Implementation of Transnationally Mandated Resilient Digital Public Goods - Learnings from COVID-19 Pandemic

doi:10.21203/rs.3.rs-4662338/v1

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Implementation of Transnationally Mandated Resilient Digital Public Goods - Learnings from COVID-19 Pandemic

https://doi.org/10.21203/rs.3.rs-4662338/v1

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Digital transformation is rapidly progressing across the world. Digital public goods are meant to be adopted transnationally, promoting countries to achieve sustainable development goals. However achieving a resilient digital implementation requires more than adopting a digital public good. In this study we explore the process of implementing a resilient digital implementation based on digital public goods. The study is based on empirical data from implementing digital systems during the COVID-19 pandemic in Sri Lanka and several other countries in Asia, Africa, and Latin America. Analysis of empirical data reveals several key factors that need to be incorporated into implementing a resilient digital system. These include agile governance and development, in-country capacity, transnationally mandated networks of support, and flexible free and open-source software platforms. The paper argues that building resilient digital public goods implementations required a socio-technical rather than a technology-centric approach. The paper contributes to the information systems domain by enhancing empirical-based contributions to the theoretical body of knowledge on resilience. In addition, it contributes to policy and development studies by generating recommendations on practices around achieving a resilient digital implementation.

Delivery of healthcare services across the world has been influenced by the use of digital technologies in the last two decades. The digital transformation observed in the global context has brought about significant impact on the use of digital technologies in the low and middle income countries (LMIC)[1]. In the context of LMICs, the strategies of the nations are geared towards achieving the development goals, mostly aligned with Sustainable Development Goals (SDGs) by 2030[2].

The adoption of digital technologies in LMIC also features efforts in large-scale deployments in order to facilitate and monitor the functioning of healthcare services[3]. While these are more planned activities, sometimes countries need to improvise and maneuver resources for rapid deployments. From 2020 to 2023, the COVID-19 era, data and digital solutions controlled the majority of societal activities. The COVID-19 surveillance data was used to decide and implement travel bans and "lock-downs." Starting in 2021, data and apps were used to allow for a progressive opening of society and mobility of people by providing certificates for vaccination and negative COVID-19 tests. Vaccination records, vaccination certificates, negative COVID-19 test results, contact tracing, port of entry registration, COVID-19 patient isolation bed unit management, integration with laboratory services, and a host of other digital solutions were demanded by countries as a response to the pandemic. For the most part, nations had to begin yet again when it came to digital solutions because they were unprepared. More and more nations investigated free and open-source systems as potential solutions to their pandemic information needs[4]. These technologies were typically chosen by countries because they met some modern information needs in their health sectors.

Large-scale deployments are vital in bringing about efficient healthcare reforms and delivering better healthcare. This is also a key requirement to expedite progress towards achieving SDGs. However, sustaining these digital implementations over time is generally a challenge in many countries [5]. COVID-19 pandemic has demonstrated the power of Opensource technologies. The United nations have identified the value of use of open technologies in building sustainable digital ecosystems in LMIC. Hence, the UN is promoting the concepts of Digital Public Goods (DPG) for achieving SDGs and ensuring digital sovereignty[6]. Digital public goods are open-source software, open standards, open data, open AI systems, and open content collections that adhere to privacy and other applicable laws and best practices, do no harm, and help attain the SDGs[7]. The DPG movement is valuable for countries in identifying a curated list of technologies and standards they can adopt building the country’s digital ecosystem. The Digital Public Goods Alliance maintains a registry of DPGs that is a curated list of technologies assessed against a set of 6 criteria termed as ‘DPG standards’[8]. The criteria are generally technical in nature to assess the production and maintainability of technology.

While the definition emphasizes concepts related to openness in technology and the related standards, it is unclear whether just by opting for DPGs countries would be able to achieve successful implementation. More specifically whether countries will be able to establish successful digital implementations that can withstand challenges and shocks in the implemented context and sustain over time to achieve SDGs.

Adopting digital public goods has proved to be a reliable strategy for selecting technology solutions that have been vetted and approved based on technical standards. However, this does not necessary indicate that implementing a DPG in a country will lead to a successful digital implementation which is able to sustain within the context withstanding challenges and shocks. We argue that the approach for implementation of digital systems which can withstand shocks requires a sociotechnical approach that strives beyond a technology driven approach. We bring the concept of resilience in digital systems as the primary concept in defining digital implementations that sustain amidst changes in the context. Digital resilience is defined as the capabilities developed with the use of digital technologies to absorb major shocks, adapt to disruptions, and transform to a new stable state[9].

This paper focuses on the broader research question of how to build resilient information system implementations using digital public goods. We will devise a socio-technical approach to explore the process of resilient implementation of digital technologies, more specifically, digital public goods. The paper will attempt to answer the research question based on empirical data derived from Sri Lanka and several countries that implemented dhis2 during the COVID-19 pandemic, along with a few other DPGs and proprietary solutions. dhis2 is a digital public good widely implemented in over 70 LMICs in the world.

