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How to read this report

The report consists of two parts: one multi-country systems analysis with the key findings and recommendations, and much more detailed information on the individual countries. You may read through the first part of the report by scrolling down and selecting sections of the report while the second part can be accessed through the country report section at the top banner or by selecting the country flags.

Audience of this report

The primary audience of the report is the NTP and IT cells within the Ministry of Health of each country. The assessment report also targets a broader audience that includes donor organizations, implementation organizations, NGOs and CSOs, among others.

How it will benefit

National TB Program: Devise operational strategies to achieve real-time case-based surveillance and plan and advocate for resources.

Ministry of Health: Make policy decisions on integrated surveillance, data security, use of technologies and budgets.

Donors/Funding Organizations: Make high-impact investments for rapid transitions to real-time TB surveillance systems.

Country IT Teams/ Tech Solution Providers: Learn from best practices from all countries to further enhance existing digital offerings to countries.

Public Health Researchers: Better understand the data ecosystem in the countries that can be leveraged for epidemiological and other public health research.

Implementation Partners/NGOs: Converge different digital innovations being implemented by NGO partners to complement the existing national data ecosystem through integration and data harmonization.

Civil Society Partners /Advocacy/ CLM partners: Promote evidence-based CLM and advocacy by harnessing and integrating with national data systems.

The report has primarily divided into two parts, one a multi-country system analysis with the its key findings and recommendations and another part dwells deep into individual country digital TB surveillance status report.

You may read through the first part of the report by scrolling down and selecting sections while the second part can be accessed from the top banner tab or after the multi-country report section at the bottom of this web report.

The report has primarily divided into two parts, one a multi-country system analysis with the its key findings and recommendations and another part dwells deep into individual country digital TB surveillance status report.

You may read through the first part of the report by scrolling down and selecting sections while the second part can be accessed from the top banner tab or after the multi-country report section at the bottom of this web report.

The primary audience of the report is the National TB Program and IT cells within the Ministry of Health in each country. The assessment report also targets a broad group of audiences such as donor organizations, implementation organizations and NGOs, Civil Society organizations etc.

Bangladesh

Cambodia

Cameroon

DR Congo

Ethiopia

Ghana

India

Indonesia

Kenya

Mozambique

Nigeria

Pakistan

Philippines

South Africa

Uganda

Ukraine

United Republic Of Tanzania

Viet Nam

Zambia

Bangladesh
Cambodia
Cameroon
DRC
Ethiopia
Ghana
India
Indonesia
Kenya
Mozambique
Nigeria
Pakistan
Philippines
South Africa
Tanzania
Uganda
Ukraine
Vietnam
Zambia
FOREWORD

Dr.Lucica Ditiu

Executive Director

Stop TB Partnership

The clock is ticking, and we are approaching the deadlines for the 2018 United Nations High-Level Meeting targets, the Sustainable Development Goals (SDGs) and End TB targets. The chaotic biennium of the COVID-19 pandemic has challenged the resilience of health systems since 2020 and has been partially responsible for slowing down the rapid progress in the TB response post-2015. However, the pandemic has also opened new doors in terms of the prevention of airborne infection, and peripheral availability of molecular diagnostics and facilities for differentiated care. It has also unveiled the highest political commitment of national governments and unprecedented global collaborations for health. I believe that the COVID-19 pandemic has demonstrated the power of the human race to conquer epidemics, and shown that funding can be made available and actions taken rapidly, if there is the will.

Since March 2020, we have had access like never before to data about the COVID-19 pandemic – people tested, diagnosed and cured, disaggregated by age, gender, small administrative units and so on. The daily reporting has been the most critical enabler of the global response to COVID-19.

For many years already, we at Stop TB Partnership have been of the strong belief that what we need to strengthen in our response is the availability of real-time temporospatial TB epidemiological information for precise, local rapid response with high-efficiency resource management and concurrent monitoring. It is encouraging to see that a small number of countries have started to report TB notification monthly and a few daily – we need many more.

Stop TB Partnership is working to contribute to and strengthen the TB response. One of the areas of interest is to strengthen the local TB surveillance systems to rapidly advance towards real-time, case-based and digital modes so that there is zero gap in timely information for action. The Global Fund, WHO and technical partners have been fortifying the Partnership’s efforts. It is therefore an amazing step forward for all partners to have the current assessment of real-time digital case-based TB surveillance systems in 19 priority countries in order to support these systems to rapidly evolve into perfect response-drivers. To the best of my knowledge, this is the first assessment of its kind, and it is encouraging for all of us to see that the local digital systems are at various stages of evolution, set out for the final war-room.

I want to thank the national leaderships for their vision, work and commitment to make their digital TB surveillance systems more sensitive, timely, intelligent and responsive, and I am looking forward to working together to use the latest available data and information for action. It is 2022 – we need rapid action based on reliable and timely information. We saw it done for COVID-19; we need the same approach for TB (as an airborne disease) and all infectious diseases.

MESSAGE

Marijke Wijnroks

Chief of Staff

The Global Fund

Real-time digital case-based surveillance systems play a key role in the proper management of people with TB across the continuum of care. They also ensure the timely availability of people-centric data that supports the monitoring of notification results and treatment outcomes, and facilitates prompt decision-making. The Global Fund recognizes this importance and, together with other donors, technical partners and stakeholders, has continuously supported ministries of health and national disease programmes to build and strengthen in-country digital surveillance systems.

Through the Global Fund Strategic Initiative on Data and in synergy with the TB Strategic Initiative, the Stop TB Partnership has assessed the TB surveillance systems in 19 of the 20 Global Fund high-priority TB countries, with a special focus on the real-time digital TB surveillance systems. Understanding the digital case-based TB surveillance systems and challenges in these 19 countries is critical, as they account for 82% of the TB burden and about 66% of the TB funding in Global Fund-supported countries in the 2020–2022 cycle.

It is our hope that the findings and recommendations from this assessment facilitate knowledge transfer between country programmes on the health and TB data needs, inform stakeholder collaboration and help to catalyse the progressive transition from paper-based to functional digital case-based surveillance systems in countries. The Global Fund also acknowledges the valuable role of the World Health Organization, Stop TB Partnership, and other technical partners and donors in moving this priority forward.

ACKNOWLEDGEMENT

This work was conceived and led by Sreenivas A Nair (Stop TB Partnership), supported by Shibu Balakrishnan (Consultant, Stop TB Partnership). Technical support was provided by the team led by Sabyasachi Das and supported by Shital Thakkar, Varun Chauhan, Viplove Dutta and Nida Yamin (Dure Technologies). The core advisory team for the project was made up of Nnamdi Nwaneri, Mohammed Yassin, Michelle Monroe (The Global Fund to Fight AIDS, Tuberculosis and Malaria), Sismanidis Charalampos (World Health Organization) and Viorel Soltan (Stop TB Partnership). The team acknowledges with gratitude the contributions from all national tuberculosis programme managers, monitoring and evaluation and digital surveillance team members, and partners from the 19 countries (listed in Annex 1) Andrei Mosneaga, Enos Masini, Thandi Katlholo and Caoimhe Smyth (Stop TB Partnership) facilitated interviews with country teams and Lalli Marek (World Health Organization) contributed to review of study protocol. The critical review was provided by Suvanand Sahu, Jacob Creswell and Zhi Zhen Qin (Stop TB Partnership), along with Puneet Dewan (Bill & Melinda Gates Foundation) and Kiran Rade (World Health Organization).

