Who were the target groups?
o How did they benefit (or not benefit) from the innovation(s)?
• Did these innovations initiate and direct the digital surge?
o In the country?
o In the health sector?
• If so, how did this happen?
• How did Kuunika program address the usual resistance to change and new technology in the health sector?
• What key challenges were faced in the process and how were they addressed?
What aspects of Kuunika project design, activities and implementation supported monitoring and response to Covid-19 pandemic in Malawi?
• Which Kuunika innovations supported Covid 19 pandemic’s planning and response at national, district and health facility levels?
• To what extent have these innovations been effective (or ineffective) in enhancing monitoring and response to the pandemic?
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
• What have been some of the bottlenecks faced in the design and implementation of these innovations?
o How were they addressed?
What aspects of Kuunika project are likely to help sustain the current digital surge in the health sector and/ or in the country?
• What aspects will help sustain it in the health sector?
• What aspects will help sustain this at national level?
In your assessment, what are some (non-Kuunika) key contextual determinants which are promoting the sustainability of the post-Covid-19 digital data surge in Malawi’s health sector?
• What is the nature of key infrastructure and related elements in the health sector and the country, which underpin the sustainability of this digital surge?
• Have the existing political environment and policy framework been in supportive of the digital surge?
o If so, to what extent?
• What are some of the major social, cultural and economic factors which promote the sustainability of the digital surge in the health sector?
Which key contextual determinants are limiting sustainability of the Covid-19 digital surge in the health sector?
• What political factors would limit, or prevent, the sustainability of the digital surge in the health sector?
• Which social, cultural and economic factors could obstruct the sustainability of this digital surge?
• When you look at the Kuunika program and its contribution to the health sector in Malawi, what key lessons can we draw from it?
• Based on your experience with the Kuunika program, what can you recommend for the prospective design and sequencing of new digital health sector programmes that can sustain and build on the current ‘digital surge’?
• What would you recommend as strategies through which the above could be adopted into the national health systems that have hitherto been resistant?
• What are the main objectives of Kuunika program?
• What major activities has Kuunika been implementing over the years for Ministry of Health?
Ministry of Health – HQ officials (DHN, QM, CMED and PHIM)
Since the advent of Covid 19 in Malawi in early 2020, do you think the country has experienced a surge in demand for digital data in the health sector, and use of it for decision making?
• What kind of evidence is there for this digital surge in Malawi since the advent of Covid 19 in the country?
• How about evidence or features of this digital surge in the health sector?
• If yes, to which program(s) and partner(s) can you attribute this digital surge?
o What did they specifically do, which stimulated this digital surge?
• What kind of digital data has been central to authorities in Government for planning and responding to the pandemic?
o What did Kuunika program specifically did on this aspect? Was it successful or not?
To what extent did Kuunika initiate, direct and sustain the digital surge in the country, in general and the health sector, in particular?
• What technological innovations has Kuunika developed and implemented for MoH/ health sector to support to Covid 19 pandemic response?
• Did the innovation(s) initiate and direct the digital surge?
• If so, how did this happen?
• How did Kuunika program address the usual resistance to change and new technology in the health sector?
What aspects of Kuunika project design, activities and implementation supported monitoring and response to Covid 19 pandemic in Malawi?
• To what extent have these innovations been effective (or ineffective) in enhancing monitoring and response to the pandemic?
• What have been some of the bottlenecks faced, and how were they addressed?
What aspects of Kuunika project are likely to help sustain the current digital surge in the health sector and/ or in the country?
In your assessment, what are some (non Kuunika) key contextual determinants which are promoting the sustainability of the post-Covid-19 digital data surge in Malawi’s health sector?
• Nature of infrastructure and related elements in the health sector and the country?
• Political factors/ policies?
• Social and cultural factors?
• Economic factors?
Which key contextual determinants are limiting sustainability of the Covid-19 digital surge in the health sector?
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
• What political factors would limit, or prevent, the sustainability of the digital surge in the health sector?
• Which social, cultural and economic factors could obstruct the sustainability of this digital surge?
• When you look at the Kuunika program and its contribution to the health sector in Malawi, what key lessons can we draw from it?
• Based on your experience with the Kuunika program, what can you recommend for the prospective design and sequencing of new digital health sector programmes that can sustain and build on the current ‘digital surge’?
• What would you recommend as strategies through which the above could be adopted into the national health systems that have hitherto been resistant?
• Are you familiar with Kuunika program and its activities?
o If yes, what do you know about Kuunika?
• What major activities has Kuunika been implementing in your district/ health facilities?
Since the advent of Covid 19 in Malawi in early 2020, do you think the country has experienced a surge in demand for digital data in the health sector, and use of it for decision making?
• In your observation, has Malawi experienced any surge in the use of digital technologies since early 2020 when first cases of Covid 19 were report in the country and eventually “lock down” measures implemented by Government?
o What kind of evidence is there to demonstrate this digital surge?
• Has there been a digital surge in the health sector in the country since the emergence of Covid 19 pandemic?
o If so, what evidence is there for this digital surge?