In this article we present and discuss a case study of a multi-country effort to develop and deploy digital systems responses to the COVID-19 pandemic based on the open source dhis2 platform [10], which was already used by more than 70 countries, mainly in the Global South. More than 50 countries, mainly among those already using the dhis2 platform, ended up applying dhis2 based ‘apps’ addressing a variety of COVID-19 use cases, such as surveillance, contact tracing, vaccination, isolation unit management, issuing of COVID-19 vaccination and test certificates and more. This large-scale digital deployment received funding from Norad and GAVI and was carried out in collaboration with WHO. Already at the onset of the pandemic in January 2020, work started in Sri Lanka to develop various digital responses using the dhis2 platform. Initiated through a ‘hackathon’ with global participation in March 2020, the wider network of countries using the dhis2 got engaged and started to adapt and implement digital solutions on contact tracing, port of entry control and ICU bed management in countries in Asia and Africa, such as Laos, Bangladesh, Indonesia Mozambique, Uganda and Rwanda. Later more than 50 countries followed suit. As this development gained momentum, funding was secured from Norad and GAVI, and collaboration with WHO could leverage on an ongoing program of developing program specific digital meta data packages on the dhis2 platform, called ‘WHO apps’. The WHO app collection was then gradually expanded with various COVID-19 response apps. Analysing this development in hindsight, we can point at two important determinants for the relative successful of COVID-19 digital solutions across countries. First, the free and open source aspects of the dhis2 apps made it possible for countries to test the solutions without much cost, and second, since countries already had capacity and experience with dhis2, the threshold for applying the apps, became low. Being able to leverage the already well-known WHO app distribution – and WHO authority – was, of course, also important.

The rest of the chapters are organized in the following order. We will explore the concept of resilience based on extant literature from diverse domains in the next chapter. In detail out the methods used in gathering empirical data in the methods chapter. This will be followed up by the chapter on case studies where we primarily focus on the case study or Sri Lanka followed by few other global implementation of dhis2 during the COVID-19 pandemic. The case study chapter will be followed up by the Discussions chapter where we portray key thematic areas from the analysis and comes out with an argument to answer the research question and to frame the contributions of the study. The conclusions chapter will highlight key findings.

In this chapter we will explore the concept of resilience which will be the key concept that we will explore based on the empirical findings in the case study section. We aim to contribute to enhancing the understanding of the concept of resilience in the information systems domain as a contribution of the study.

Resilience

Resilience is described using different terms in several domains, including sociology, psychology, ecology, management, engineering, and regional development. Resilience, which was initially introduced in the field of ecology by Rose [11], serves as a measure of the ability of intricate natural systems to withstand change and swiftly recover from disruptions. In order to tackle the difficulties presented by intricate social-ecological systems (SES), Folke et al.[12] put up a conceptual framework called "resilience thinking" that incorporates the concepts of adaptability, transformability, and resilience. The resilience of such systems lies in their capacity to continuously evolve and adapt while staying within crucial limits.

From an individual's perspective, resilience can be defined as the positive ability of individuals to effectively handle and overcome stress and catastrophic events, as stated by Walker and Salt [13]. "Individuals and societies that possess resilience are more inclined to perceive challenges as opportunities for advancement" (Ibid.). Furthermore, individuals who possess resilience exhibit a reduced level of emotional attachment to a certain geographical region, hence facilitating their ability to adapt to unfamiliar circumstances and surroundings with greater ease [14].

Blanchet et al.[15] conducted a detailed study on ecology and complexity science to define resilience as the ability of a health system to handle stress by absorbing it, adapting to it, and transforming itself, all while maintaining its structural and functional control. The extent of structural change and the severity of the crisis are believed to impact the levels of capacity for absorption, adaptation, and transformation. As the crisis worsens, there is a greater need for structural change and transformation. Consequently, the health system must make organisational adjustments to ensure that healthcare services are maintained, even with limited resources.

Most of the research on resilience originates from the domain of information systems (IS), which is a branch of engineering that encompasses supply chain management, infrastructure, and risk management. In their work, Heeks and Ospina[16] highlight the lack of attention given to the question of "resilience of what" and express their criticism towards the lack of progress in resilience research within the field of Information Systems (IS). The health information system is a fundamental component of health systems, including the health staff, funding, services, medication, financing, and governance [17]. By adopting this approach, we need to consider the integration of digital resilience into the healthcare system and eliminate the distinction between object and target systems. One way in which the health system impacts the digital realm is by expanding the range of data reporting using digital methods.

The definition of a resilient information system is derived from existing knowledge on the subject. It is characterised by its durability, adaptability, and transformative nature. Additionally, it has the ability to continuously change and adapt while remaining within crucial thresholds [18]. Research on digital resilience has experienced a surge since the onset of the COVID-19 pandemic. However, despite its significance for national policy and information systems research, the aspect of resilience capability building that pertains to temporality has been largely overlooked, as noted by Boh et al. [9].

This project utilises an interpretive case study technique [19, 20] to investigate the deployment and maintenance of the digital information system during the pandemic, focusing on its dynamics and context. We adhere to an interpretivist viewpoint, which posits that reality is a product of social construction by human actors, in contrast to realist perspectives that assert the existence of an objective, external reality [21]. An interpretive case study technique was used to explore the behaviours and perspectives of human stakeholders during the process of digitization and deployment of digital solutions across many countries [20, 22, 23]. According to Darke et al. [24], this strategy is beneficial for investigating less-researched areas of inquiry, such as the one being examined in this project. Consistent with Flyvbjerg's [25] and Yin's [26] characterization of a case study, our methodology involved conducting an empirical examination of a contemporary occurrence within an authentic environment. This enabled us to examine various viewpoints on developing phenomena by concentrating on a genuine scenario. Yin asserts that multiple approaches, including qualitative ones, were employed to collect data in this particular case [27].

