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Ten years ago, Bangladesh’s health information system was paper-based and built in a disorganised manner around the unique needs of different programmes and organisations. Today, Bangladesh is the largest DHIS2 deployer in the world and DHIS2 has been a vehicle for data systems improvement and other areas of health systems strengthening overall.

• The reporting rate is on average 98% and routine health information is now available in a timely manner, in a format accessible to all.
• The system now connects central, divisional and district levels with sub-district health facilities and over 13,000 community clinics.

Transforming the Health Information System in Bangladesh through DHIS2 is a compelling story to be learnt from. In August 2018, UNICEF conducted over 50 key informant interviews to collect knowledge from the Ministry of Health, key supporting partner organisations, health workers at all levels of the health system and community members, to develop a case study for critical learning.

5 Phases of DHIS2 Implementation in Bangladesh

This case study document outlines the way in which the DHIS2 system was implemented at-scale in Bangladesh. Analysed in retrospect, there have been five phases of DHIS2 implementation so far:

1. An initial phase, in which the need for improving HIS was defined, Government commitment
   was established, a situation analysis was carried out, DHIS2 was chosen as the best tool for Bangladesh’s context and necessary technical and financial support was secured.
2. An implementation phase, in which a digital infrastructure within Ministry structures was built, a reliable online national data warehouse was set-up and ‘buy-in’ to set-up and use DHIS2 across Ministry programmes was established.
3. An expansion phase, in which the focus was on improving the data reporting rate: datasets from multiple programmes migrated to DHIS2, DHIS2 was expanded to the community level and individual health records were introduced.
4. A capacity building phase, in which the focus was on the ‘human factors’ of DHIS2 implementation to improve the quality and use of the data: ownership and increased capacity for DHIS2 was created at all levels of the health system, efforts were made to improve transparency and accountability of the system, patients, families and communities were engaged with and DHIS2 was used for emergency response.
5. A sustainability and policy phase, in which DHIS2 was included in the health operational plan and information and learning on the implementation experiences were shared nationally and internationally.

10 Recommendations for DHIS2 Deployments

This case study documents the 10 key recommendations made to other countries to consider, based on the experience in Bangladesh.

1. HIS government leadership for 5 years

Bangladesh’s HIS achievements have been linked with the determined and focused leadership of Professor Abul Kalam Azad, Director General of Directorate General of Health Services, guiding the robust coordination of all stakeholders. For other countries with a less mature HIS, and without a centralised motivation, developing a management strategy or taking increased leadership to implement HIS will be key.

2. Adopt a pragmatic stakeholder approach

In the absence of an overarching policy, Bangladesh adopted a pragmatic approach to implementing DHIS2, bringing together multiple stakeholders including the Government, international organizations, development partners, health planners and health professionals.

GIZ provided substantial support to MOHFW through setting up the National Data Warehouse, modernising the HIS infrastructure, promoting DHIS2 and providing capacity building between 2011 – 2014. Since 2014, other partners including HISP Bangladesh, ICDDR,B and UNICEF have been pivotal in reforming the HIS from central to grassroots levels, in particular focusing on improving data quality and use.

As Paul Rueckert, the former head of the Support to the Health Sector Programme summarised: “All of this would have been easier to achieve if a policy was in place, but the experience here has shown that one doesn’t always require a traditional policy approach. We had a very narrow horizon at the outset – just one step after another. And at some point, it became faster and faster, and everything began to converge”.

3. Take a comprehensive approach

HIS are linked to all areas of the health system and therefore sustainable implementation requires more than good decisions on software and infrastructure, it requires a comprehensive approach with continuous capacity building at all levels of the health system, attention to governance and ownership of the data by communities and health workers, accountability and transparency practices and regular feedback.

A critical success factor in Bangladesh was community HMIS building, in line with the UNICEF health systems strengthening strategy to capacity build through both top-down and bottom-up approaches. In 2014, UNICEF started building the HMIS system in three districts from the community level, which was scaled-up to the national and divisional levels nationwide in 2015. Building community capacity was essential to improving data collection, from 13 percent to over 98 percent in less than a year.

4. Predict future health needs

In Bangladesh, when DHIS2 was implemented there was a focus on the prevalent diseases from 10 years’ ago. However, since 2009, Bangladesh has gone through an epidemiological transition with the rise in NCDs and an aging population, and there is a more turbulent landscape of emergencies in Bangladesh. The HIS now needs to reorient to serve the new demand.

Having learnt from the experience in Bangladesh, on reflection Dr Abu Sadat Mohammad Sayem stated; “First, when implementing a HIS there is need to think about the health needs in 10 years’ time. Secondly, I would look at technological transitions too, where is the technology going? Will people be using mobile phones more, what will the connectivity be like? Thirdly, I would strongly consider starting a HIS now with emphasis on individual records rather than aggregated data collection.
This was not an option in Bangladesh, but it will be for other countries in the future”.

5. Assess the capacity of local people

Study the people and learn from it. Focus on the local level capacity. In Bangladesh, a strength in the health system is the ambitious and motivated health workforce at the community level, who are excited to learn about new technology and to be educated.

This has been one of the biggest advantages when expanding DHIS2 to the community level. Other countries can look at their own strengths and work with them when implementing a new software.

6. Commit to long-term capacity building

Since DHIS2 implementation, there has been continued emphasis on training DHIS2 data entry, analysis, interpretation and feedback to the health workforce at central and decentralised levels. Despite this, there are still large challenges in health workforce capacity for analysing and interpreting the data, particularly at district and sub-district levels.

On reflection of Bangladesh’s experience, there is a need for more trainings with follow-up and monitoring, to assess how behaviour changed following capacity building initiatives.

7. Be flexible to changing needs

There is need for continuous evaluation of priorities and needs, through regular communication between all levels of the health system and multiple partners has been key to implementation. At times, this may mean not providing a quick intervention, but instead learning to slow down to reflect on progress, gaps or bottlenecks that need to be addressed.

8. Ensure collective responsibility and behaviour

In Bangladesh, there has been an added motivation to use DHIS2 because it is understood as a long- term Government initiative, rather than a short-term externally funded initiative by an external partner. The continued motivation from Professor Abul Kalam Azad, and the positive feedback from the central levels is important for a collective belief in the importance of a strong HIS.

This is particularly important when there was resistance to new technology. It was found that making the software user-friendly and/or providing punitive measures to reporting performance was not enough to incentivise good behaviour. A good health information culture is absolutely essential for behaviour change, alongside these other measures.

9. Engage with patients, families and the community

In a country with a huge population living in hard- to-reach urban areas, accessible only through community ties and outreach, empowering communities to have ownership and participate in decisions and actions and integrating community- based systems with different levels of the health system is essential to DHIS2 implementation and sustainability.

10. Adopt a multi-stakeholder approach

Bangladesh’s model of implementation has been of national level integration, slowing scaling downwards to decentralised levels. It is a nationally owned initiative, supported by multiple stakeholders. The vision was created by DGHS MIS, and the Ministry is very proud of the DHIS2 achievements. This Government ownership has been key to the sustainability of implementation.

The benefits of implementing a health information system at scale are clear. It is hoped that this case study will help policymakers to apply the learning from Bangladesh in their own countries, so that more of the world’s population can benefit.

An edited synopsis of Transforming the Health Information System in Bangladesh through DHIS2 by UNICEF