• To which program(s) and/ or partner(s) can you attribute this digital surge?
o What did they specifically do, which stimulated this digital surge?
To what extent did Kuunika did Kuunika initiate, direct and sustain the digital surge in the country, in general and the health sector, in particular?
• How do you routinely monitor and report about Covid 19 cases and response plan?
o Which reporting forms do you use (manual or electronic)?
o What medium do you use for reporting and how often?
o Why do you use this platform?
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
• What technological innovations has Kuunika developed and implemented in your district and/ or health facilities?
o When were these innovations developed and rolled out?
o What purpose(s) do they serve?
o Did these innovations initiate and direct the digital surge in your district and/ or health facility?
o If so, how did this happen?
What aspects of Kuunika project design, activities and implementation supported monitoring and response to Covid-19 pandemic in Malawi?
• Which Kuunika innovations supported Covid 19 pandemic’s planning and response at district and health facility levels?
• To what extent have these innovations been effective (or ineffective) in enhancing monitoring and response to the pandemic?
o What have been some of the bottlenecks faced, and how were they addressed?
What aspects of Kuunika project are likely to help sustain the current digital surge in the health sector and/ or in the country?
In your assessment, what are some (non-Kuunika) key contextual determinants which are promoting the sustainability of the post-Covid-19 digital data surge in Malawi’s health sector?
• Nature of infrastructure and related elements in the health sector and the country?
• Political factors/ policies?
• Social and cultural factors?
• Economic factors?
Which key contextual determinants are limiting sustainability of the Covid 19 digital surge in the health sector?
• What political factors would limit, or prevent, the sustainability of the digital surge in the health sector?
• Which social, cultural and economic factors could obstruct the sustainability of this digital surge?
• When you look at the Kuunika program and its contribution to the health sector in Malawi, what key lessons can we draw from it?
• Based on your experience with the Kuunika program, what can you recommend for the prospective design and sequencing of new digital health sector programmes that can sustain and build on the current ‘digital surge’?
• What would you recommend as strategies through which the above could be adopted into the national health systems that have hitherto been resistant?
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
• In your observation, has Malawi experienced any surge in the use of digital technologies since early 2020 when first cases of Covid 19 were report and eventually “lock down” measures implemented by Government?
• What kind of evidence is there to demonstrate this digital surge in Malawi since the advent of Covid 19 in the country?
o What are the key features of the digital surge?
• Which sectors have been demanding, purchasing and consuming more data/ internet services for connectivity during the pandemic?
a. Internet Service Providers (Airtel, TNM, MTL and Globe Internet)
b. IT experts
• Do you have metrics to share comparing internet uses prior to Covid 19 and during the pandemic?
• What kind of information do you think people have been accessing or want to access?
• Crossing over to health, have you been providing any specific support to this sector during the pandemic? If yes, what kind of support and under what framework or agreement?
• Are you aware of Ministry of Health’s Kuunika Data for Action program?
• If yes, what do you know about Kuunika?
• Do you have any formal agreement or partnership with Kuunika program? If yes, what is the agreement about?
• In your view, has Kuunika helped in any way in the digital surge in the health sector?
• What are the major impediments to digitalization in Malawi, and in the health sector in particular?
• What solutions would you propose to overcome these impediments?
• What needs to be done to sustain the digital surge in the country? (policy, technology, socio economic aspects?)
• What specific components are required for this sustenance of the digital surge (infrastructure? data cost? etc)?
• In your observation, has Malawi experienced any surge in the use of digital technologies since early 2020 when first cases of Covid 19 were report in the country?
• What kind of evidence is there to demonstrate this digital surge in Malawi?
(Ministry of Information,
• What kind of information has the public been demanding and accessing since the onset of Covid 19 pandemic?
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
• What platforms do the majority of members of the public use to access such information?
o How effective have these platforms been?
• To what extent do we have digital divide in Malawi?
• In general, which groups or categories of people lack access to: o Digital technology?
o Digital information? o Internet?
• What can be done to bridge this gap?
• What is your observation on digitalization in the health sector during the Covid 19 pandemic?
• What aspects in health sector did you see went digital during the Covid 19 pandemic?
• What digital/ IT related innovations during the pandemic helped Government (MoH, Dept. of Disaster and other key stakeholders) plan and respond effectively to the Covid 19 pandemic?
o Who provided support on such innovations?
• Did the innovation(s) make any difference in the fight against Covid 19?
• Was Government going to manage the situation without such innovation(s)?
• Are you aware of Ministry of Health’s Kuunika Data for Action program?
• If yes, what do you know about Kuunika?
• Has your Ministry/ Department be involved in any Kuunika activities? If so, which ones?
• What was the extent of your involvement in the above activities?
• Which of these activities directly relate to Covid 19?
• In your view, has Kuunika helped in any way in the digital surge in the health sector? If so, how?
• What needs to be done to sustain the digital surge:
o In the health sector?
o In the country?
• What specific components are required for this sustenance of the digital surge (infrastructure? data cost? etc)?
Special Study 1: Kuunika and the COVID 19 ‘Digital Surge’: Malawi’s Pandemic Monitoring and Response