Funding support: The Global Fund - Data Strategic Initiative

About Stop TB Partnership

The Stop TB Partnership is a unique United Nations-hosted entity based in Geneva, Switzerland, committed to revolutionizing the TB space to end the disease by 2030. The Stop TB Partnership’s various teams and initiatives take bold but measured risks to identify, fund and support innovative approaches, ideas and solutions to ensure the TB community has a voice at the highest political levels and that all TB-affected people have access to affordable, high-quality and people-centred care. Learn more at www.stoptb.org

About The Global Fund Strategic Initiative

The Global Fund Data Strategic Initiative (Data SI) aims to improve monitoring and evaluation systems in countries, collection, collation, analysis and use of such data for decision-making and quality improvement. Stop TB Partnership (STBP) and WHO are among the implementers of this SI. As part of the first phase of this SI, STBP assess and report country status on availability, readiness and requirements for real-time case based TB surveillance system for TB in the 19 TB SI countries in consultations with NTPs/MOHs & in-country stakeholders, WHO and other relevant technical partners. This assessment will be followed with necessary facilitation for transition to digital real-time case based TB surveillance systems in the TB SI countries

NTP MANAGER VISION BOARD

The value for real time digital TB surveillance system is well accepted by all National TB programs across all 19 countries that were assessed. All 19 countries in their best capacity have created a TB surveillance platform. However, each country differs in terms of maturity of these tools and scale of implementation, which is a function of resource availability, access to existing digital ecosystem, political will and enabling digital environment. The map shows the level of maturity of the digital case based TB surveillance system in the 19 countries during the assessment period.

While countries like India and Philippines have fully matured TB digital surveillance systems in operation, Indonesia, Ukraine, Viet Nam, South Africa, Nigeria and Bangladesh have fairly advanced systems and with some additional efforts can quickly move to fully functional digital TB surveillance system. Cambodia, DR Congo, Kenya and United Republic Of Tanzania have digital case-based systems and with additional support for scale and IT support systems including data entry tools are on the way for a mature system. Countries like Cameroon, Ethiopia, Ghana, Mozambique, and Pakistan have a strong vision and political will for creating a comprehensive case-based TB surveillance system and need additional support in system development and scale up.

Composite Digital TB Surveillance Score

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Composite Digital TB Surveillance Score

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The designations employed and the presentation of the material on this map do not imply the expression of any opinion whatsoever on the part of the Stop TB Secretariat concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. White discontinuous lines are used to represent boundaries under dispute and to approximately show the line of control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. This map is based on UN Map No. 4170 Rev. 15 (July 2018). Every effort is made to ensure this map is free of errors but there is no warrant the map or its features are either spatially or temporally accurate or fit for a particular use. This map is provided without any warranty of any kind whatsoever, either express or implied.

Composite Digital TB Surviellance Score

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16
24

Disclaimer

The designations employed and the presentation of the material on this map do not imply the expression of any opinion whatsoever on the part of the Stop TB Secretariat concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. White discontinuous lines are used to represent boundaries under dispute and to approximately show the line of control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. This map is based on UN Map No. 4170 Rev. 15 (July 2018). Every effort is made to ensure this map is free of errors but there is no warrant the map or its features are either spatially or temporally accurate or fit for a particular use. This map is provided without any warranty of any kind whatsoever, either express or implied.

EXECUTIVE SUMMARY

Tuberculosis (TB) is one of the world’s leading infectious disease killers. The End TB Strategy aims to end the global TB epidemic and has a vision of a world free of TB, with no deaths, disease or suffering due to TB. A strong, responsive TB surveillance system that is digital, case-based and real-time, with data on the full cascade of care and necessary analytics for national TB programmes (NTPs), is critical in the global fight against TB. The COVID-19 pandemic has shown the importance of the availability of real-time data globally, nationally and locally to mount the necessary actions for prevention and care. Most high TB burden countries currently have digital case-based TB surveillance systems at various scales of implementation. While some countries use TB-specific and locally developed ICT systems, many others use platforms including DHIS2. However, there are challenges related to software, hardware, coverage, human resources, training, data regulations, data hosting and ownership, political and administrative will, and so on that need to be systematically identified and prioritized.

Part of the critical task of the Global Fund Data Strategic Initiative (Data SI) is to facilitate countries to rapidly adapt and scale up real-time digital case-based surveillance systems for TB. Stop TB Partnership, as a partner implementing the SI, has initiated this project to conduct a rapid assessment of the real-time digital case-based surveillance systems in TB SI priority countries virtually and to provide country-specific recommendations. Following this, the SI will provide the necessary support to implementers, including national governments, NTPs and partners, to strengthen countries’ real-time TB surveillance systems. This assessment was done with the intention to understand the timeliness of data availability, use and coverage of digital tools, granularity of data, use of the information for surveillance and action, and the system to develop, maintain, integrate and innovate such tools with adequate data security measures.

The assessment was done virtually, primarily through a series of in-depth interviews with various stakeholders in the country, including NTPs and partners supporting TB surveillance, using structured questionnaires, online surveys, desktop review of published reports and other relevant documents. The assessment was done for 19 high TB burden SI priority countries.

The report consists of two parts: one multi-country systems analysis with the key findings and recommendations, and much more detailed information on the individual countries.

Key Findings of the Assessment

All 19 NTPs have a digital TB surveillance platform. However, each country differs in terms of the maturity of its tools and the scale of implementation. The functional maturity of the digital TB surveillance platform to capture data at different stages of the continuum of care (screening, testing, treatment, treatment adherence, treatment outcome, etc.) varies with country programmes. Although some countries have progressed further in digital data on contact-tracing and preventive treatment, these have yet to be scaled up in most countries.

While all assessed countries have a digital TB surveillance system, 10/19 (53%) countries have a case-based system with at least diagnosis, treatment initiation and treatment outcome reported digitally; 5/19 (26%) countries have case-based systems, but with limited data variables; and 4/19 (21%) countries have yet to develop a case-based system. Countries use different digital platforms for TB surveillance. While many countries have transitioned to case-based digital data entry at facility level, others are still reporting aggregated data primarily from the district level, abstracted from paper-based line lists at the health facilities. The DHIS2 platform is used in 10 countries, whereas e-TB Manager is being leveraged in five countries. Some of the countries use a mix of different platforms, while other NTPs use their own in-house digital TB surveillance systems.

All surveyed countries, especially those with well-developed case-based TB surveillance systems, expressed the need to have an interoperable and integrated system that could allow data exchange between the different systems, such as diagnostic laboratory modules, digital adherence tools, and private sector notification tools. Apart from the core digital system available for TB surveillance and notification, countries have been implementing a range of other complementary digital innovations for their TB programme, including modules for digital adherence, private sector TB notification/monitoring, logistics management, laboratory information management, digital X-ray supported by artificial intelligence (AI), community-led monitoring (CLM), contact investigation/TB preventive treatment (TPT), pharmacovigilance, and so on.

Key Priority Needs Identified

The key priority needs identified include in-house IT capacity, hardware for data entry, data servers, and software development for necessary linkages. NTPs often have limited in-house IT capacity and depend on external private or public IT service providers. This limits their flexibility and autonomy in upgrading and enhancing the system. The lack or limited availability of devices (mobile devices or laptops etc.) and the right infrastructure, such as servers, Internet connectivity and a dedicated technical team at the central level, is a challenge in many countries.

Digital tools are most often used in addition to paper-based tools by the generally overburdened local health staff at the health facilities and outreach. Furthermore, the lack of a training mechanism limits operationalization of the digital tools and results in data quality issues.

Countries with case-based TB surveillance systems also have some form of data dashboard. However, there is a tangible need for advanced analytics and AI-based approaches to ensure real-time information for action. CLM is still a weak link in programme monitoring and surveillance systems.

Key Recommendations

Investment to enhance the hardware infrastructure: Most of the countries need devices for data entry at the peripheral level to ensure real-time TB surveillance and data use at the lowest level units. Providing mobile devices and securing Internet connectivity are crucial steps to ensure successful implementation of the digital case-based TB surveillance system.

Case-based monitoring across the continuum of care: While case-based TB notification is the most basic indicator for the digital TB surveillance system that all countries should strive to achieve, a comprehensive workflow-based system to monitor individual cases throughout the entire continuum of care – from client enrolment and risk assessment through to screening, referral, testing, treatment and follow-up – needs to be ensured.

Interoperability and system integration: The existing digital platform for TB surveillance should have the capacity to integrate and facilitate seamless data exchange between different data systems such as medicine inventory, laboratory information management systems, GeneXpert (GxAlert) system, CLM system, etc.

