Improving climate-sensitive disease surveillance in Grenada

In the face of climate change, the introduction of DHIS2 opens the way for greater intersectoral collaboration

A DHIS2 training workshop in St. George’s, Grenada

Grenada’s paper-based health information system is poorly suited for monitoring climate-sensitive diseases. With German support, the Ministry of Health is adopting the open source software DHIS2 which will greatly ease routine data collection – and provide a powerful platform for integrating health, vector and climate data.

Fragmented, paper-based information systems hamper rapid disease surveillance

Authorities in Grenada have long known that climate change is likely to affect the incidence of vector-borne communicable diseases such as Dengue, Chikungunya, and Zika. Despite this, the health system’s ability to identify disease outbreaks and to mobilise a rapid response to them has been constrained by a cumbersome paper-based health information system.

The Records Room at the Ministry of Health

Health workers at health facilities across the country’s three islands prepare weekly reports about cases of communicable and non-communicable diseases; these are then re-aggregated at parish level and eventually captured electronically at the national level by staff at the Ministry of Health, Social Security and International Business. Because so much time is spent generating and managing information flows, relatively little is left for actually analysing, interpreting and acting upon the information being collected.

What’s more, there is currently no easy way to analyse health data in relation to other datasets, such as the vector monitoring system which tracks the Aedes aegypti mosquito population or the Grenada Water Information System, which monitors rainfall, temperature and humidity. If brought together, these separate datasets could form the basis of an early warning system for emerging outbreaks of climate-sensitive diseases and help authorities to map the risk of potential new outbreaks.

Transforming Grenada’s health information system

This long-standing situation is soon set to change. During three whirlwind weeks in May, the groundwork was laid for a fundamentally new approach to capturing and working with health data in Grenada – one driven by the powerful and flexible capabilities of the District Health Information System (DHIS2).

A team of experts from the University of Oslo, which developed and maintains the free open source software, undertook an intensive working visit to Grenada to customise a local version of DHIS2 and train people in its use. They worked closely with a core team from the Ministry of Health and with staff from the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, which is supporting the introduction of DHIS2 in Grenada on behalf of Germany’s Federal Ministry for Economic Cooperation and Development (BMZ).

Grenada’s Ministry of Health decided to adopt DHIS2 late last year in response to the findings of an assessment of climate-related health risks which German Development Cooperation conducted in 2015. The assessment highlighted the absence of timely, accurate and comprehensive health data as a major vulnerability for the health sector and recommended strengthening the health information system as a matter of priority. It also urged the Ministry to work with other institutions in Grenada and the Caribbean region to bring together health data with information about climate variables, water quality, and vector populations to enhance climate-sensitive surveillance and reporting.

‘The assessment showed that we needed to increase our capacity to plan for the specific impacts of climate variability and change,’ says Dr. George Mitchell, the Chief Medical Officer at Grenada’s Ministry of Health. ‘We saw that DHIS2 could help us address significant gaps in terms of both data management and creating linkages between health and meteorological data.’

Towards a customised version of DHIS2

DHIS2 is currently used by health systems in 30 low- and middle-income countries and is endorsed by the World Health Organization. The software’s popularity can be attributed in part to the fact that it is fully customisable. In each setting where it is used, DHIS2’s core version is modified to reflect the structure of the health system, the hierarchy of facilities, and the organisation of health services and programmes.

DHIS2 team from University of Oslo in Grenada

While in Grenada, the experts from Oslo worked closely with staff from the Ministry, health districts and health facilities to determine which elements of the current reporting system should be reflected in DHIS2, which digital formats needed to be developed to replace existing paper forms, which indicators should be included in standard reports, and which ‘legacy data’ – existing health datasets – could be imported into DHIS2.

After a prototype version of DHIS2 for Grenada was ready, nurses had the chance to test out the interface and to suggest adjustments to make it more suitable for their needs. The team from Oslo trained a group of trainers who will be responsible over the coming months for teaching health workers at the country’s six district-level health centres how to capture data directly in DHIS2 before the system is taken live.

Greater efficiency and more time for patients

Lydia Francis, the Chief Community Nurse, likes what she sees: ‘Community nursing says thumbs up for DHIS2 and bye-bye to the paper-based system,’ she exclaims enthusiastically. Dr. Shawn Charles, the Chief Epidemiologist at the Ministry of Health in Grenada concurs: ‘Nurses at some medical stations have to maintain 10 different registry books and go through them at the end of every month to prepare summary reports. With DHIS2, we will be able to replace all these books and reports with a single form.’

Not only will nurses have more time to spend with patients, but the quality and completeness of routine information will also improve: DHIS2 eliminates the need for manual tallying, which is prone to errors, and reduces duplication through the use of a ‘tracker’ function which allows individual patient records to be accessed from any facility countrywide.

A powerful data repository with benefits beyond the health sector

DHIS2 is being introduced in Grenada primarily as a tool for health authorities. Yet because it is interoperable with other information systems, it will be relatively easy to import external datasets and analyse their contents alongside health information using pivot tables, charts and GIS-based maps. Once water quality and health data are linked in DHIS2, for example, it will be possible to map disease outbreaks against water sources, thereby supporting a better and more coordinated response between health and water authorities.

DHIS2 allows multiple datasets to be integrated in a single platform

At a stakeholder workshop held in May, representatives of the National Water and Sewerage Authority, the Meteorological Office, the Land Use division of the Ministry of Agriculture, and the public health department of St George’s University joined colleagues from the Ministry of Health to discuss using DHIS2 as a shared data repository.

Participants voiced significant support for the idea of integrating datasets and established a technical working group to coordinate this effort in the long term. An important next step is to standardise the enumeration units being used to collect data across different systems, as there are currently discrepancies in the lists of villages being used across sectors. Another priority is to develop data sharing agreements and protocols between agencies.

Improving the quality of information will be an ongoing challenge, according to Laura Scheske of GIZ’s Adaptation to Climate Change in the Health Sector programme. ‘DHIS2 is ready and able to do a wide range of analyses, but for this to be useful the data from different sources must be up to a certain standard.’

Stimulating intersectoral collaboration in the age of climate change

Climate change poses a fundamental threat to human civilisation and the natural systems upon which it depends. Effects on human health are already being felt and are likely to intensify in the coming decades.

To successfully address these challenges, different sectors must plan and act jointly as a matter of urgency. The introduction of DHIS2 in Grenada offers an opportunity to do just this. While aimed first and foremost at strengthening basic health system capacity, DHIS2 provides a quick and efficient way for the health, climate and water sectors to start tackling health, social and environmental challenges in an integrated way.

Karen Birdsall
June 2017

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