Study Setting

The study was conducted in 10 nations that were mostly chosen based on their availability of access, considering that the interviews and observations took place during the COVID-19 pandemic. These countries largely utilised dhis2 as their national health management information system, either at the national level or within a specific vertical health plan. The focus of our study was on the implementation of dhis2 and other DPGs in the healthcare industry. While the study covered 10 countries, our main focus was on Sri Lanka. The reason was due to accessibility of data collection during the pandemic. In addition to the 10 countries, we also derive qualitative information from the University of Oslo, Norway, which is the coordinating entity of the global HISP network as well as production of the dhis2 platform.

Data Collection

Qualitative data gathering for this study involved conducting interviews with stakeholders from the Ministry of Health and various multi-sector organisations. In order to create case studies, the interviews were enhanced with additional information obtained from meeting notes and observers. Individuals belonging to the specified categories were subjected to interviews. Table 1 depicts the various categories of profiles of participants that were interviewed.

Table 1

Types of stakeholders interviewed
Health administrators at national and district level	Information system implementers at national and district level
University academics	Public health experts
Trainers of digital systems	End users of digital systems at health facilities & ministry of health
Multi-sector stakeholders involved with digital implementation policies/discussions	Clinicians involved with digital health system

Interview instructions were prepared using the findings from previous studies on the adoption of health sector information systems. Each interview had a duration ranging from 30 minutes to 1.5 hours. Comprehensive records were taken during the interviews. The interviews were transcribed exactly as they were spoken, directly from the digital recordings. The interviews yielded valuable insights that were used to make adjustments to the first interview guide, which had been developed based on existing literature in the field of Health Information Systems (HIS). Conducting interviews with individuals from different organisations, who have unique perspectives, and then analysing their statements, was a crucial method to reach the point of saturation. This means that no new ideas were being uncovered in the interviews, as stated by Michael D. Myers in 2009 [28].

Our comprehension of the pandemic response has been enhanced by publicly accessible reports, meeting minutes, and research papers, together with primary sources of information. The updates provided by the ministry of health and other public service websites have been beneficial in keeping us informed about the continuously changing regulations and limitations.

Data Analysis

The data analysis in this study is conducted using a Hermeneutic method, as described by Klein & Myers [29], Mingers & Willcocks [30], Ritzer [31], and Walsham [32]. This method focuses on comprehending and interpreting the thought processes of the respondents. Additionally, it utilises a comprehensive study of publicly available reports and internet materials. According to Klein and Myers [29], this implies that in order to understand the individual components, we must first understand the entirety. This aligns with the concept of the hermeneutic circle. The seven principles for interpretive field research proposed by Klein and Myers (ibid) are all linked to the hermeneutic approach. The first principle among them is the hermeneutic circle. While the principles are presented as suggestions rather than strict rules, interpretative researchers are advised to discuss and select the ones that are most relevant to their topic [29]. Adhering to these criteria has been crucial as we have systematically gathered and examined data in a repetitive manner.

Adhering to the principle of contextualization, we have collected and examined data in a manner that enables us to perceive our interviewees as active participants in the process of change, rather than passive recipients of historical events. This is because digitalization has been an ongoing process of transformation throughout our research.

Through the iterative process of data collection and analysis, we have identified many principles that consistently reoccur. In accordance with the concept of generalisation and abstraction put forward by Klein and Myers [29], we will analyse our discoveries in relation to the idea of digital platform ecosystems. We enhanced our comprehension of digital platforms by systematically collecting new evidence and utilising the current knowledgebase on digital platforms. According to Walsham [20], theory is expected to evolve alongside the iterative process of gathering and analysing data in a longitudinal case study.

Recognising the potential influence of the social context on actor activity, we conducted a comprehensive investigation of the cases using document analysis, interviews, and observations in order to gather diverse interpretations. This method is commonly referred to as researchers' triangulation. The data analysis involved a thorough reading and thoughtful reflection on the field notes. To prepare our data, we using NVivo to construct codes and themes by combining similar remarks from the interviewees. In addition, we examined interview transcripts to identify any comments or actions that resembled platform ecosystems.

In this chapter, we will present the findings from the data collected using the research methods highlighted in the previous chapter. We will initiate with the case study or Sri Lanka which will be followed up by the case of HISP Centre at University of Oslo which is the coordination entity of the production of dhis2 platform and the global opensource network. This will be followed up by case studies from few salient countries that implemented dhis2 platform during the COVID-19 pandemic.

Sri Lanka

Phase 1: Building capabilities

The Ministry of Health (MoH) in Sri Lanka is responsible for managing, developing, and executing the country's healthcare system at national, district, and field levels. The country has a robust public health system, similar to those found in many affluent nations, and has achieved significant milestones outlined by the United Nations Sustainable Development Goals [33]. The country's achievements can be attributed to its long-term efforts in enhancing public systems, particularly in health and education. Since the 1950s, policy steps have been implemented to ensure healthcare and education are accessible to all citizens without cost. The government has also implemented measures to enhance medical professionals' proficiency in health informatics.

