Integrating Tuberculosis Disease Surveillance Data into DHIS2 (now KHIS2) in Kenya: Processes and Lessons Learned

Wandia I¹ , Brenda M¹ , Owour K¹ ,Lorraine M¹ , Wekesa P¹ , Githiomi M², Kandie T, Oghera W³

1. Centre for Health Solutions – Kenya
2. National Tuberculosis Program
3. Department of Health Information Systems

Abstract

Kenya’s National eHealth Strategy 2011-2017, anchored on the Kenya Vision 2030, prioritised the roll out of the District Health Information System Software (DHIS2 now KHIS2) with an aim of providing efficient and effective health services delivery to Kenya Citizens. The strategy also strived to re-engineer the accessibility and sharing of information across health systems (Kenya National eHealth Strategy 2011-2017).

The eHealth Policy 2016-2030 acknowledges that eHealth is one of the vehicles «which service providers will use to provide the highest standards of health » and integration into existing system as one of its six guiding principles (Kenya National eHealth Policy 2016-2030) . District Health Information Software 2 (DHIS2 now KHIS2) is an open source and web based health management data platform which enables governments and organizations to collect, collate, analyse and visualise health data.

It (DHIS2) is also designed with a platform that allows receiving and sharing of data form other health and reporting systems. In 2010, Kenya became the first country in Sub-Saharan Africa among the seventy three low and middle income countries to adopt the District Health Information System Software (DHIS2 now KHIS2) for healthcare information management.

It is estimated that Tuberculosis (TB) is the second leading infectious cause of death after COVID-19 with approximately 1.5 million deaths globally (WHO 2021) . Kenya is a high Tuberculosis burden county and the national TB prevalence survey of 2016 indicated that the actual burden of TB in Kenya was 426 cases per 100,000 population with an estimated annual incidence of 169,000 persons (The Kenya Tuberculosis Prevalence Survey, 2016) .

Public Health agency define Public health surveillance « as the continuous process of collection, analysis and interpretation of data, and the subsequent dissemination of this information to policy makers, healthcare and other professionals ». The use of Information Communication and Technology (ICT), Digital innovations, mHealth and eHealth has been associated with efficient and effective data collection. Kenya TB disease surveillance system was traditionally paper-based, with collection, collation and aggregation reliant on manual processes from the primary data sources such as patient registers and cards. This system was time consuming, laborious case-based data abstraction during reporting periods resulting to delayed case notification for disease surveillance to the National Tuberculosis Program (NTP). To address these terrestrial challenges, in 2009, the NTP piloted an electronic TB reporting system using Personal Digital Assistant device (PDA), despite its potential of providing case-based data, the system had limited capability in transmitting real time data at the national level, subsequently, a web-based TIBU surveillance system was rolled out in late 2011.

Process 1: Development of the TIBU Surveillance System

In 2012, through the support of USAID, Tuberculosis Accelerated Response and Care (TB ARC) in collaboration with the NTP and other stakeholders, commenced the development of the system which was planned in three phases. Kenya was the first East African Country to implement a national case based electronic  system for TB (Sharma et al, 2015) .

The first phase was to collect the demographics, treatment and outcomes data for each person diagnosed with TB disease recorded in the facility register, generation of both the case finding and cohort reports for DS and DR TB which is now known as the Patient Management System (PMS).

The second phase developed the supervision checklist which enabled the Sub County Coordinators do technical visits to TB treatment and diagnostic sites across the 47 counties in Kenya and allow for transport facilitations through the system which is known as the TIBUcash.

The third phase introduced the additional TB programmatic and control activities such as those for laboratory, leprosy, Community, asthma, pharmacovigilance, and other system enhancements.

Process 2: Integration of TIBU System into DHIS2 (noW KHIS2)

In 2015, through the support of USAID TB ARC, NTP commenced the process of integrating TIBU surveillance system with DHIS2, whose specific objectives were :

• To increase availability and accessibility of TB disease reports to as many users as possible via DHIS2 (KHIS2) for decision making towards effective and efficient health services delivery
• To ensure the availability of TB disease available in the TIBU system into DHIS2 (now KHIS2)
• To ensure reports in the TIBU system are «  pushed «  into DHIS without Health records officers re-entering the same from the facility.

Specific processes included :

• Harmonising, cleaning up and matching of facilities listed in TIBU, DHIS2 and eHealth for harmonised list with matching MFL code
• Re-designing of data elements with unique Identifiers in DHIS2 for both case finding and cohort reports for Drug Susceptible and Drug Resistant TB.

Consequently after these processes, an end to end testing, aggregate TB disease case finding and cohort reports were successfully pushed to DHIS2 test bed (http://test.hiskenya.org/kenya/api) and ultimately moved to the DHIS live environment in 2018 and this has been the practice to date.

Process 3: Pushing Data from TIBU to DHIS2 (now KHIS2)

• TB disease surveillance data keyed into the TIBU system by the County and Sub County Tuberculosis, Leprosy and Lung Disease Coordinators (C/SCTLCs) is collated on a quarterly basis. For timely push of TB data into DHIS2 (now KHIS2), there is «  Closure of quarter » on the fifth day of the preceding quarter done by the national level by the NTP Monitoring and Evaluation team
• Upon the completion of the push process of the data, there was validation of the concurrence in the reports in both systems especially in the initial stages to test the integration of the two systems, this entailed mapping of each facility in DHIS2(now KHIS2) and TIBU system.
• A sample of the TB disease indicators available in DHIS2 (now KHIS2) include for case finding.

Case Finding Indicators

• Case Notification Rates per 100,000
• Proportions of children (<5 years) contacts of bacteriologically confirmed TB
• Proportion of registered new and relapse TB patients with documented HIV positive status
• Proportion of TB HIV positive patients started on Co-trimoxazole Preventive Therapy(CPT) among HIV-positive TB patients
• Proportions TB patients with result for isoniazid and rifampicin Drug Susceptibility Testing (DST)

Cohort Analysis for both DS and DR TB: Treatment Outcomes

• Treatment success rates
•  Lost to follow up
• Death rates
• Failure rates.

Lessons Learnt and Potential for Scale Up

• For successful integration, a country ought to have a harmonised list of health facilities which have unique identifiers.
• There is need for specific resource allocation towards system integration
• The integration of the two systems provides for accessibility of aggregate TB surveillance data at a national level and by many stakeholders
• Integration of Electronic Medical Records (EMRs) to (TIBU) is an opportunity that be leveraged on which can ultimately push data to DHIS for a complete cycle of data (EMR–TIBU–DHIS2) from the Point of Care
• Siloed Health Information or Digital systems by other health program areas can leverage on the successful TIBU/DHIS2/KHIS2 integration.

References

• Kenya National eHealth Policy 2016-2030. (n.d.). The Kenya National eHealth Policy
• Kenya National eHealth Strategy 2011-2017. (n.d.). Kenya National eHealth Strategy 2011-2017
• Sharma et al. (2015). A Review of Data Quality of an Electronic Tuberculosis Surveillance System for Case- based Reporting in Kenya
• The Kenya Tuberculosis Prevalence Survey. (2016)
• WHO 2021. (n.d.). WHO. Global tuberculosis report 2021. Geneva: World Health Organization; 2021.