Advanced analytics for better data use: Real-time big data analytics that provide the right information for action need to be built into the digital TB surveillance architecture. Existing tools like DHIS2 have strong data analytics and dashboard functionality with robust indicator configuration. It is also recommended to explore the best-of-breed tools such as Tableau, Power BI and AI solutions for improved use.

e-Training: Developing a comprehensive e-Training/e-Learning platform is necessary to improve data collection and data use processes, and can also be used for continuing medical education.

Costed action plan for digital TB surveillance: An estimated budget has been recommended for each country to strengthen the digital TB surveillance system based on the current e-readiness and IT capacity, maturity of the existing platform (case-based vs. aggregated), number of facilities and users, and other parameters. However, countries need to develop a costed action plan for strengthening their digital TB surveillance system.

Digital TB Surveillance System Assessment Report
BACKGROUND

Tuberculosis (TB) is one of the leading infectious causes of death worldwide. Throughout human history, it is estimated that over 1 billion people have succumbed to TB. At the 2018 United Nations High-Level Meeting on TB, world leaders agreed to end TB by 2030. A robust TB surveillance system is the foundation on which to build and adapt locally appropriate strategies for ending TB. TB surveillance is the continuous and systematic collection, analysis and reporting of data related to TB infection and TB disease in the population. (1) While the coverage and quality of data are critical in making the surveillance system supportive for end-TB actions, the availability of real-time surveillance data helps in making timely decisions and taking proactive actions to meet the end-TB timelines. Real-time digital and case-based surveillance systems for TB have several advantages over paper-based reporting of aggregated data. Digital systems enable automated data quality checks, timely access to data and the availability of individual-level data on people with TB – from community level up to the national level. Strengthening the technology platforms to make the surveillance real-time is a key enabler in the global fight against TB. Such technology is also integral to the daily management of people with TB and provides critical data on the reach and efficacy of programmes.

Currently, there are many high TB burden countries with digital case-based TB surveillance systems at various scales of implementation. While some countries use TB-specific and locally developed ICT systems, many others use ICT tools including DHIS2. However, there are gaps and challenges that prevent uniform uptake of and benefit from such tools to establish a good TB surveillance system that is real-time and responsive. Challenges are related to software, hardware, coverage, human resources, training, data governance, policies and regulations, digital health architecture, data hosting and ownership, political and administrative will, and so on. These challenges need to be systematically identified, prioritized and addressed. There is also a need for smart analytics, including the potential scope of artificial intelligence (AI) in linking programme data with other ecological data to generate predictive models and other epidemiological information. Another challenge is data fragmentation; different tools are often used by public and private providers, or by different branches of a health department, even for managing comorbidities such as TB and HIV. There are also challenges in local implementation and timeliness of reporting; even the best tools need customization, maintenance and support, as well as strong local champions to ensure effective training, monitoring and ongoing use of new technologies.

The COVID-19 pandemic has shown the importance of the availability of real-time data globally, nationally, and locally to mount the necessary actions for prevention and care. This pandemic has also shown the power of digital data and the feasibility of quickly setting up information systems in almost every country. (2) The impact of COVID-19 disruptions on TB notification was first reported in India very early in the pandemic, thanks to the daily reporting of TB notification on a publicly available website (3) and data from the country programme’s well-developed case-based TB surveillance system called ‘Nikshay’. Later, countries were encouraged to report TB notification at least monthly, and more than 80 countries reported their TB notification data to WHO monthly to the end of 2021. (4) Timely availability of data on TB notification and treatment outcomes at the national and subnational levels is critical for monitoring the results of TB catch-up plans and impact mitigation plans. There has recently been high demand for and political commitment to real-time data; therefore, it is the right time for further aggressive efforts in this area.

The Global Fund Data Strategic Initiative (Data SI) has the important task of facilitating countries to quickly adapt real-time TB notification systems. Stop TB Partnership, as a partner implementing the SI, has conducted an assessment of the TB surveillance systems virtually, with a special focus on the real-time digital TB surveillance systems in 19 SI countries, and provided necessary high-level advocacy support to implementers, including national governments, national TB programmes (NTPs) and partners, to enable the programmes to strengthen their real-time TB surveillance systems.

The assessment aimed to understand the timeliness of data availability, use and coverage of digital tools, granularity of data, use of the information for surveillance and action, and the system to develop, maintain, integrate and innovate such tools with adequate data security measures as a real-time digital case-based TB surveillance system.

  • Data availability timelines are considered real-time when the relevant data on people with TB/cohorts are entered/reported immediately after diagnosis or initiation of treatment, or reported within a period of one month, since at least monthly notification is encouraged.
  • Data are considered case-based when individual data are made available to the relevant levels of monitoring and decision-making units for validation, analysis and feedback.
  • Data tools are considered digital when a digital application (web-based, mobile-based online or offline) is used to capture data, as opposed to the data being captured using pen and paper.
  • Surveillance is when the gathered data are linked to epidemiological action beyond service delivery.
  • A system implies that there is a systematic approach to the development/customization and maintenance of the tools used for recording, reporting, analysis and feedback.

Each of the components of the real-time digital case-based TB surveillance system are highly relevant in order to give the system the highest efficiency and have the desired impact on the country’s TB burden. Real-time systems, for example, reduce the redundancy of information and time lag in decisions and actions. Digital systems enhance ease of operation in data entry, enhance the granularity of data, and facilitate the transmission, storage, validation and processing of data at multiple levels. Case-based systems improve the people-centric orientation and customization of the TB care continuum, and promote accountability of health programmes and individual care providers. Such systems also have the potential to evolve to accommodate treatment support, grievance redressal, adverse reaction management, differentiated TB care and access to low or no cost TB services. Although surveillance has been an integral part of disease programmes, provision of prompt feedback, linkage of surveillance to timely action, transparency and data accessibility improve with a well functioning and quality-controlled digital system.

Most country programmes currently use the relevant TB data and analytics for feedback to subnational levels, programme reviews and performance reports. However, digital TB surveillance systems can make key programme performance indicators, such as TB notification and treatment outcomes, available in the public domain for necessary action by various key stakeholders. Access to real-time programme data by all stakeholders can also augment programme transparency.

The assessment also aimed to understand the challenges and gaps in political/administrative support, infrastructure, funding, human resources, system development, maintenance capacity and training.

The digital TB surveillance systems in the countries have developed over time and are continuously evolving with the addition of diverse features, supported by various technical and funding agencies including the World Health Organization (WHO), University of Oslo, United States Agency for International Development (USAID), Stop TB Partnership, KNCV Tuberculosis Foundation, the International Union Against Tuberculosis and Lung Disease (The Union), and the Global Fund to Fight AIDS, Tuberculosis and Malaria. The current assessment gained many insights from existing global guidance and reports, including WHO’s Digital, case-based, real-time surveillance for TB: status of progress (1); WHO Toolkit for routine health information systems data (5); A new digital platform for timely analysis and use of TB data (6); Microsoft Research, the Global Fund, Stop TB Partnership’s Mapping the technology landscape of national TB programmes (7); the Stop TB Partnership’s field guide: Strengthening Information systems and linkages to care (8); and USAID’s TB DIAH Project (9).

OBJECTIVES

The key objectives of the assessment were:

❖ To describe the existing digital TB surveillance systems in the countries in terms of the systems and technologies, coverage, timeliness of reporting, data ownership and dissemination modalities, and hosting arrangements;

❖To describe the e-readiness and capacity of the countries to implement a comprehensive digital case-based TB surveillance system;

❖ To describe the capacity at the national and subnational levels to analyse and use data for evidence-based decision- and policy-making and overall strengthening of programmatic monitoring and evaluation (M&E) efforts;

❖ To describe the challenges in implementing digital case-based TB surveillance systems in terms of software, hardware, human resources, training, connectivity, private sector involvement, political and administrative commitment, data housing and ownership, data through the entire cascade of care, and information dissemination with appropriate dashboards;

❖ To provide country-level recommendations for addressing identified challenges, including resource needs, to enable the NTP to implement a real-time digital case-based TB surveillance system and make the information accessible to all concerned at the appropriate levels for real-time actions;

❖ To share innovative solutions and success stories with the NTPs on real-time digital case-based TB surveillance systems.