However, the current information systems are predominantly characterized by a high degree of specialization and a strict hierarchical structure, which hindered the response to the pandemic due to lengthy administrative procedures. In 2009, the UoC collaborated with UiO to launch the BMI programme, which laid the groundwork for developing expertise in health informatics and data governance in Sri Lanka. The BMI aimed to cultivate "hybrid doctors" [34] who would be temporarily assigned from the MoH for a two-year period with full salary to pursue further studies. Despite initial opposition from trade unions and traditional medical experts, the dedicated efforts of local academics and UiO successfully overcame these obstacles and gained global recognition for their initiative. Figure 1 provides a summary of the involvement of stakeholders during Phase 1.

Since its inception in 2011, over 200 students have completed the BMI curriculum, with some currently employed as instructors and holding positions in the Ministry of Health (MoH). The graduates have played a crucial role in managing healthcare and digital systems, particularly in developing health informatics capabilities in Sri Lanka. The curriculum focuses on data governance and digital platforms, which were essential for addressing the pandemic. Many graduates specialized in governance-related subjects, conducting extensive research for their thesis work. Over 15 doctoral theses were focused on standards, data policy, data governance, security, and interoperability. The proficiency in digital platforms, particularly dhis2, was facilitated through the relationship with UiO. dhis2, a free and open-source digital platform, was incorporated into the curriculum, allowing students to gain practical experience by actively participating in the development of dhis2 apps and implementing them in various departments. The MoH saw a proliferation of dhis2-based apps, leading to a digital innovation environment but also causing fragmentation and increased need for specialized technical assistance. The following table provides a summary of various applications based on dhis2 that have been developed by graduates from BMI.

Table 2

dhis2-based information systems in Sri Lanka
Aggregate data based dhis2 Implementations	Individual data based dhis2 Implementations
Maternal & Child Health Information System (eRHMIS – Phase 1) School Health Information System Perinatal and birth defect surveillance system Information System on Food Safety & Environmental/Occupational Health Quarantine Information System Mental Health Information System Disaster Management Information System Health Promotion Activities Information System National blood transfusion service information system Non-communicable diseases information system	District Nutrition Monitoring System Injury Surveillance System Tuberculosis & Chest Diseases Information System Malaria Information System National Nutrition Information System of the Presidential Secretariat Maternal and new-born reporting system National COVID-19 Surveillance System COVID-19 Immunization Tracker

The Ministry of Health (MoH) did not completely trust the extensive expansion, considering it largely as an intellectual endeavour [35]. Over time, the Ministry of Health (MoH) developed and expanded several crucial applications, which contributed to a gradual increase in the MoH's confidence in dhis2. From 2014 onwards, certain BMI graduates collaborated with the Family Health Bureau of the MoH to establish a fundamental system for reproductive, maternal, child, and youth health. The positive outcome of this initiative led to the implementation of several other dhis2 based systems, as seen in the figure below.

Phase 2: Period of adaptability of processes

Owing to Sri Lanka's status as a renowned tourism hotspot and the significant influx of Chinese travellers engaged in building ventures, the government promptly recognised the imminent danger posed by COVID-19. The Ministry of Health (MoH) acknowledged the necessity of overcoming the constraints of the current surveillance system, specifically in regards to handling multi-sectoral information. One of the main concerns noted was the demand for software that could be quickly built and implemented, adaptable enough to accommodate fast evolving requirements, cost-effective and resistant to obstacles in the procurement process, and user-friendly. The Ministry of Health (MoH) selected dhis2 as the most suitable platform due to its ability to fulfil the specified criteria and its sufficient technical capacity present in the country including the local node of the global HISP network.

The initial module created was designed for the purpose of registering individuals entering the nation at the designated port of entry. Its main function is to facilitate the sharing of information regarding positive COVID-19 instances with the Ministry of Health (MoH) officials, enabling them to conduct additional monitoring and surveillance. Following that, a compulsory quarantine was enforced on all individuals arriving from mid-March, necessitating a change in attention to the management of quarantines. The adjustment was implemented through the setup of the dhis2 tracker module. Due to a rise in hospitalisations, the Ministry of Health (MoH) mandated the expansion of the system to include both suspected and confirmed cases. This expansion was made possible by the adaptable nature of dhis2. dhis2 facilitated the administration of both personalised data (such as tracking confirmed cases) and collective data (such as hospital resources).

As the pace of new requirements increases, the development team has also become aware of certain limitations of dhis2. In mid-March, the government ICT agency organised a hackathon to encourage further voluntary participation from the wider software community in Sri Lanka and the dhis2 team from UiO. This partnership between local and worldwide entities led to the development of many novel features and tailored web applications. These include tools for visualising content mapping, monitoring ICU bed availability, and tracking individuals who have been infected. Within a brief period of three months, a grand total of eight novel modules were created (refer to the timeframe depicted in Fig. 3).

During the initial weeks, it became evident that implementing physical exercise programmes was impractical due to the heightened risk of transmission. Zoom-based training and training videos were the main components of the capacity building initiatives at both national and district levels.

The period of adaptability emerged as a result of a series of events triggered by the COVID-19 pandemic. These events led to the establishment of new governance structures involving multiple stakeholders, such as the HISP team, the Ministry of Health (MoH), the government's ICT agency, and the steering committee. These structures were put in place to oversee the response to the pandemic, as depicted in Fig. 4.

In the end of year 2021, the Ministry team together with the local HISP group embarked on customizing dhis2 platform for COVID-19 vaccination. The team was able to customize the new module and test it over few weeks and rapidly rolled out in the country with pre-populated basic data of entire adult population of the country. This was then integrated with DIVOC, a DPG successfully operating in India then. The government ICT agency collaborated with MoH in sustaining the integration between dhis2 and DIVOC together with support from the local HISP group.

