ICTworks

Over the past two months, major funding cuts have created profound disruptions across global health programs, putting local and global health at risk.

According to Dr. John Kaseya, Director General of Africa CDC, countries depend on international aid for up to 80% of the costs of critical health programs like those for malaria and HIV. Africa CDC estimates that these cuts will result in 4 million extra deaths in Africa per year and increase the risk of future pandemics.

When it comes to the health data that helps guide these programs, there has been one bright spot amid these challenges: most locally-owned national health information systems have remained online and ministries of health continue using them to monitor public health and plan interventions. This resilience is due to years of investment in these systems and in local capacity to manage and sustain them.

However, the situation remains fragile. Most low-income countries still rely on external funding for their public health systems, and the digital public goods (DPGs) that power these systems are also primarily supported by global health funders.

At a time when budgets for global health are tight, it is imperative to support sustainable solutions—that means investing in routine data, open-source tools, and local system ownership.

Health information system risks

Data systems are a small but integral part of national health systems, enabling countries to monitor population health, assess health risks, prioritize interventions, make budget decisions, and evaluate programs.

The open-source DHIS2 software platform is the backbone of the national health information systems in more than 75 countries. These locally-owned DHIS2 systems enable routine data collection on public health programs like maternal and child health, immunization, HIV, malaria, and TB, among many others, that touch more than 40% of the world’s population—roughly 3.2 billion people.

These systems have delivered measurable impacts:

• In LMICs like Ethiopia, Kenya, Bangladesh, Nigeria and Somalia, ministries of health have scaled their DHIS2-based systems to improve treatment results, boost immunization coverage, and more.
• Countries have leveraged their existing DHIS2 systems and capacity to quickly adapt to respond to emerging threats, such as Rwanda’s recent Marburg virus outbreak, Uganda’s Ebola outbreak, and the Covid pandemic, drastically reducing the time and cost needed compared to implementing new digital tools.

Investing in these kinds of flexible, routine digital systems, and building the capacity for local teams to operate and maintain them, ultimately makes LMIC health systems more effective and resilient.

While disruptions to these systems pose a less immediate threat than shutting down HIV treatment centers or stopping food distribution, for example, the impact remains significant:

• Funding cuts can lead to systems going offline or running at reduced capacity.
• Without access to this data, governments struggle to manage health programs effectively.
• If information systems are underfunded over time, it can mean that they are less functional, less secure, and less able to adapt to changing needs.

National HIS remain online–for now

At the HISP Centre at the University of Oslo, our team develops and maintains the DHIS2 software and coordinates the HISP network, which is made up of 23 local HISP groups based in Africa, Asia, the Middle East, and Latin America.

When the news of the U.S. funding cuts broke, we surveyed the HISP network to document DHIS2 system status per country. The responses revealed:

• Many project-funded or program-focused parallel systems have been shut down.
• All locally-owned, routine national health information systems are still running.
• Some parts of routine systems are experiencing disruptions—or are at risk—if they were primarily funded or staffed through U.S. government sources.

This finding supports the HISP network’s core belief: The key to building resilient, sustainable, and effective health information systems is to focus on routine data that serves the needs of country stakeholders and to strengthen capacity for local information system ownership.

“Despite recent budget cuts, DHIS2 implementations have remained resilient, continuing to deliver critical health data and support decision-making. Uganda’s experience highlights DHIS2 as a transformative tool for sustainable health information management and service delivery.”– Paul Mbaka, Assistant Commissioner, Division of Health Informatics, Ministry of Health Uganda

Invest in what works and what lasts

Long-term investments in routine health information systems and open-source technology have helped LMICs make progress toward Sustainable Development Goal (SDG) 3 by enabling better decisions through timely data. These investments also sustained operations during the current funding crisis, thanks to local ownership and capacity—a model HISP has championed for over 30 years.

While our informal survey indicates that all DHIS2-based national health information systems remain operational, some have been hit harder than others. Isolated examples we have uncovered include data collection being halted for certain programs (such as TB) where local staff were being paid from U.S. project funds, or furloughs of core DHIS2 technical teams that were funded by U.S. agencies.

The HISP network is working with partners to address these gaps, but long-term sustainability depends on continued investment in health system strengthening, including data and digital infrastructure.

While many DPGs—including DHIS2—are free for LMICs to use, they are not free to develop or maintain. The work of HISP UiO has largely been funded through grants and contracts with global health institutions and development agencies, and we are transitioning toward country-level contributions to reflect the costs in national budgets.

We think this will support greater sustainability of our project, and increase ownership of our platform in the global south.

However, these changes will not happen overnight.

The Financing Global Health 2023 report found that global health funding to LMICs had already decreased from Covid-era highs and may continue falling. Government spending on health in LMICs remains “far lower than what is needed,” and given limited available resources in LMICs, shifting to local health financing will take time. “Funding for global health,” the report states, “remains as urgent as ever.”

The urgency is even greater now

The full effects of U.S. funding cuts remain to be seen. Thankfully, donors and aid agencies are already stepping up to fill the gaps and keep vital health programs running.

For health data, our message is simple: when budgets are tight, invest in what works and what lasts—locally owned routine information systems, the digital public goods they are built on, and the local capacity to keep them running.

This will ensure that these systems remain resilient and adaptable, helping low- and middle-income countries meet health needs and respond to challenges in the years to come.

By Max Krafft of DHIS2 at the University of Oslo