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

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 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. ^[6]

Tentative timeline: Month 0-6

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 digital adherence tools which help in use the data effectively for the continuum of care as highlighted by the NTP.

Recommended exchange / ETL tools like Talend , Informatica which include these features make the data management task much easier and simultaneously improve data warehousing should be evaluated. ^{[7.1] , [7.2]}

The data exchange process should follow and comply with FHIR , GDPR standards for more secured and seamless data exchange supporting standard data taxonomy and meta data management processes. The DHIS2 platforms architecture is easily compatible with these standard tools and processes making this an effective solution. ^{[8.1] , [8.2]}

Tentative timeline: Month 6-12

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 personnel trained on DHIS2.

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

The NSP 2017-20 clearly emphasizes on the importance and need for improve data use. This can be made possible by making case-based TB data and patient line listing 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 and individual line lists and with timeline views are extremely useful.

As expressed by the NTP, the recommendation is to first upgrade the current aggregated DHIS2 based Dashboard and leverage the fullest potential.

Also , to ensure that there is a seamless data exchange from ENRS, LMIS without any information loss and to effectively use data from Match AI , TB – DMIS the DHIS2 data transformation API should be explored.

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. ^{[9.1] , [9.2]}

Other source ETL tools over Postgres DB and / or WHO powered XMart which can be installed within the current environment can also be considered. ^[10]

Once a robust data analytics and data use 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

As the NTP already have a vision to implement mobile based TB surveillance, it is recommended that the model is first piloted and validated in the top 10% most high burden facilities in Pakistan. This will help validate the solution in a short period with effective cost.

In addition, the Mobile App for data collection should also have treatment supervisor specific Dashboard and case management module to handle individual cases better in terms of follow-up, alerts and other care interventions.

As a recommendation the latest DHIS mobile app version which has additional features on data collection , security ,offline data collection , encryption etc supported with a configurable set up should be evaluated to fast track the development of the changes from the learnings of the pilot and for the national scale up.

The DHIS2 mobile application has features for auto – alerts and aggregated data set analysis which should be enabled for improved data use. DHIS2 Mobile app also supports features for restricted data access for different user groups , , version management which make this as more robust solution. ^[12]

Tentative timeline: Month 6-12

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

Tentative timeline: Month 6-12

Pakistan receives a huge number of migrant workers from neighbouring borders such as Afghanistan and similarly a large number of migrant population crosses borders from Pakistan to other neighbouring countries. In order to strengthen the cross-border TB initiatives, it is recommended to accommodate additional cross border modules like transfer-in and transfer-out that would help track treatment across borders and also help reduce large number of lost to follow-up cases attributed to cross border migration.

The cross border monitoring platform (built on DHIS 2.34) developed by UNDP under the Global Fund multi-country grant can be integrated with the DHIS2 tracker in future.

Tentative timeline: Month 0-6

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

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. ^[15]

Tentative timeline: Month 12-18

Any national scale roll-out will have its own capacity and training challenges which requires development of a comprehensive eLearning module allowing all health staffs involved in data collection process for training not only on the new eTB tracker-based application but also on the latest manual of procedure and continued medical education on TB care.

To address the challenges with periodic training of facility level staff to orient them on using eTB 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 ^[16] 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 specially 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