The title of this blog is derived from many questions we have faced during the implementation of DGFP eMIS under the Directorate General of Family Planning, Ministry of Health and Family Welfare. Put simply, people have asked as to why DGFP eMIS was developed when, an open-source tool like DHIS2 was available and have successfully been implemented in Bangladesh. This somewhat long blog aims to provide answers to some of those questions.
Questions and Answers
Q1: What were the needs for developing eMIS when DHIS2 system have been successfully implemented in Bangladesh or in different countries of the world?
Ans: This can be best answered by describing the planning and initial implementation stage of the eMIS that started in 2015, but have roots earlier than that year. The eMIS Initiatives is supported by USAID and its implementing partners (MEASURE Evaluation (now D4I)/icddr,b/RDM and Save the Children/MaMoni HSS – now MaMoni MNCSP) contributed to the development of eMIS tools for community and facility level implementation. The implementing partners had good understanding of the business processes of the Bangladesh health system with capacities for implementing large digital projects.
At the planning stage of eMIS, open-source tools that were available globally were considered. Especially, in international forums, OpenSRP, DHIS2 and OpenMRS were proposed as the three pillars for digitization of health system. Of those, the first was intended for community level workers (through eRegisters), the second for aggregating data at district level and the last for using in facility setting to keep the digital records of services provided to in- and out-patients.
The eMIS needed tools for automating the tasks of community level workers and their supervisors (possible with Android based mobile apps). Actually, OpenSRP was the tool that came closer to the requirement of the eMIS. However, due to its stage of development, lack of required documentation and some other constraining factors, it was clear that off-the-shelf tools were not suitable for the tasks ahead for eMIS. Therefore, it was decided to develop from scratch using open-source programming languages. Skills for developing such digital tools are available locally. Tools were needed to be customized to meet the local needs sufficiently. There was no scope to select DHIS2 for the intended solutions at that stage.
Q2: How different is eMIS from DHIS2?
Ans: We say, comparing eMIS and DHIS2 is like comparing apples with oranges or, in software terms, comparing Microsoft Word with Microsoft Excel, which are popular word processing and spreadsheet software used for document generation and financial tasks. You can perform calculation in Word tables and write letters in Excel, but none would probably think of doing so. The use is obviously dictated by functionalities, not easy availability. The eMIS tools are transactional and captures individual data over periods of time. The DHIS2 was developed for aggregation of data from district or sub-district level as its name suggests. The DHIS2 tracker (mobile app) introduced later is also not yet as versatile as any eMIS apps.
The architecture of eMIS is enterprise oriented and eMIS aimed to automate the entire business processes of the certain category of providers through different mobile apps and web-based applications that are interconnected, integrated both vertically and horizontally (sharing facility and community data). Month-end reports are generated at providers’ levels at the click of a button and aggregated at higher levels. The eMIS hosts very elaborate web-based monitoring tools.
Q3: What other factors relating to DHIS2 could have influenced the development of eMIS?
Ans: In short, flexibility and control. The DHIS2 is developed and maintained by University of Oslo (UoO). The source codes, though open, cannot be modified at will (possible with consequences). Any request for modification must be approved by UoO. Even if any national request is accepted, that may take long to implement. That means there is lack of flexibility, long waiting time and uncertainties; which is not suitable for a national system like eMIS. For example, the DGFP make modifications to their registers in a 3-year cycle. The eMIS can accommodate any requirement in no time and as papers have been eliminated, such changes need not wait for the new version of paper register.
The maintenance of DHIS2 is also not easy. It has been observed that difficulties arise when back-end database sizes grow bigger. Even, upgrading from the previous version of PostgreSQL, its back-end database, could also become a challenge for the organization.
Q4: What are other strength of eMIS?
Ans: The eMIS is developed locally by the local developers. The organizations responsible for software development have in-depth knowledge of the business processes and organizational culture of DGFP or other organizations in the public sector. Comprehensive digitization of routine health information system of DGFP have been made possible by eMIS.
The strength of eMIS also expressed in the fact that gradually the DGFP is eliminating all paper registers and declaring the eMIS districts as paperless implying that a fully digital eco-system has been established in the DGFP through use of eMIS.
Q5: Are there no benefits of using DHIS2?
Ans: Definitely, there are. The strengths of DHIS2 lie in aggregation of data and user-friendly interfaces. The eMIS supported the DGFP in developing FP-DHIS2. The DGFP had a legacy system called Service Statistics or SS. Month-end reports are sent directly to SS. The eMIS monthly aggregated data are also sent directly to DHIS2. The interface and presentation of SS has been replicated into the DHIS2. As a matter of fact, in Bangladesh, at least 4 instances of DHIS2 are running in DGHS, DGFP, DGDA and icddr,b respectively suiting the specific organizational needs of those organizations.
Q6: Could you have used the DHIS2 tracker?
Ans: The DHIS2 tracker have been implemented in some settings in Bangladesh. But it was introduced probably a few years ago or much later than full implementation of eMIS. However, as we understand, such tracker does not have the potential to replace eMIS apps.
Current status of eMIS
We end the blog with a short description of the eMIS, its coverage and achievement so far.
DGFP eMIS is a complex ecosystem of apps and web-based applications. The eMIS was conceived after evaluation of all paper documents, registers and it is rooted in national needs and driven by the national aspiration for Digital Bangladesh vision. It is now nearing 7 years of its existence. It connects 37 out of 64 districts of Bangladesh having more than 13,000 users spread across the organizational hierarchy of community level workers, their supervisors, sub-district and district managers and above.
There are apps designed exclusively for specific category or providers (eRegisters, eSupervision system and facility eRegisters and eManagement system) with links to local and central/distributed databases running on cloud. The databases are hosted in the National Data Center of the Bangladesh Computer Council. Data are generated/captured when the providers interact with the individual clients at a home visit or during service delivery in a facility (union level first-line facility providing services like maternal and child care, general ailments). The eMIS now have individual records of more than 37 million individuals (which is growing day by day) who are categorized into eligible couples, pregnant women, newborn etc.). Data are granular and reflect health and family planning situation of the covered areas. The database is transactional and data are uploaded and downloaded on a daily basis by the users or as a part of system functions or database management. Socio-economic status of households are captured through household and population registration. Measurable performance data of the providers are also generated in the system.
The eMIS went through intense implementation phases. The tools were elaborately tested before implementation and users’ input were used to modify/refine the apps incorporating the principles of digital development. The apps correspond to 100% or nearly 100% of the business processes of the providers at rural level. It is supported by elaborate web-based monitoring tools for managers and decision makers at central level. It is ingrained in the administrative system, culture and procedures of the DGFP. The users are full-time public servants and come under systems of accountability which is replicated in digital tools with supervision, inspection and monitoring functions. Such environment is definitely different from duties performed by community level workers in other countries whether in the public or the private sector. NGO or voluntary sector in Bangladesh also hosts great number of community level workers. Some NGO partners of the DGFP, who work side by side the DGFP providers, also use eMIS tools. Data generated by eMIS contains birth and death records of individuals and are made ready for sharing with appropriate authorities. The data has been used in piloting of a health insurance scheme. The potentials of eMIS data, as such, are huge for the future.
The DHIS2 could offer some functionalities for community level workers of Bangladesh like elsewhere in the world but eMIS would be unique to Bangladesh. Local context and content played a key role in development of DGFP eMIS. it might be difficult to comprehend the work of eMIS without a fair understanding of this local context as well the limitations and context of DHIS2. Finally, eMIS is not contradictory to DHIS2, rather it could be complementary to the eMIS.