Approach and Methodology

The approach was devised for a rapid, remote assessment over a short study period, as time was of the essence, especially during the COVID-19 crisis. The assessment attempted to identify the digital TB surveillance systems operational at country level, relying mainly on the inputs from programme implementers, and to make recommendations based on country programme aspirations, system requirements and practical considerations including resource availability. The approach was to optimize the time and effort of the NTPs and other stakeholders, yet assess key components that would help countries to better articulate their digital capacitation needs.

A structured process-led approach was designed to execute this assessment, which involved multistakeholder consultations and participation (see Figure 1). The assessment team tried to promote insight, introspection, and cross-learning as the core philosophy throughout the process of assessment and reporting.

The assessment was done primarily through a series of in-depth interviews with various stakeholders in the countries, including NTPs and partners supporting TB surveillance, along with structured questionnaires, online surveys, and desktop review of published reports and other relevant documents. Repeat interviews with probing questions were also conducted to gather more technical information, especially on the existing digital systems, fill information gaps and triangulate information from different stakeholders. Non-English-speaking countries were supported by interpreters and translated information was made available for cross-verification by the respective NTPs and stakeholders.

Following the data collection process, data gathered by the team from different sources (i.e. desktop research, online survey, introductory meetings, and detailed workshops) were curated to extract meaningful insights for country-wise compilation. Data analysis was done using the country assessment template. The analytical template consisted of the complete country assessment information put into a structured format. The framework enabled the team to convert subjective and unstructured information into more structured and analysed insights. It also enabled them to capture relevant recommendations from participants.

The filled in country analytical frameworks with all findings and recommendations were sent to the participants (NTPs and partners) for validation. Further iterations were made following the feedback from the NTPs, and the draft reports were shared again with the NTPs and partners for further validation.

In addition to the individual country reports, the data were further analysed with characteristics such as types of digital platforms, timeliness, coverage and comprehensiveness, collated for multi-country analysis and presented in this report.

Some core principles were followed when designing the approach:

  • Multistakeholder engagement and participation
  • Open-minded discussion
  • Proactive information collection
  • Avoidance of any conflict of interest
  • Validation of information at each stage
  • Sign-off and approval by countries.

The methodology was formulated to conform to the above-mentioned principles. The detailed step-by-step process is further explained in Annex 2

Figure 1. The methodology was divided into 5 main steps starting from Collection, Curation , Validation , Analysis , Recommendation.

Collection

Curation

Validation

Analysis

Recommendation

Countries Assessed

The 19 TB priority countries assessed were: Bangladesh, Cambodia, Cameroon, Democratic Republic of the Congo (DR Congo), Ethiopia, Ghana, India, Indonesia, Kenya, Mozambique, Nigeria, Pakistan, Philippines, South Africa, Ukraine, Uganda, United Republic of Tanzania, Viet Nam and Zambia.

Key Findings - Multi Country Comparison & Analysis
1. Status Of Digital TB Surveillance Systems - Functional Maturity Level

All NTPs across the 19 countries acknowledge the value of a real-time digital TB surveillance system. All 19 countries have created a TB surveillance platform to the best of their capacity. However, each country differs in terms of the maturity of these tools and scale of implementation, which is a function of resource availability, access to the existing digital ecosystem, political will and the presence of an enabling digital environment. Table 1 show the level of maturity of the digital case-based TB surveillance systems in the 19 countries during the assessment period. The maturity level was assessed on a scale of 1 (basic) to 4 (full maturity) based on six parameters: 1) timeliness of data availability (score of 1 for quarterly reporting to a score of 4 for daily data entry and real-time analytics); 2) digital case-based (score of 1 for no case based system to 4 for case-based for both drug-susceptible [DS-] and drug-resistant [DR-] TB); 3) coverage (score of 1 for pilot to 4 for full national coverage); 4) level of granularity and use of data for surveillance (score of 1 for national-level reporting only to 4 for dashboards, line lists, job aids and feedback, including publicly available key information); 5) IT systems, including human resources (score 1 for externally supported limited resources to 4 for full IT systems, a dedicated IT team and necessary data entry tools at all levels); and 6) cascade of care (score 1 for notification only to 4 for presumptive TB to outcome data). The assessment found that India and Philippines have fully mature digital case-based TB surveillance systems in operation. Bangladesh, Cambodia, Indonesia, Nigeria, South Africa, Ukraine and Viet Nam have fairly advanced systems, and, with some additional effort, these countries could quickly move to fully functional digital case-based TB surveillance systems. DR Congo, Kenya and the United Republic of Tanzania have digital case-based systems; with additional support for scale-up and IT support systems including data entry tools, these countries are on their way to achieving a mature system. Cameroon, Ethiopia, Ghana, Mozambique, Pakistan, Uganda and Zambia have a strong vision and political will to create a comprehensive digital case-based TB surveillance system, but need additional support in system development and scale-up.

1
2
3
4
Timeliness of Data Entry Digital and Case Based Scale/ Coverage Case Based Surveillance - Level and Granularity IT System and Support Team Cascade of Care Composite Country Score

Table 1. Digital TB Surveillance system - functional maturity level

Case-Based
Aggregated
2. Status of digital TB surveillance systems – continuum of care

It was encouraging to learn that all 19 TB priority countries have some form of digital tool for TB notification and surveillance. Although some countries are ahead of others in terms of the maturity of the tools, the vision for moving to a fully interoperable digital case-based TB surveillance system was clearly articulated by each NTP. The functional maturity of the digital TB surveillance platform in terms of its ability to capture data variables at the different stages of the continuum of care – from screening and TB testing through to treatment, treatment adherence and treatment outcome – varies with the respective country programmes (see Table 2). Although some countries have progressed further in digital data on contact-tracing and preventive treatment, this has yet to be scaled up in most countries.

Case-Based
Aggregated
Manual
Presemptive TB Screening TB Testing Treatment Initiation Treatment Adherence Treatment Outcome Contact Tracing
Bangladesh
Cambodia
Cameroon
DR Congo
Ethiopia
Ghana
India
Indonesia
Kenya
Mozambique
Nigeria
Pakistan
Philippines
South Africa
Uganda
Ukraine
United Republic Of Tanzania
Viet Nam
Zambia

Table 2. Data systems for continuum of care

While all assessed countries have digital TB surveillance systems in their programmes, 10/19 countries (53%) have a case-based system reporting at least TB testing, treatment initiation and outcome digitally; 5/19 countries (26%) have case-based systems, but have data only for either notification or treatment initiation and outcome; 4/19 countries (21%) have yet to develop a case-based system. Countries such as Bangladesh, Cambodia, Kenya, India, Indonesia, Nigeria, Philippines and Viet Nam have fairly advanced systems. However, the national-level coverage and comprehensiveness vary.

3. Digital TB Surveillance Platforms

Countries use different digital platforms for TB surveillance. While many countries have transformed to case-based digital data entry at facility level, others are still reporting aggregated data primarily from the district level, abstracted from paper-based line lists at the health facilities.

Table 3 shows the different platforms used by the programmes, data types (case-based or aggregated) and point of data entry. (Note: The scale/coverage of the platform or data entry point is not depicted here. This can be seen in Table 1 describing the functional maturity.)

