The NTP has already established DHIS2 environment which has the core infrastructure in terms of database and deployment environment. It has built the DHIS2 expertise and capacity which acts as a strong foundation for executing the vision of implementing a comprehensive and integrated real-time case-based TB surveillance and notification system.

It is recommended that this existing capacity is leveraged for expanding the DHIS2 tracker app. While the current tracker development has been planned to cover all the DR TB patients, the application should be further expanded to include monitoring of entire continuum of care for both DR and DS TB, including presumptive screening, referral, treatment initiation, treatment adherence & 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

One of the challenges reported by the NTP during the assessment is 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.

As a recommendation, the mobile application offered by DHIS2 which has additional features on data collection, security ,offline data collection, encryption ,version management etc should be extended for use even for aggregate data reporting, specially from facilities with limited IT infrastructure should be reviewed.

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, Postgres, React and Android, which are easily supported by country IT teams. The standard best practices of mobile development like version management , data encryption etc are also part of the mobile framework which make this a more robust solution. ^[8]

Tentative timeline: Month 6-12

One of the challenges highlighted by NTP is the leveraging the data collected from the multiple sources into the main DHIS2 systems as a central system for effective use.

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 continuum of care as highlighted by the National program.

Recommended exchange / ETL tools like Talend , Informatica which include these features make the data management task much easier and simultaneously improve data warehousing that need to be considered. ^{[9.1] , [9.2]}

The DHIS2 platforms architecture is easily compatible with these standard tools and processes making this an effective solution. ^{[10.1] , [10.2]}

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

Tentative timeline: Month 12-18

The NSP clearly emphasizes on the importance and need for improve data use. This can be made possible by making case-based TB data and required line listings available at the lowest level health functionary involved in TB care.

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 ,individual line lists and job aids 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.

To achieve this , and to strengthen and expand the data visualisation scope and making effective use of data for predictive modelling , data science and for advanced analytics it is also recommended to use best of the breed tools like Tableau , Power BI which offer these features. 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. ^[11]

Tentative timeline: Month 6-18

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 trained system administrators will help in reducing costs (in seeking technical support) and improving and expediting the planned implementations.

Tentative timeline: Month 0-6

To address the challenges with periodic training of facility level staff to orient them on using eTB manager 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 ^[12] built on 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

Establishing a direct and secured mechanism for engaging with patient has potential for drastic improvements in tracking lost to follow-up patients. Auto generation of notification and messaging by the system through communication channels like Social Media channel, IVRS and SMS outbound messages should be explored. Open-source applications like Open MRS can be used for these activities. ^[13]

Tentative timeline: Month 12-24

As part of the standard practice, the application(s) / solutions should follow a set of standard data quality mechanisms or the Data Quality Assurance (DQA) framework which would help in improved data credibility and use.

UIC Code : Having a centralized Unique Patient ID system or leveraging existing national ID supported with an improved search functionality can help drastically reduce the duplication of case-based records.

This should be generated automatically through the new case-based TB surveillance system that is already being planned.

Data access control is one such DQA measure that will regulate user’s access to only relevant metadata. It will involve the principle of least privilege (POLP), i.e., user’s access will be determined based on their role in the project. POLP will define and limit what data they have access to and who has that access.

Tentative timeline: Month 6-18

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

As expressed by the NTP, the national TB notification and surveillance system should explore ready-to-use open source CLM platforms like One Impact.

Tentative timeline: Month 6-12

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