A critical juncture for SORMAS: from national to regional outlook and beyond
Data on blood samples is entered into the SORMAS system via mobile phone © HZI-VerenaMeier 2019
SORMAS (Surveillance Outbreak Response Management & Analysis System) is increasingly recognised as a digital system that can provide policy-relevant data and management support across the One Health domains – not only at local and national level, but potentially at regional and global levels too.
‘SORMAS is a system in transition’, says Damien Bishop, Head of Programme for RPPP2. The SORMAS journey began with the development of the software in Nigeria in response to the Ebola epidemic of 2014-16, followed swiftly by its adoption in Ghana. The urgency of measures to prevent and manage COVID-19 across the globe proved to be a catalyst for an accelerated national scale-up of SORMAS in Nigeria and Ghana, and led to increased attention from other national and regional agencies interested in a more comprehensive and joined-up approach to preventing and managing epidemics, as well as other crises.
These developments have shone a light on the need for more sustainable structures to support the expansion and maintain the integrity of the SORMAS system, and to ensure its alignment with key global health security and environmental concerns.
Responding to complexity in today’s interconnected world
The SORMAS story has been well-documented (for example, in a 2019 GHPC case study and by Exemplars in Global Health). Since the publication of these studies, the world has witnessed a rapid escalation in climate-related disasters, the resurgence of infectious diseases, such as monkey pox and the life-threatening Ebola, and the global COVID-19 pandemic which has, to date, resulted in more than six and a half million deaths.
In today’s highly interconnected and increasingly complex world, it is more important than ever for governments to work across sectors and disciplines to achieve optimal health outcomes for all their citizens. National stakeholders, such as ministries of health and public health institutes, need access to real-time data on existent and potential health and environmental hazards to help them design appropriate interventions and policies.
Approaches are also needed which facilitate data exchange between countries in order to address the risks arising from the movement across borders of people, plants and animals. This also enables regional and global institutions to elaborate guidance based on learning about what works in different contexts to combat each new crisis.
Documenting learnings for GIZ’s Sector Network Working Group on Global Health Security
GIZ’s Working Group on Global Health Security advocates a ‘One Health’ approach to health security and health systems strengthening. Comprised of multidisciplinary experts dedicated to facilitating evidence-informed policy for the detection, prevention and control of infectious disease, it meets regularly to share information, gather base-line knowledge and hold discussions through thematic workshops.
According to Karen Gosch, Speaker of the Group, countries’ health security, resilience and health systems strengthening cannot be separated and German development cooperation strives to foster all three. ‘By documenting our learning on Healthy DEvelopments, our Working group wants to build institutional memory and facilitate links with other partners to ensure that the lessons learned from projects like the one covered in this article are sustained.’
A system in transition
Interest has continued to grow in SORMAS as an open source, digital global good which can help countries to strengthen prevention of epidemics through surveillance and early warning systems, and to build health systems resilience. It does this through targeted, timely responses to so-called health events (i.e. events which represent an immediate threat to human health whether from biological, environmental, chemical or radiological agents), as well as through strengthening management processes and capacities.
Since its inception, SORMAS has been supported by Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), which provides financial and technical assistance. In West Africa, this has been through the Regional Programme Support to Pandemic Prevention in the ECOWAS Region (RPPP) project on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ) and the European Union. Support to SORMAS during the second phase of RPPP (2021 – 2024) focuses on building both increased sustainability at national level in Ghana and Nigeria and creating capacities for regional surveillance and response. It will also actively look for ways of introducing SORMAS into new countries in the ECOWAS sub-region.
SORMAS is now at a critical juncture in its development, where it needs to broaden its stakeholder base:
‘We are now playing an important role in facilitating an exchange between the different SORMAS stakeholders, including funders, system users, the developer community, and the private sector at all levels’.Damien Bishop, GIZ
Different solutions are needed for different contexts. In Ghana, for example, software companies have been contracted to provide the full SORMAS technical solution, including system hosting, configuration and maintenance, software development, and system security. In Nigeria, the Nigeria Centre for Disease Control (NCDC) is taking a different approach, developing a central IT management unit in-house and a multi-donor approach to supporting implementation. German Development Cooperation support is tailored to these different contexts.
Strengthening health security in West Africa
Based in Abuja in Nigeria, the Regional Centre for Surveillance and Disease Control (RCSDC), an Agency of the West Africa Health Organisation, plays an important role in mobilising and coordinating a regional response to epidemics and other health events, and in helping members states to strengthen their resilience. RCSDC will soon begin working with partners to develop SORMAS dashboards which will facilitate the rapid decision making needed for responding to outbreaks across the region.
By providing access to real-time data on health events, whether from SORMAS national systems or other digital surveillance programmes that can interact with SORMAS, a SORMAS regional platform has the potential to strengthen health security across the region:
Of course, our response is more valuable for diseases which travel across borders. We will facilitate coordination between the member states, and we can also take responders from one country to another to support efforts on the ground.Dr Babacar Fall, RSDC
The Centre will also support Member States to adopt and roll out SORMAS, which is already being piloted in Côte d’Ivoire, and interest is growing from other countries in the region. The further expansion of SORMAS will, however, require both political commitment and additional funding, and RCSDC will help to leverage resources through advocacy efforts.
