Ghana has already developed the core infrastructure in terms of the database and deployment of DHIS2 and e-Tracker platforms, which lays a strong foundation for executing the vision of creating a single comprehensive and integrated real-time case-based TB notification and surveillance system.

It is recommended that this existing capacity is leveraged for developing e-tracker for a comprehensive case-based surveillance system, which accommodates 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. Additionally, inclusion of TB Preventive Treatment (TPT) module and inclusion of data from Lab Referrals and other key modules would make this a comprehensive solution.

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

Some of the existing templates of TB case-based tracking, currently being used by other countries (and standardized by WHO) can be helpful in fast-tracking the software development processes. ^[7]

Tentative timeline: Month 0-12

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

To ensure that there is a seamless integration of data from multiple data systems like e-Tracker and other data sources like excel files maintained at facilities without any data loss , the DHIS2 data upload / transformation API should be explored. The same can even support the movement of case-based records to the central data warehouse or HMIS.

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 database.

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 in 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 6-12

Building on the current eTB manager and DHIS2 visualization modules that offer 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 are extremely useful.

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 the 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. ^[10]

Tentative timeline: Month 6-12

One of the challenges highlighted by NTP is the leveraging the data collected from the multiple sources (like GeneXpert) into the main eTB manager system as a central data repository for effective use.

The current eTB Manager 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 would help in effective use of the data for the patient care continuum as highlighted by the NTP.

Recommended data exchange / ETL tools like Talend , 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 can be considered as an alternate route of system integration. ^[12]

Tentative timeline: Month 12-24

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 some platforms offer standard training modules on the application, training tools like Moodle ^[13] built on standard Learning Management System (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 challenges reported by the NTP during the assessment processes is the lack of availability of real time data to stakeholders. One effective way to overcome this is to support the current data collection processes by introducing a mobile application for e-Tracker, which is in line with the country’s efforts of improving the overall digital ecosystem.

The mobile application should be developed such that it supports offline data collection , security, encryption ,version management etc and multiple tools can be evaluated to access the suitability for easily extending to the current systems.

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

Additionally, the mobile framework is recommended to use open-source technologies like Java, Postgres, React and Android, which are easily supported by country IT teams. Also, the standard best practices of mobile development like version management , data encryption etc should be a component to make this a more robust solution. ^[14]

Tentative timeline: Month 6-18

One of the limitations highlighted by NTP is the need to improve the data collection processes 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

Tracking the lost to follow-up cases is highlighted as one of the main challenges given the migrant population is sizable.

Establishing a direct and secured mechanism for engaging with patient has a potential for drastic improvements by tracking the patients lost to follow-up. Auto generation of notification and messaging by the system through communication channels like Social Media, IVRS and SMS outbound messages should be explored. Open-source applications like Open MRS ^[15] can be used for these activities.

Tentative timeline: Month 12-18