Case-Based
Aggregated
National Digital TB Suviellance TB Platform Data Type Point of Data Entry
Bangladesh e-TB Manager Facility level (Upazila Health Complex and other hospitals)
Cambodia e-TB Manager (Cam TBMIS) Facility level (Treatment health centers)
Cameroon DHIS2 Regional level
DR Congo DHIS2 Health zone level
Ethiopia DHIS2 Facility level
Ghana DHIS2, e-Tracker (high burden facilities) (High burden facilities) + Facility level
India NIKSHAY Facility level
Indonesia SITB Facility level
Kenya TIBU, KHIS 2 Sub-county level (on behalf of health facilities)
Mozambique SIS-MA (DHIS2) Facility level
Nigeria e-TB Manager, DHIS2 High Burden facilities, District level
Pakistan DHIS2, ENRS DHIS2 - District level ENRS - Facility level
Philippines ITIS Facility level
South Africa Tier.Net (DS TB), EDR web (DR TB) Facility level
Uganda DHIS2 Facility level
Ukraine eTB-Manager , MIS SSD Facility level (TB servicing units)
United Republic Of Tanzania DHIS2 Facility level
Viet Nam VITIMES, e-TB Manager VITIMES - District level e-TB Manager - Facility level
Zambia DHIS2 District level

Table 3. Digital platforms

The DHIS2 platform is used in eight countries (Cameroon, DR Congo, Ethiopia, Ghana, Pakistan, Uganda, United Republic of Tanzania and Zambia), whereas e-TB Manager is being leveraged in five countries (Bangladesh, Cambodia, Nigeria, Ukraine and Viet Nam). Some of the countries in the list also use a mix of different platforms (Ghana, Nigeria and Viet Nam). For the remaining countries, the NTP has taken leadership to develop its own in-house TB surveillance system (Kenya, India, Indonesia, Mozambique, Philippines and South Africa).

4. Complementary Digital Innovations, Interoperability and System Integration

All surveyed countries, especially those with well developed case-based TB surveillance systems, expressed the need to have an interoperable and integrated system that could enable data exchange between different systems, such as diagnostic lab modules/GxAlert, digital adherence tools, private sector notification tools, etc. Countries have yet to implement comprehensive data warehouses and interoperable standards such as FHIR(Fast Healthcare Interoperability Resources) or HL7.

Apart from the core digital system available for TB surveillance and notification, countries have been implementing a range of other complementary digital innovations for the TB programme (see Table 4). Some of the key modules/platforms assessed include the following:

Digital adherence module/platform

This module/platform enables either adherence reporting by health workers/community/facility treatment supporters or self-reporting of adherence by the people on TB treatment themselves. The format can range from a software application to devices like a pill box integrated with an application to a 2G channel-based (USSD, Missed Call, IVRS, SMS) solution like 99DOTS.

Private sector TB notification /monitoring module/ platform

Many programmes use separate apps/modules for notification/monitoring from the private sector. While some mobile applications for this purpose are well integrated into the main digital TB surveillance platform, other standalone apps also exist.

Logistic management module/ platform

This includes medicines/diagnostics reagents/commodities/consumables inventory and logistics management systems. Most often, these solutions cut across different health programmes and are not necessarily dedicated to one single programme like TB.

Laboratory information management module / platform

This includes different activities from test result updates – including for culture, drug susceptibility testing (DST) and line probe assay (LPA) – to sputum collection and transport systems, and integrated system/applications for GeneXpert/Truenat.

Digital X-Ray supported by AI

Digital X-ray machines are being scaled up in many countries. Computer-aided detection (CAD) technology is also increasingly used to provide presumptive screening. However, these data often exist in silos and are not linked to laboratory diagnostic data, for example. Therefore, health care workers have to double-enter the X-ray screening data into the existing platforms. Interoperability solutions between X-ray/CAD databases and the main TB surveillance platform are crucial.

Community Led Monitoring module / platform

This is a very essential yet new area of focus. Many countries realize the importance of community-centric approaches and the use of CLM systems and different digital innovations to facilitate community-based reporting, grievance redressal, access to information, community forums and discussion platforms.

Contact investigation / TB Preventive Treatment (TPT) module / platform

These apps/modules contain screening, contact investigation and TPT data. Most of the countries follow WHO’s screening and contact investigation pathways to ensure access to TPT for eligible clients.

Pharmacovigilance module/platform

This involves systems or modules to report adverse events from TB medicines. In most of the countries, pharmacovigilance platforms cater to different programmes and medicines including TB medicines.

5.Other Complimentary Digital Modules

As far as the integration of the complementary digital modules into the national digital TB surveillance system is concerned, three main categories were identified:

Module within the national TB Surveillance platform: Some of the advanced systems have most of the complementary modules already built into the TB surveillance system. This means that the modules share a common code base and are deployed in the same data environment, which ensures complete harmonization and data exchange with the national TB surveillance platform.

External platform fully integrated with the national TB surveillance platform: Modules/platforms falling under this category are those that, despite using a different code base and having been developed as a separate platform, have all the necessary data exchange capabilities and integrations. Systems such as GxAlert or QureAI, WHO’s Prevent TB platform, 99DOTS and OneImpact that are integrated into TB surveillance systems fall under this category.

External platform not integrated with the national TB surveillance platform: These are systems where a data exchange mechanism has yet to be put in place. These systems often have their own database and deployment in different environments.

Digital Adherence Logistics Management Lab Information Systems Community Led Monitoring Contact Tracing Pharmaco-vigilance
Bangladesh 99DOTS QuanTB GxAlert, CAD4TB mHealth, ConnecTB e-TB Manager
Cambodia Cam TBMIS Cam TBMIS OneImpact Cam TBMIS
Cameroon DHIS2 GxAlert, Data2Care Household survey
DR Congo QuanTB OneImpact
Ethiopia GxAlert eCHIS VigiLyse, VigiBase
Ghana QuanTB GxAlert, ASPECT DHIS2
India NIKSHAY, 99DOTS, evriMED/ MERM box NIKSHAY Aushadhi LIPMS, Qure.AI NIKSHAY Arogya Sathi, TB Mitra Prevent TB PVPI Pharmacovigilan ce system
Indonesia EMPATI SITB, SITRUST GxAlert, SITB EMPATI SITB, SITK
Kenya TBMeds, KEMSA LMIS GxAlert, LabWare TIBU TIBU
Mozambique SIS-MA Ferramenta Central GxAlert, Disalink OneImpact DHIS2
Nigeria 99DOTS, VideoDOTS LMIS GxAlert, CAD4TB EWORS, Commcare e-TB Manager
Pakistan TB DMIS GxAlert, CAD4TB OneImpact
Philippines 99DOTS, VideoDOTS, Smart Pillbox, ConnecTB, CareTB QuanTB, PMIS GxAlert,Data2Care, C360 OneImpact (CareTB) CareTB, ITIS, ConnecTB PVIMS
South Africa Wisepill, PCAM Stock Visibility System GxAlert, Qure.AI Ritshitze (SMS to patients) EDR Web, PVIMS
Uganda VideoDOTS, 99DOTS DHIS2 DHIS2, GxAlert Toll Free call centre DHIS2
Ukraine VideoDOTS, EvriMED pill box e-TB Manager, QuanTB e-TB Manager, LMIS OneImpact
United Republic Of Tanzania 99DOTS, TambuaTB eLMIS GxAlert OneImpact
Viet Nam VITIMES, e-TB Manager VITIMES, e-TB Manager VITIMES, eTB manager, GxAlert, PACS, Qure.Ai, DrAids ZeroTB Vietnam ACIS e-TB Manager
Zambia eLMIS GxAlert, DISA, Data2Care

Table 4. Other complementary digital modules

6.Key Priority Needs Identified

The following are some of the key priority needs identified. The specific needs and urgency assessed during the stakeholder discussions form the basis of the recommendations outlined in the next sections of this document.

IT capacity

Many countries highlighted that the in-house IT capacity of the NTP was limited, often dependent on external private or public IT service providers, thus limiting the flexibility and autonomy of upgrading and enhancing the system. There was a clear need to strengthen internal IT capacity. Doing so will not only provide autonomy to innovate, but also ensure sustainability and scalability in the long run in terms of expanding to different modules and different user groups. Lack of a dedicated technical team at the central level for digital TB surveillance is another challenge in many countries.

Hardware and device needs

One of the most common challenges faced by countries is the availability of devices (mobile devices, mobile Internet or laptops, etc.) and the right infrastructure such as Internet connectivity or even electricity.. Providing the necessary devices to health functionaries at the lowest level units will help to optimize the work of health staff and ensure timely collection of data, which is crucial for the success of any digital TB surveillance system.

Double systems for data entry

Most often the health staff at the local levels are overburdened, and the digital entry tool is often being used in addition to the paper-based tools (rather than the digital tool as the only data collection tool). This duplication of data entry adds to the workloads of the health staff at the facilities or outreach.