Supporting cross-border surveillance in East Africa
Plans are also well underway to integrate SORMAS into the digital health agenda of the Inter-Governmental Authority on Development (IGAD) in East Africa, representing the countries of Djibouti, Eritrea, Ethiopia, Kenya, Somalia, South Sudan, Sudan and Uganda. With funding from the European Union as well as BMZ, SORMAS will initially be introduced at border crossings to prevent the spread of COVID-19, monkey pox and Ebola.
Following the model of Nigeria, SORMAS will be rolled out gradually, working first with ministries of health and/or public health institutes, and then gradually scaling up to all 23 border crossings during 2023. Post-2023, full national roll-out of SORMAS for interested IGAD members is on the cards, depending on capacities for implementation as well as available funding.
Over time, new diseases – particularly waterborne diseases – will be added to the SORMAS platform for East Africa and trends from outside the health sector will increasingly have to be figured in:
One Health is high on the strategic agenda both for the Horn of Africa and at the pan-African level with the African Union and Africa CDC. The interrelationships between climate change, drought and migration are important factors for creating pandemics and future SORMAS developments will need to recognise this.Jochen Schmidt, Head of Component – Digital Health at IGAD, GIZ
Establishing the SORMAS Foundation as an agile platform
Recognizing the need for a more independent, non-profit organisation dedicated to SORMAS’ future deployment, HZI set up the SORMAS Foundation, which was launched in September 2022, with financial support from German Development Cooperation among other funders. This move was prompted in part by the growing requests for implementation support coming from an ever more diverse group of countries, including from Europe, and the recognition that, as a German national research institute, HZI was not ideally placed to provide this level of support.
The mission of the Foundation is to oversee and curate the development of the open source software, to facilitate the exchange of learning on SORMAS between different stakeholders, and to support the introduction of the software in new countries, for example through pilot studies.
Managing director (Business Development & Projects) Pilar Hernandez is very aware of this:
With the Foundation, we have an agile platform that can support countries in implementing SORMAS, in addition to being able to ensure the integrity and high quality standards of the software. The goal is to have an organisation which responds both to the needs of the countries and the needs of the system itself.Pilar Hernandez, SORMAS Foundation
Triangulating environmental and human disease data
The sustainability of SORMAS is a key objective of the Foundation and this means ensuring its continual adaptation to global health priorities such as One Health. With research funding, HZI is working with the Kumasi Centre for Collaborative Research in Tropical Medicine in Ghana to develop an environmental surveillance module for water samples. The prototype will be ready for piloting in the coming months and the Foundation will then work with SORMAS implementing countries to secure funding for its introduction and scale-up. Among other things, this prototype will enable the mapping of contaminated water sources and triangulation of this information with the number of disease cases. As Pilar said, ‘this would then be a modern version of the famous John Snow cholera map, in which you can get all the information on each case and water source with just one click’.
Harnessing the power of south-south cooperation
It makes good sense to harness the technical expertise and hands-on experience of more experienced national agencies implementing SORMAS to support its further expansion. As a SORMAS founding partner, NCDC has built strong institutional expertise in supporting SORMAS implementation at all levels, which proved to be critical to Nigeria’s response to COVID-19. As the national public health institute, NCDC has hosted study tours from Ghana and Sierra Leone and presented SORMAS at many meetings and workshops, including for IGAD and its members in Djibouti.
As Dr Yashe Usman, SORMAS National Lead in Nigeria says, ‘Nigeria is now playing a global role. Our knowledge and experience have been useful to Ghana and to other countries, and for introducing SORMAS to East Africa’. Jan Böhme, SORMAS Foundation Managing Director (Technology & Operations) underlined this when he said, ‘we do anticipate that these pioneer countries will play a strong role in helping each other’. Plans are also underway to set up a SORMAS Community of Practice to bolster this kind of south-south support.
The global outlook
Whereas the traditional focus of SORMAS has been on introducing the platform in lower- and middle-income countries, the advent of COVID-19 saw its introduction in European countries. In a nice example of reverse engineering, lessons from using SORMAS in Nigeria and Ghana have informed its introduction and use in German federal states, as well as in France and Switzerland, to support the monitoring and response to the pandemic. Today, a growing number of countries are at different stages in their SORMAS journeys, from the planning phase through piloting and proof of concept, to gradual roll-out and full national scale-up (see interactive map of SORMAS countries).
The SORMAS footprint (December 2022)
The last few years have seen the expansion of SORMAS into new geographical areas, including countries as far afield as Fiji and Nepal (see graphic below), as well as the continued development of the platform to tackle new health and environmental challenges across the One Health spectrum. As recognition of the complex links between the health of people, of animals and of the planet grows, we will surely see new and innovative uses of SORMAS. Stay tuned as the story continues to unfold.