Phase 3: Post-pandemic Routinization

From the year 2022, the acute phase of the COVID-19 pandemic subsided. The majority of the adult population received COVID-19 vaccination. The country contemplated challenges and learnings from their approach during the pandemic. This led to several changes in the policies and practices related to the implementation of digital technologies. A major obstacle encountered during the pandemic was the ability of sharing data between existing information systems deployed in the health sector. To streamline these challenges, the Ministry of Health embarked on the development of a digital health blueprint for the country. This document defined how the implementation of digital solutions in the health sector should be streamlined and how data should be shared across the systems. Based on this, work is underway in integrating existing digital systems and defining standards to be adhered to for newly implemented systems. Based on the success in implementing open-source technologies and DPGs during the pandemic, the ministry has started considering DPGs as the first level of option when selecting a digital technology for a designated task. The ministry has designed a local community of practice for dhis2 which is being sustained by the ministry. The community of practice is also used for capacity building and peer support. Engagement of the health informatics community with the global open-source communities has been more prominent in the post-pandemic era. This includes the dhis2 community as well as communities of several other DPGs. Networking with global communities has benefitted the health informaticians in the ministry in building local capacities as well as obtaining support and sharing experiences. The hackathon launched in the early phase of the pandemic paved the path in onboarding local developers as well as accelerating the development of modules. Learnings from this has motivated the health ministry in organizing connectathons which are targeted to come up with a specific deliverable related to interoperability work conducted in implementing the digital health blueprint of the health sector.

The country was also hit by the worst economic crisis in their history during the year 2022. Some of the practices related to information management that they were able to establish during the pandemic such as conducting data review meetings online, was of immense value to continue the data quality and review practices during the financial crisis with limited mobility due to lack of availability of fuel for transportation of health staff for district review meetings.

Therefore, we observe a solid set of actions launched by the ministry in the health sector in strengthening the digital health activities during the 3rd phase which is the post-pandemic period.

Scaling from Sri Lanka to multiple countries: Leveraging dhis2 country network and WHO ‘app’ collaboration and with financial support from Norad and Gavi

Witnessing the early initiative and relative success of developing digital COVID-19 responses based on the dhis2 open-source platform in Sri Lanka, other countries quickly followed suit. This was made possible by three important factors: 1) Dissemination and further innovations of digital solutions could leverage the already existing network of countries using the dhis2 software and the capacity in countries and the supporting cross-country network of dhis2 activists in the HISP network, making sharing of best practices and digital solutions possible. 2) The already existing development and dissemination practices of WHO digital health program-specific metadata packages (also known as Health Data Toolkit) provide both a channel for dissemination and a certain level of WHO-mandated authority. 3) Norad and GAVI provided emergency funding support to the dissemination of the dhis2 based digital solutions responding to the COVID-19 crisis.

dhis2 open-source platform and HISP network

The dhis2 software is an web based open source platform which is used as an aggregate general Routine Health Information System as well as for case based application for various health programs in more than 60 countries in the global south, mainly in Africa and Asia. Development of the software is coordinated through the University of Oslo and funding has been provided by various agencies, such as Norad, Global Fund, PEPFAR and GAVI. Starting in South Africa in the 90’s, a network of universities, researchers and groups providing training and support of the dhis2 platform, called HISP, has been instrumental in supporting the support, development and implementation of dhis2 in countries[36]. The flexibility of the meta data structure in the dhis2 software makes it easy to configure new modules and applications that can be deployed in new use cases, and platform capacities make it possible to develop and use external ‘apps’ that can communicate with the ‘core’ dhis2 database through an open API (application interface).

dhis2 Health Data Toolkits

Since 2014, the dhis2 software team has been working with WHO to develop digital health packages consisting of meta data, analytics and training manuals targeting data needs of specific health programs, such as TB, HIV, EPI/vaccination, etc [37]. These ‘packages’ can be downloaded and installed in the local dhis2 system, or the standards could be used as templates and points of departure for local configuration. Based on collaboration with Sri Lanka and short time after the hackathon there in March 2020, the first version of a digital health package for COVID-19 including case registration and contact tracing was released based on WHO guidelines.

Funding from Norad and Gavi

To make it possible to respond to the rapidly increasing country demand to use dhis2 for COVID-19 surveillance, Norad started to provide financial support to countries through the University of Oslo already from March 2020. This early support from Norad was instrumental in enabling the scaling up of existing global and regional support structures in a time of great uncertainty, limited travel and need for innovative remote and virtual support solutions. When vaccination became possible in the global south, Gavi started supporting the use of dhis2 for COVID-19 vaccination from March 2021. The University of Oslo’s Gavi Global contract saw three major releases of new WHO digital health packages for the ‘COVID-19 Vaccine Delivery Toolkit’ and dhis2 was used by 34 countries as an immunization registry for COVID-19.

Country cases: comprehensive platform ecosystems in Bangladesh and Rwanda

Bangladesh

The Ministry of Health in Bangladesh has directed the Management Information System - Directorate General of Health Services (MIS-DGHS) to develop a comprehensive surveillance system for COVID-19. The objective of the system is to detect patients displaying suspected symptoms of COVID-19, verify their condition using RT-PCR assays, and offer suitable subsequent medical attention. HISP Bangladesh offered technical assistance and tailored the national COVID-19 systems using the 'global' dhis2 software created by the University of Oslo. The system underwent expansion to encompass a broader platform ecosystem, using data from both the corporate and public health sectors.