Despite having advanced digital systems, most countries continue to rely on paper-based data entry at the periphery. The lack of complete coverage of digital systems, and thus the need to maintain paper-based systems, continues to present a challenge. Data validation is another important issue, which is different when using a paper-based system. Digital systems can provide necessary quality checks/deduplication etc. and instil better confidence in programme managers to do away with paper-based systems. There have been concerns about transfer/migration of historical data from paper-based systems to the digital system and the availability and use of the historical data during the transition period. Countries that have fully transitioned to digital systems have made extra effort to enter the backlog of case-based data for the last few years.

Training and capacity-building needs

Training has multidimensional challenges. First, the ongoing COVID-19 pandemic has paused training to a considerable extent in most countries. Assessment of training needs and provision of fresh/update training on TB surveillance systems have been replaced by the more demanding need for COVID-19 infection prevention and control and impact mitigation. Virtual training/training with remote assistance are being promoted by many NTPs. Some national programmes, such as those in India and Philippines, have developed e-Learning platforms and self-learning modules with release alerts. Provision of self-learning and assisted learning opportunities to complement or reinforce physical learning has proven helpful. However, complete transition to remote or self-learning may not be an option for the most peripheral staff, especially general staff who additionally manage TB data. Furthermore, the lack of a scalable remote training mechanism limits the operationalization of digital tools and results in data quality issues at the source of collection during restricted access situations.

Cascade of care monitoring

Although many countries have case-based TB surveillance systems, many often lack a comprehensive workflow-based model to monitor a person with TB through the continuum of care – from risk assessment to screening and referral. However, all countries unequivocally expressed the importance of capturing real-time data across the entire cascade of care, as this has the potential to increase the yield and plug the leaks in the cascade.

Community Linkages/CLM

CLM is still a weak link in providing holistic TB care. Although many countries are implementing community screening/sputum collection and outreach work using community workers and volunteers, the countries have yet to implement standardized CLM frameworks or use the data to strengthen the TB response through community and civil society organization (CSO) participation. However, all NTPs recognize the importance and value of strengthening community and civil society engagement, and addressing community challenges such as social barriers to access, stigma, TB support services, and human rights challenges.

Data sciences, analytics needs and AI for a comprehensive TB surveillance system

Most of the countries with a case-based TB surveillance system also have some form of dashboard. Some countries are ahead of others, but the need to effectively analyse data for programmatic decision-making is acknowledged by all. Countries in advanced stages of digital platform implementation envision the use of advanced data science and AI-based approaches not only for analysing data, but also for predictive modelling to facilitate better resource planning and programme management, smart digital job aids powered by AI solutions, epidemiological intelligence, impact assessment, etc.

The use of AI enables reasoning with uncertainty in complex environments and helps find missing cases. Using survey or programme data at high resolution can help to predict risk of disease, health-seeking behaviour, vulnerabilities and treatment outcomes at the individual or population level. Predictive modelling approaches can be used to map at-risk population groups and support active case finding through the engagement of local stakeholders, including private health care providers.

Recommendations
Key Principles and Approaches
Leveraging and maximizing existing IT infrastructure and capacity

One of the core principles considered in the country recommendations is to maximize the existing IT infrastructure and data ecosystems already in place, instead of creating a parallel system and “reinventing the wheel”. In general, the approach should be “build on what you have''. The digital systems will keep on evolving and, at some point, every country programme will need to jump systems. For some, that shift might come sooner, while for others it might be a better option to shift at a later time. There should always be consideration of when it may make sense to change systems, followed by a full cost–benefit analysis, aligning with the country’s national HMIS/M&E plans and digital health national strategies.

In addition, if there is an opportunity to integrate the TB surveillance system into an existing sound general electronic medical records (EMR) system, it might be a better option, but without compromising the need for comprehensive TB surveillance.

The recommendations aim to leverage the following key strengths of the countries.

❖ Existing software/Data ecosystem

The assessment revealed that almost every country has some form of digital infrastructure and capacity in place. As indicated earlier, eight countries have DHIS2-based systems in different phases of implementation, and five countries are already using e-TB Manager-based systems. Kenya, India, Indonesia, Mozambique, Philippines and South Africa have systems developed by their internal IT teams.

This infrastructure provides the country with an excellent launchpad for creating a comprehensive digital TB surveillance system without much need to depend on external systems. However, while the existing platforms provide a core foundation, countries may use this assessment report to discover different functional and technical innovations and modules that other countries are implementing. There is also a great deal of scope to integrate external digital innovations into the core foundation countries already have in place.

This approach makes the digital roadmap not only cost-effective, but also sustainable in the long run, as it has the potential to integrate with the overall health system and help to reduce health data silos.

❖ Human resource/IT capacity

In line with this core principle, countries should maximize and strengthen the human resources and IT capacity already available in countries. For example, one of the most common recommendations is to leverage the existing DHIS2 resources or other technical experts already in the countries. Capacitating and increasing existing resources will not only lead to a smooth transformation of the digital landscape in the country, but also ensure long-term sustainable growth. The recommendation is for these digital initiatives to be increasingly country-led, strengthening the country's in-house technical team and capacity.

❖ Hosting and deployment environment

Like software applications, the recommendation ensures that countries' existing hosting and deployment environments, such as servers, clouds, data warehouses and repositories, are maximized.

Align recommendations with country's vision and challenges

One of the other core principles followed is to align the recommendations with the country's existing vision and priorities in order to address the key challenges faced by the country. These challenges can differ significantly from country to country based on different factors discussed below.

❖ Stage and maturity of TB surveillance system

The recommendations vary from country to country based on the stage and maturity of the TB surveillance system. For example, for countries that have only an aggregated TB notification system, the typical recommendation is to first create a case-based TB surveillance system for the entire continuum of care, whereas for countries that already have a case-based TB surveillance system, the recommendation is to explore other advanced features/modules such as contact investigation, GxAlert integration, etc.

❖ Alignment with roadmap and vision

The approach is also to keep the recommendations aligned with the country's existing vision and roadmap, shared as part of the assessment exercise.

❖ Prioritization based on challenges

The recommendations also reflect the challenges highlighted by the countries as part of the assessment. While many of the basic challenges are similar across the countries, the countries also vary significantly in terms of how and when they can resolve the challenges.

Non-prescriptive

Another core principle of the recommendations is to keep them non-prescriptive. The idea is to share the best practices based on our combined understanding from multiple countries and stakeholders. However, the countries should evaluate these recommendations based on their country context, budget availability, priorities and mandates.

Key Generic Recommendations

While the recommendations vary from country to country based on the principles indicated in the previous section, some of the common recommendations provided to achieve the ideal functional and technical architecture for a case-based TB surveillance system are as follows:

Interoperability and system integration

One of the biggest opportunities and enabling environments is the digital ecosystem that already exists within the national programme – whether fully owned and managed by the NTP or managed by an external private or public entity, including other programmes in the Ministry of Health, and across Ministries such as Information or Telecommunications.

These existing data ecosystems form a strong foundation for promoting interoperability, which would enable countries to integrate and facilitate seamless data exchange between different data systems such as medicine inventory, laboratory information management systems, GeneXpert (GxAlert) system, CLM and more. The idea is to create an integrated and harmonized data exchange system in which each part is complementary and duplication of effort is avoided. This ensures that existing efforts are better optimized and utilized, instead of introducing a new system.

As part of the assessment, we recommend that countries implement the following broad measures to ensure interoperability:

❖ Leverage interoperability standards like FHIR (Fast Healthcare Interoperability Resources). FHIR is a standard describing data formats and elements and an application programming interface for exchanging electronic health records. This would enable NTPs to exchange data with other health records or data systems such as diagnostic devices, logistics management systems and other data systems. It would also ensure high-level data security and privacy during the data exchange processes.

❖ Creation of centralized data warehouse: A strong data warehouse, data governance and analytics framework are core to ensuring interoperability. These aspects will not only enable the sharing and reporting of TB data with other national health information systems, but also facilitate the consumption and triangulation of data from other data sources, including open data repositories.

❖ Recommended exchange / ETL tools: Tools like Talend or Informatica that include these features make data management and data governance tasks much easier.

