5.5.2 Factors that May Affect Sustainability

Use of Open Source Software

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.

Creation of a foundation for current and future digital solutions

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.

5.5.2 Factors that May Affect Sustainability

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.

Factors Transition and handover of systems to Ministry of Health

Missed opportunities for internal coordination

Financial commitment from government

IT infrastructure

Cost of data and digital technologies Description

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

Capacity building

Lack of clarity on status of mobile devices

Mindset

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.” KII1-1 Politics in the digital space 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.