EXECUTIVE SUMMARY

Background

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.

Summary of Main Findings

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 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 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.

– 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’.

3. Aspects of Kuunika most important in supporting the immediate monitoring response and in sustaining a step change in digital data use

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.

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 coordination 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.

Factors that Promote Sustainability

• 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.

Factors that may Limit Sustainability

• 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 systems and 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.