❖ Develop the necessary application program interface (API) and single sign-on: TB surveillance systems that have already been developed or are in the process of development should ensure development of the necessary APIs so that they can integrate with other systems.

Enhancing hardware infrastructure

All countries without exception expressed the need for and highlighted the importance of devices to ensure real-time TB surveillance and data use at the lowest levels. Providing mobile devices and mobile Internet could be a crucial and cost-effective way to ensure successful implementation and adoption of these tools, and investing in hardware as the backbone of the case-based TB surveillance system and other ancillary data systems. The investment made in devices can be optimized by maximizing their use in other health programmes, as most health functionaries at the lowest level units are often tasked with responsibilities from multiple programmes.

Hardware includes mobile devices/tablets/laptops for outreach/facility staff for real-time data entry and access to analytical dashboards/job aids, etc.

Although servers are also an important component of the hardware infrastructure, in most of the countries assessed, servers and deployment infrastructure are already available either directly within the TB programme or within the broader Ministry of Health or national government. Cloud-based hosting is generally recommended, as it offers appropriate security and ease of operation.

Case based monitoring across the continuum of care

While digital case-based TB notification is the most basic and important data variable and early indicator for the development of a digital TB surveillance system that all countries should strive to achieve, one of the key processes and functional recommendations common to all countries is to achieve a comprehensive workflow-based system to monitor individual cases throughout the entire continuum of care – from client enrolment and risk assessment through to screening, referral, testing, treatment, treatment adherence, treatment outcome, comorbidity management and post-treatment follow-up. This should also ideally include the complete screening pathway for TB disease and infection for vulnerable groups such as HIV(Human Immunodeficiency Virus) patients and contacts of people with TB in order to identify and refer clients for TPT.

Advanced analytics for better data use

One of the most crucial aspects of the assessment was to review the status of data use in the countries. Most country programme leaderships unequivocally consider this to be one of the most crucial areas. Although most countries have some form of data and data use tool, very few countries have a real-time dashboard with data at the lowest levels, not only for M&E purposes but also for better patient management and care. There are various innovations that can result in the most effective use of data for programmatic improvement. Some of the recommendations include:

  • Enabling real-time monitoring of the cascade of care pathway;
  • Big data analytics and AI-based predictive modelling, mapping, risk profiling and prioritization for actions of people with TB using appropriate machine learning and AI systems;
  • Geospatial analytics;
  • Integration of CLM indicators with programme indicators;
  • Automated AI-based job aids for programme staff, etc.

Given that there are different data systems working in conjunction, it is also recommended to explore creation of a centralized data repository/data warehouse system, bringing data from multiple sources into one place.

Existing country tools like DHIS2 have strong data analytics and dashboard functionality with robust indicator configuration. It is also recommended to explore best-of-breed tools such as Tableau and Power BI, which offer these features. APIs can be generated and connected with these applications, and these can be used as an extended analytical component of the data analysis framework.

Community Led Monitoring (CLM)

Community-based monitoring (CBM)/CLM is one way of generating granular data to provide feedback to service providers and decision-makers in order to collaboratively solve barriers and bottlenecks to services and improve the quality of services. Examples of CBM models include community treatment observatories, human rights complaints mechanisms, and scorecards. Users and communities gather, analyse and use information to improve access to services, better target resources, and address human rights and gender barriers. This is crucial for the overall success of the programme. One of the key recommendations is to fully integrate CLM into the programmatic framework of the country. This can be achieved in different ways, as outlined below:

  • Include CLM indicators among the core indicators of the NTP – mainly in terms of how different barriers to services reported by the community are impacting programmatic targets and outcomes.
  • Promote CLM data collection by CSOs and other human rights organizations, or include key CLM data variables as part of the M&E of the national programme.
e - Training

Providing training to health staff at the lowest level units has always been a challenge. The COVID-19 crisis has only broadened the training gaps, resulting in huge data quality issues related to the completion of data, timeliness of data, and authenticity of data in the M&E process across the globe.

Developing comprehensive e-Training/e-Learning platforms to facilitate synchronous and asynchronous video and audio training sessions, dynamic training content management systems and the use of gamification has the potential to improve data collection and data use processes and contribute to CME and Manuals of Procedures for TB programmes.

A Costed Action Plan For Digital TB Surveillance

An estimated budget has been recommended for each country for strengthening its digital TB surveillance system based on the country’s current e-readiness and IT capacity, maturity of the existing platform (case-based vs. aggregated), number of facilities and users, and other parameters (see Figure 3). However, countries need to develop a costed action plan for strengthening their digital TB surveillance system.

The estimated budget is only designed to provide a rough estimate of the costing and should by no means be considered to be the final budget requirement. Each country is encouraged to evaluate its country-specific budget needs based on the current funding available and vision for creating a case-based TB surveillance system. Based on the NTP’s vision and the recommendations for improvements, the plan should clearly define targets with actionable interventions and funding requirements, supported by a detailed work plan with timelines.

Country Reports

Resource Library

Case-based TB surveillance. In: Global tuberculosis report 2021. Geneva: World Health Organization; 2021

Digital, case-based, real-time surveillance for TB: status of progress Tuberculosis (TB) surveillance is the continuous and systematic collection, analysis and reporting of data related to TB infection and TB disease in the population. To support countries to implement national surveillance systems for TB in a consistent and comparable way worldwide, the World Health Organization (WHO) has, since the mid-1990s, provided guidance with standardized definitions, forms, registers and reports (1). There were major updates to this guidance in 2006 (2) and 2013 (3).

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Agarwal S, Jalan M, Pandya S, Ferguson R, Moustafa D, Ng C, et al. Digital solutions for COVID-19 response: an assessment of digital tools for rapid scale-up for case management and contact tracing. Baltimore: John Hopkins Global mHealth Initiative – Johns Hopkins Bloomberg School of Public Health; 2020
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Nikshay reports: dashboard. Delhi: Ministry of Health & Family Welfare, Government of India
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Tuberculosis data. In: Global Tuberculosis Programme. Geneva: World Health Organization

Global Tuberculosis Programme: The WHO Global Tuberculosis Programme works towards the goal of a world free of TB, with zero deaths, disease and suffering due to the disease. The team’s mission is to lead and guide the global effort to end the TB epidemic through universal access to people-centred prevention and care, multisectoral action and innovation.

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WHO Toolkit for routine health information systems data. Modules. Geneva: World Health Organization

WHO Toolkit for Routine Health Information Systems Data This effort is led by WHO and its Collaborating Centre on Innovation and Implementation Research for Health Information System Strengthening at the University of Oslo, with support from Health Data Collaborative partners, including UNICEF, Global Fund, GAVI and PEPFAR. For questions or comments, please contact healthinfo@who.int Health service data are essential for patient management, facility management, disease surveillance and monitoring of service provision and resource use. Countries also need reliable facility data to assess the performance of their health services as they work towards the UHC targets and the SDGs.

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A new digital platform for timely analysis and use of TB data. Geneva: World Health Organization; 2019

The WHO Global TB Programme has developed and is supporting country implementation of a new digital platform to store, analyze and visualize national and subnational TB surveillance data. The platform will facilitate timely planning and programmatic action.

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Mapping the technology landscape of national TB programs: report. Geneva: The Global Fund to Fight AIDS, Tuberculosis and Malaria; 2021

Harnessing the power of digital health technologies is essential to driving progress in the fight against tuberculosis (TB). The COVID-19 pandemic has further underlined the importance of digital tools and international cooperation and collaboration for global health. This report, produced in collaboration with our partners Microsoft and the Stop TB Partnership, shows that there is a need for countries, donors and procurers to use their purchasing power and influence to promote market shaping for these tools. Shortcomings of financing, policies and appropriate resources need to be addressed in order to make digital health tools available in each country and realize the full potential of existing innovations. Different countries use different infrastructures as the backbone of their health systems, making it difficult to distribute new tools and digital subsystems globally.