The integrated COVID-19 systems consist of several essential elements, including a centralised hub for complete COVID-19 information, up-to-the-minute reports on hospitalisations, availability of ICU beds, and logistical details on ICU operations. Additionally, it provides real-time updates on the status of oxygen supply, progress in vaccination efforts, and the logistics of vaccine distribution. A total of 15,676,173 tests have been carried out, utilising 1800 public and private sample collection sites and hospitals to acquire documented samples. The surveillance system employs an automated SMS notification system to inform those who are under suspicion of their test results. Additionally, it offers a secure electronic verification method for COVID-19 certificates.

The system also provides current information on the availability of ICU beds, allowing the hospitalisation of persons requiring medical oxygen assistance. Data statistics are provided to health managers, decision-makers, and development partners. The system functions as a tool for reporting the utilisation of vaccines at the district and Upazila levels, as well as for controlling and tracking the supply of COVID-19 vaccines through the Vaccine Logistics Management Information System (VLMIS).

Rwanda

The Rwandan Ministry of Health adopted the dhis2 platform to mechanise the laboratory procedures, reduce reliance on paper, and enhance the accessibility of data and visibility of samples amidst the COVID-19 pandemic. The software comprised modules for clinical examination, diagnosis, sample collection, laboratory request, sample processing, and laboratory findings.

Following the implementation of automated COVID surveillance procedures, it became necessary to provide certificates for those who had been tested. HISP Uganda and Rwanda worked to customise their COVID-19 truck driver application to fit local parameters and distribute certificates over email. Nevertheless, the app proved to be insufficient as airports and land border crossings resumed operations, prompting the creation of an online platform for citizens to retrieve their credentials.

HISP Rwanda extended assistance to more nations, including Sudan, Chad, and Madagascar, by facilitating the adaptation and implementation of authorised COVID-19 modules and certificate portals. As a result, a verification capability for certificates was implemented, which was made possible via a verifier app. This improved the authentication procedure at airports and streamlined the verification process.

In March 2021, vaccines that were approved by the World Health Organisation (WHO) became accessible. Additionally, the Ministry of Health (MoH) team created a vaccination registry and support module in the dhis2 system, utilising unique identities. Nevertheless, a rival system proposed by a development collaborator failed to meet the changing demands of the Ministry of Health (MOH) and the immunisation campaign. The Ministry of Health (MoH) selected the dhis2 platform as the foundation for their Covid vaccination system and subsequently determined to utilise the dhis2 platform for other Covid-related processes.

Networking cases: Lusophone countries and West and Central Africa

HISP Mozambique, Lusophone countries and Guinea-Bissau

HISP Mozambique introduced the dhis2 Covid-19 package in Mozambique, Guinea Bissau, Cape Verde, and Sao Tome & Principe. They created additional modules, such as data compatibility with laboratories, and extended the dhis2 Vaccination package to incorporate COVID-19 monitoring and vaccination modules. The approach encompassed the localization, translation of package metadata into Portuguese, and customisation to meet local requirements.

In Guinea-Bissau, the implementation of dhis2 necessitated enhanced functionality and integration, encompassing real-time data inquiries, verification of test outcomes, screening at Port of Entry, waiting durations for testing, and public availability of data. The incorporation of test result data into dhis2 and the incorporation of a verified QR code in a downloadable pdf certificate resolved the issue of inaccurate negative COVID-19 test results. A mobile application for Android was created to allow border authorities at Ports of Entry to verify test findings by scanning the QR code on their mobile devices.

The "Index Case" application integrated patient data contained in the dhis2 Tracker with laboratory findings, enabling laboratories and health facilities to generate printed COVID-19 test results straight from the dhis2 system. The public dashboard encompasses a comprehensive range of public services, including the ability to request COVID-19 testing, access test results, download certificates, and stay informed on the national status of the pandemic.

HISP's efforts in addressing the COVID-19 pandemic were reproduced in neighbouring countries such as The Gambia and Cape Verde. Some of the innovative approaches were partially implemented in Sao Tome and Mozambique, as well as in São Tome and Principe. External applications utilised dhis2 data to tackle challenges such as certificate generation and the promotion of data accessibility.

West and Central Africa

COVID committees were established by West and Central African countries to supervise monitoring and response actions. Nevertheless, the illness surveillance team of the Ministry of Health was frequently inadequately represented. The primary stage centred on the implementation of monitoring and social distancing protocols. In February 2020, the HISP community provided COVID surveillance packages, which included case-based monitoring and Point of Entry case management. After participating in webinars, HISP groups worked together with the Ministry of Health and other stakeholders to customise surveillance packages according to specific local circumstances. The dhis2 information system has provided an opportunity for any proposed solution to be submitted and defended before these committees.

The dhis2 community in countries such as Senegal, Cameroun, The Gambia, DR Congo, and Mali promptly embraced packages for the management of COVID cases. Nevertheless, Burkina Faso and Guinea opted to utilise the packages as a blueprint to independently create their own COVID modules. Specific country needs prompted the development of innovations, such as the creation of contact tracing apps in Guinea. These methods facilitated the ability of countries to efficiently monitor cases and handle daily reporting on the COVID situation.

