One of the challenges reported by the NTP during the assessment is inconsistent internet connectivity/network issues and the lack of availability of real time data for stakeholders. One effective way to overcome this is to support the current data collection processes by introducing a mobile application, which is in line with the country’s efforts of improving the overall digital ecosystem.

One effective way to overcome this is to support the current data collection processes by introducing a mobile application which will help the data entry process easier and also has feature to store data offline which can then later be synched with the central systems .

The advantages for a mobile application include better performance, effective use of device features like in house system updates, usage of location, security measures and tracking user patterns and issue log mechanisms and other analytics measures.

In line with with the current system design and NTP’s ongoing procurement of Compbook laptops (with SIM cards) , the latest DHIS2 mobile app version should be evaluated. This app also has additional features on data collection , security ,offline data collection , encryption ,version management etc should be evaluated which would easily extend to the current systems.

This would also ensure that the data structures are consistent. Also, the app is supported with a configurable set up to support any updates / changes to the program.

Additionally, the DHIS2 mobile framework uses open-source technologies like Java, Postgre, React and Android, there are easily supported by country IT teams also the standard best practices of mobile development like version management , data encryption etc which make this as more robust solution.^[6]

Tentative timeline: Month 0-6

In line with country’s vision outlined in the NSP 2020-24 ,Cameroon has already developed core infrastructure in terms of database and deployment environment for DHIS2 in form of the country HMIS, which lays a strong foundation for executing the vision of creating a comprehensive and integrated real-time case-based TB surveillance and notification system.

It is recommended that this existing capacity is leveraged for developing DHIS2 tracker for creating case-based notification system which accommodate monitoring of entire continuum of care for both DS TB and DR TB patients starting from presumptive screening, referral, testing, treatment initiation, treatment adherence, treatment outcome and contact tracing in real-time.

The solution architecture should support adding all the above components in phases supported with versioning to ensure seamless upgrades and continuity.

Some of the existing templates already built on DHIS2 tracker systems currently being used by other countries such as WHO’s prevent TB tool or other DHIS2 tracker-based systems can be explored for fast-tracking the software development processes. ^[7]

Tentative timeline: Month 0-12

Another key area highlighted by NTP is the leveraging of data collected from the multiple sources like the excel files maintained at the facilities without any data loss.

There may also be some other distributed data collection systems and processes which are existing, and it might be difficult to replace them, in such a scenario data can be extracted, transformed and loaded into the central repository.

This DHIS2 data transformation API feature also offers creation of standard templates which can be easily mapped with external data collection tools. ^{[8.1] , [8.2]} Apart from this it also supports batch upload for historical data for large volumes to ensure minimum disruption to the live systems.

Other source ETL tools over Postgres DB and / or WHO powered XMart ^[9] which can be installed within the current environment can also be considered.

Tentative timeline: Month 0-6

Building on the current DHIS2 visualization module which offers a comprehensive dashboard for reviewing of program and data indicators, additional features of pivot table , event reports which support dimensions , data aggregation reports and individual line lists and with timeline views are extremely useful.

Once a robust data analytics and data use model has been established with the current DHIS2 and other systems then a more advanced analytical dashboard should be designed linked to the new case based TB surveillance system that is already being planned.

The current DHIS2 platform offers APIs which can connected for these applications and be used as an extended analytical component of the data analysis framework. ^[10]

Tentative timeline: Month 6-12

As visioned by the national TB program with the concept of an integrated Health Information Management System (HMIS) , leveraging the current platform and foundation , basic integration and data exchange mechanisms should be worked out to avoid duplication of efforts and complement the existing data systems.

The current DHIS2 platform and infrastructure needs to be extended to support integration with external systems like GeneXpert, TruNat, Digital X-Ray outputs, Pill boxes and other adherence tools which help in use the data effectively for the patient care continuum as highlighted by the National program.

Recommended exchange / ETL tools like Talend and Informatica which include these features make the data management task much easier and simultaneously improve data warehousing. ^{[11.1] , [11.2]}

The DHIS2 platforms architecture is easily compatible with these standard tools and processes making this an effective solution. ^[12]

The data exchange process should follow and comply with FHIR , GDPR standards for more secured and seamless data exchange.

Tentative timeline: Month 6-18

Digital training packages to train health professionals on DHIS2 data entry, information use, M&E and workflows:

To address the challenges with periodic training of facility level staff to orient them on using DHIS2 for direct data reporting, the MOH must engage in development of a comprehensive eLearning module for app training.

While DHIS2 offers standard training modules on the application , training tools like Moodle ^[15] built om standard LMS framework can be reviewed for application rollouts.

Additionally for training and updates on the latest manual of procedure and continued medical education on TB care modules can be developed for TB Health providers , administrators at facility and district level to develop and enhance M&E competencies for ensuring a consistent program oversight, especially for the case-based tracker roll out within the existing applications.

Guide TB platform developed by WHO Philippines is a good example of eLearning module for health staffs involved in TB care.

Tentative timeline: Month 0-3

One of the main challenges highlighted by the NTP is the ongoing maintenance and enhancements of the platform. Since the application requires regular updates and to ensure effective adaptation and scale up the system support team requires trained personnel on DHIS.

Strengthening the NTP team with DHIS2 trained system administrators will help in improving and expediting the planned implementations.

Tentative timeline: Month 6-24

One of the limitation highlighted by NTP is the need to improve the hardware availability at the facility level. To streamline this, procurement, distribution and maintenance of the required data entry equipment like laptops, mobile/tablet devices should be done on an urgent basis. Improving the current infrastructure at the facilities is crucial for a complete transition to digital notification.

Tentative timeline: Month 0-6

To strengthen the TB surveillance efforts of the country and for reaching out to all TB positive individuals, an active focus on contact tracing becomes crucial. The standard guidelines for household screening can be incorporated as a module in the national TB notification tool and be implemented to fast track the country’s efforts to eliminate TB and target the initiation of preventive treatment for all TB contacts.

Tentative timeline: Month 6-12