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Stop TB field guide 9: strengthening information systems and linkages to care. Geneva: Stop TB Partnership; 2018

This document is one in a series of 11 field guides produced by Stop TB Partnership in collaboration with the Global Fund to Fight AIDS, Tuberculosis and Malaria, KIT Royal Tropical Institute, Interactive Research and Development Global (IRD), and multiple global experts and implementation partners.

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TB Data Hub – Enhance data. Expand data analysis. End tuberculosis. Chapel Hill: TB DIAH Project, University of North Carolina

The TB Data, Impact Assessment and Communications Hub (TB DIAH) project, funded by the United States Agency for International Development (USAID), is associated with USAID’s Global Accelerator to End Tuberculosis (TB). The Accelerator is USAID’s new business model to focus on performance-based measures for combating TB. We will work to strengthen the capacity of national TB programs to reach every person with TB, including vulnerable groups; cure those who need treatment; and prevent the spread of new infections. TB DIAH will also help foster country commitment to policies and action for inclusive and accountable governance of TB programs with strong information systems, infrastructure and financial support, and participation of all of civil society.

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Guideline: Recommendations on Digital Interventions for Health System Strengthening

The key aim of this guideline is to present recommendations based on a critical evaluation of the evidence on emerging digital health interventions that are contributing to health system improvements, based on an assessment of the benefits, harms, acceptability, feasibility, resource use and equity considerations. This guideline urges readers to recognize that digital health interventions are not a substitute for functioning health systems, and that there are significant limitations to what digital health is able to address.

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A new digital platform for timely analysis and use of TB data

The WHO Global TB Programme has developed and is supporting country implementation of a new digital platform to store, analyze and visualize national and subnational TB surveillance data. The platform will facilitate timely planning and programmatic action.

Strengthening Information systems and linkages to care - StopTB Field Guide

Finding and treating people with tuberculosis (TB) is a multi-step process involving awareness generation, prevention, screening, testing, diagnosis, treatment initiation, multiple follow-ups and finally a successful treatment outcome.

A new digital platform for timely analysis and use of TB data

The WHO Global TB Programme has developed and is supporting country implementation of a new digital platform to store, analyze and visualize national and subnational TB surveillance data. The platform will facilitate timely planning and programmatic action.

Strengthening Information systems and linkages to care - StopTB Field Guide

Finding and treating people with tuberculosis (TB) is a multi-step process involving awareness generation, prevention, screening, testing, diagnosis, treatment initiation, multiple follow-ups and finally a successful treatment outcome.

ADDITIONAL RESOURCES
  1. Guideline Recommendations on Digital Interventions for Health System Strengthening
  2. Classification of Digital Health Interventions
  3. National eHealth Strategy Toolkit
  4. https://www.digitalhealthindex.org/
  5. Digital Implementation Investment Guide
  6. Digital Health Platform Building a Digital Information Infrastructure ( Infostructure )for Health
  7. https://www.who.int/data/data-collection-tools/health-service-data/toolkit-for-routine-health-information-system-data/modules
  8. https://dhis2.org/metadata-package-downloads/#tb
  9. https://docs.dhis2.org/en/topics/metadata/tuberculosis/tb-aggregate/design/tb-notifications-and-outcomes.html
  10. https://docs.dhis2.org/en/topics/metadata/tuberculosis/tb-case-surveillance-tracker/design.html
Guideline: Recommendations on Digital Interventions for Health System Strengthening

Digital, case-based, real-time surveillance for TB: status of progress Tuberculosis (TB) surveillance is the continuous and systematic collection, analysis and reporting of data related to TB infection and TB disease in the population. To support countries to implement national surveillance systems for TB in a consistent and comparable way worldwide, the World Health Organization (WHO) has, since the mid-1990s, provided guidance with standardized definitions, forms, registers and reports (1). There were major updates to this guidance in 2006 (2) and 2013 (3).

Read More
Classification of Digital Health Interventions

The classification of digital health interventions (DHIs) categorizes the different ways in which digital and mobile technologies are being used to support health system needs.

Read More
National eHealth Strategy Toolkit

Nikshay reports: dashboard. Delhi: Ministry of Health & Family Welfare, Government of India

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Global Digital Health Index

The Global Digital Health Index is an interactive digital resource that tracks, monitors, and evaluates the use of digital technology for health across countries.

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Digital Implementation Investment Guide

This practical Guide serves as a companion to the “WHO guideline: recommendations on digital interventions for health system strengthening”

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Digital Health Platform : Building a Digital Information Infrastructure (Infrostructure) for Health

This practical Guide serves as a companion to the “WHO guideline: recommendations on digital interventions for health system strengthening.

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Data Collection Tools

Health service data are essential for patient management, facility management, disease surveillance and monitoring of service provision and resource use. Countries also need reliable facility data to assess the performance of their health services as they work towards the UHC targets and the SDGs.

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Metadata Package Downloads

Metadata packages for TB programmes contain modular components to support case notification, treatment outcomes, prevention activities, drug resistance monitoring, and monitoring stock levels at service delivery sites.

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TB Aggregate System Design

This document describes the system design for the TB configuration package for aggregate reporting, focusing on how the data collection part of the configuration has been designed in DHIS2 (i.e. data sets and data elements).

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TB Case Surveillance Program (Tracker)

The TB Case Surveillance Tracker digital data package for DHIS2 is based on the WHO recording and reporting framework from 2013. It provides a set of recommended metadata (data elements, program rules, etc) to enable electronic capture of individual/case-based TB surveillance data

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A new digital platform for timely analysis and use of TB data

The WHO Global TB Programme has developed and is supporting country implementation of a new digital platform to store, analyze and visualize national and subnational TB surveillance data. The platform will facilitate timely planning and programmatic action.

Strengthening Information systems and linkages to care - StopTB Field Guide

Finding and treating people with tuberculosis (TB) is a multi-step process involving awareness generation, prevention, screening, testing, diagnosis, treatment initiation, multiple follow-ups and finally a successful treatment outcome.

A new digital platform for timely analysis and use of TB data

The WHO Global TB Programme has developed and is supporting country implementation of a new digital platform to store, analyze and visualize national and subnational TB surveillance data. The platform will facilitate timely planning and programmatic action.

Strengthening Information systems and linkages to care - StopTB Field Guide

Finding and treating people with tuberculosis (TB) is a multi-step process involving awareness generation, prevention, screening, testing, diagnosis, treatment initiation, multiple follow-ups and finally a successful treatment outcome.

Progress Report

When Ms. Ramadhani Bernadina Developed A Fever And Cough That Lasted For Months, He Began Purchasing Over-The-Counter Antibiotics In Hopes Of Ridding Himself Of The Illness. To His Dismay, His Health Continued To Deteriorate, Forcing Him To Move In With His Sister And Extended Family. Bernadina Was Unaware He Was Experiencing Early Symptoms Of Tuberculosis (TB) And Exposing Those He Now Lives With To The Disease.

Thankfully, His Sister Acted – Taking Him To The Kigwa B Dispensary, Where Bernadina Would Learn More About TB Signs And Symptoms. A Health Care Worker, Trained Through The Afya Jumuishi Project, Provided TB Counseling, And Administered A TB Test. Next, The Test Sample Trekked Over 37Kms (23 Miles) To The Kitete Regional Hospital For Laboratory Testing Where Bernadina Was Finally Diagnosed With TB Disease.

When Ms. Ramadhani Bernadina Developed A Fever And Cough That Lasted For Months, He Began Purchasing Over-The-Counter Antibiotics In Hopes Of Ridding Himself Of The Illness. To His Dismay, His Health Continued To Deteriorate, Forcing Him To Move In With His Sister And Extended Family. Bernadina Was Unaware He Was Experiencing Early Symptoms Of Tuberculosis (TB) And Exposing Those He Now Lives With To The Disease.

Thankfully, His Sister Acted – Taking Him To The Kigwa B Dispensary, Where Bernadina Would Learn More About TB Signs And Symptoms. A Health Care Worker, Trained Through The Afya Jumuishi Project, Provided TB Counseling, And Administered A TB Test. Next, The Test Sample Trekked Over 37Kms (23 Miles) To The Kitete Regional Hospital For Laboratory Testing Where Bernadina Was Finally Diagnosed With TB Disease.

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