Amidst the pandemic response, the dhis2 community provided novel packages for the administration of the COVID immunisation programme. Individual packets facilitated the tracking of vaccinations on a per-dose basis, including information such as the batch number, any adverse events that occurred after immunisation, and the total number of doses administered. Aggregate packages are designed to focus on collective figures, such as the total number of individuals who have received their initial dosage and the total number of adverse events following immunisation (AEFI).

Countries select between options for handling aggregated data or individual data based on their specific requirements, skills, and aspirations. As an illustration, the Central African Republic made the decision to gather combined information on immunisation, while simultaneously establishing a dhis2 monitoring system for individuals who travel. Togo utilised dhis2 for both aggregate reporting and individual-level data, capitalising on the preexisting dhis2 ecosystem consisting of proficient healthcare professionals, internet access, and electronic devices.

Togo achieved the distinction of being the inaugural sub-Saharan African nation to have its digital immunisation certificate officially acknowledged by the European Union. This achievement not only enabled the complete resumption of administrative activities but also strengthened worldwide economic connections. Other nations pursued comparable trajectories with various levels of achievement.

Nevertheless, the public's enthusiasm for the vaccine has diminished following over a year of immunisation, resulting in certain countries having unrecorded data that has accumulated over time.

Many countries found it very straightforward to adopt dhis2 for COVID surveillance and immunisation. However, there was a conflict between traditional surveillance, HMIS, and HISP groups. The COVID committees, comprised of influential individuals lacking expertise in current systems, facilitated the implementation of several additional digital systems. Nevertheless, certain systems encountered constraints as a result of the sheer volume of cases and the absence of necessary design and process modifications. In nations such as country A, the system was terminated within a year, and administrators were unable to transfer data for integration into another system like dhis2. In nations such as country B, the donor organisations successfully established themselves as an IT solution for overseeing the COVID immunisation campaign, resulting in a state of conflict and uncertainty. In country C, the government allocated millions of dollars for the acquisition and execution of an electronic system, which attracted the attention of a new contender to secure the contract and receive a substantial payment for selling an immature technology.

Outlier cases: Tanzania, Norway and Chile

Tanzania case

Tanzania stands up as an exceptional case in our study during the initial stages of monitoring the pandemic. Until the demise of the former president Magufuli in March 2021, Tanzania implemented a policy of rejecting the existence of the pandemic and ceased publishing data on COVID-19 cases after May 2020. The World Health Organization's recommended measures to combat COVID-19 were deliberately disregarded, and instead, the population was encouraged to rely on prayer as a remedy. Testing for COVID-19 was actively discouraged, as it was believed to instill fear among the people (Tanzania Leader Says Prayer Will Cure Covid, as Hospitals Overflow | Tanzania | The Guardian, n.d.). The newly appointed president instigated a substantial change in COVID-19 policy, which involved the establishment of a committee of COVID-19 experts and the commencement of a vaccination programme.

Prior to this policy shift, a surveillance system was established to oversee the movement of travellers crossing the border between Tanzania and Kenya. This was in response to Kenya's requirement for Tanzanian individuals to present negative COVID-19 test results in order to enter. Although Tanzanian authorities first prohibited testing and other measures to address the pandemic, they were obligated to provide testing services in order to adhere to the legislation of neighbouring nations. During this phase, all services were performed manually, including the booking process and the delivery of results. Therefore, in December 2020, the Ministry of Health, in collaboration with HISP Tanzania, commenced the creation of a digital tool for COVID-19 testing and result generating using the dhis2 platform, known as PIMA COVID. This website facilitated the booking of testing services and issuance of certificates, effectively accommodating the rapidly changing demands of Tanzania.

In addition, Tanzania initiated the development of AFYAMSAFIRI, a new COVID monitoring module for incoming travellers, in February 2021. Upon arrival, guests were obligated to cover the cost of a PCR COVID test. The app was rapidly deployed, with financial partners actively involved in creating the applications as the payments had to be processed through their banks.

Tanzania became a participant in the worldwide GAVI COVAX vaccine effort in June 2021 and initiated preparations for a large-scale immunisation campaign. In the past, vaccination data were documented in a registry and reports were manually prepared. Additionally, individuals were given paper-based certificates after receiving their vaccinations. In order to alleviate the strain on health workers when it comes to manually recording personal information of each patient in registries, HISP and MoH collaborated to create the CHANJO COVID application, which is designed to track immunisations. The system incorporates a public web platform that enables individuals to choose health institutions offering immunisations, sign up for appointments at certain times, and receive confirmation of their appointments. In August 2022, vaccination certificates containing QR codes that may be verified were introduced. This solution was created and distributed via the Open Source network. The COVID-19 dhis2 metadata packages were provided and served as the foundation for the creation and localization of the aforementioned apps.

Norway

This case study analyses the deployment of the Fiks contact tracing system in six municipalities in Norway. For nearly two centuries, the health care industry has been in charge of contact tracing. However, thanks to the widespread vaccination against contagious diseases, local authorities have been able to manage small outbreaks using traditional methods such as phone calls, writing on paper, and organising data in spreadsheets. Nevertheless, the absence of a vaccine for COVID-19 prompted the exploration of digital contact tracing systems (CTS) as a means to facilitate contact tracing. The Norwegian Association of Local and Regional Authorities (KS) offered IT assistance via a software-as-a-service platform known as Fiks. The initiation of dhis2, an open-source system equipped with Application Programming Interfaces (APIs), was prompted by suggestions from the World Health Organisation (WHO) and the Centre for Disease Control and Prevention (CDC). KS and HISP Oslo commenced a grassroots digitalization process by deploying the Fiks contact tracing system on the KS digital platform. The digitization of COVID-19 has been recognised as the most rapid collaboration in Norwegian history, involving all participants who possess an exceptional willingness to assist.

The stand-alone system, Fiks contact tracing, encountered difficulties as a result of its limited interaction with other health information systems (HIS). With financial assistance from NIPH, KS established connections between Fiks contact tracing and the national population register, NIPH's laboratory database, and NIPH's clinical report database. A self-registration module was implemented for public use, enabling the automatic transfer of recorded positive cases from one municipality to another.

The municipalities in Norway exhibited a bureaucratic and hierarchical structure, which constrained the ability to engage in interdisciplinary collaboration. Amidst the pandemic, a municipal project manager formed an interdisciplinary team with individuals from several fields including law, health, IT, project management, and economics. The team reduced the distance between stakeholders and established connections between Fiks contact tracing and the readiness team, facilitating the effortless generation of reports and swift digitization. The team's proficiency in digitalization, ICT operation, analysis, health, and welfare technologies played a crucial role in expediting the process of digitalization.

Chile

The Epidemiology Unit of the Ministry of Health played a pivotal role in overseeing the management of information and IT responses to the COVID-19 epidemic. At first, it modified the preexisting epidemiological information system in Chile for COVID-19 and created a nationwide platform for handling samples. This platform consolidated all the outcomes of PCR testing carried out in the country. In addition, a specialised system was created to document interventions at healthcare facilities.

Nevertheless, the country encountered substantial obstacles since it was unable to make modifications to the current platforms, such as the national epidemiological surveillance system, due to their development being carried out by external teams that were no longer functioning or affiliated with the ministry. Chile came across dhis2 when searching for system improvements and decided to investigate and install it using the "fail fast and cheap" approach. As the country advanced in online training and technical documentation, they created tailored programmes. Significantly, these initiatives encompassed the Paxlovid programme, which facilitated the registration and surveillance of COVID-19 medicine distribution, as well as a novel system for health residences that enabled the tracking of occupied and vacant beds at isolation centres across the entire country. Later on, other programmes were implemented to monitor monkeypox, childhood cancer, and units for notifying cases of polio, measles, and rubella.

Chile conducted experiments with various system topologies, deploying them in the cloud and utilising Kubernetes, a previously unused paradigm. These operations were carried out in an isolated and autonomous manner. Thanks to its elastic capacity, this design effectively managed large amounts of data and supported multiple concurrent connections. It dynamically adjusted to changing demands and efficiently returned to a stable state, resulting in greatly reduced maintenance costs.

An important drawback that was discovered is the utilisation of open-source software. This can lead to mistrust, especially when an organisation lacks a culture that is familiar with free software. Furthermore, the Ministry did not possess the resources to sustain an in-house development team for dhis2. Additionally, due to the limited recognition of this system in Chile and Latin America, there was a scarcity of foreign development teams accessible.

Upon analysing the examples, the following dominant themes emerged as having played a crucial role in fostering resilience for implementation of digital public goods:

Agile governance and development. The pandemic came with great uncertainty and urgent need for data, and with high level (eg: ‘presidential’) committees in charge of responses demanding swift action.
Capacity in the countries. The ability to leverage existing dhis2 systems and capacity in using them in countries were crucial
Transnationally mandated networks of support – or ‘action networks’. The ability to leverage the existing open source dhis2 and HISP network to provide effective support to countries - global capacity – were also important.
Flexible free and open-source software with platform ability, made it possible to link systems and share data, develop new ‘apps’ and modules. The flexibility of the dhis2 software platform and the included open API were crucial in being able to respond to the rapidly changing needs and requirements during the pandemic.

These four themes were shown to be interdependent in our specific scenario. In the initial months of the pandemic, we witnessed swift modifications in the circumstances and demands for various novel digital solutions. The development of these solutions needs both speed and adaptability, facilitated by a digital platform approach. The manifestation of agility was evident in both the rapidity of decision-making and the implementation of traditional software agility methods, such as hackathons. From the very beginning of the development process in Sri Lanka, solutions, ideas, and knowledge were rapidly disseminated and enhanced across long distances through a "action network" consisting of developers, users, and government officials. This was made possible by the internet during a time when travel was restricted.

Agile Governance and Development

Following the start of the pandemic, there was a surge in actions in several countries. High-level committees dedicated to addressing COVID-19 were formed, and various interventions, many of which relied on digital technology, were expedited. The actions implemented in Sri Lanka exemplify the agile methodology. Within a brief timeframe of three months, a grand total of 8 novel modules and apps were created in dhis2. A developer remarked on the efficiency and flexibility of the process:

“… it takes weeks or even months to get approval to implement a system within the ministry usually. But during the early days of the pandemic it was hard to believe how stakeholders outside the ministry and sometimes even outside the country could collaborate with ministry officials and get systems designed and implemented in few weeks…”

Including a hackathon in March 2020 was a component of this procedure, which serves as a typical illustration of the agile software development process [38]. The hackathon and webinars in Sri Lanka convened local and international collaborators in a dynamic setting of agile development, testing, and deployment of novel solutions within an ongoing pandemic. Through collaboration on this testbed, stakeholders were able to develop a shared comprehension of a previously unknown occurrence. The collaborative effort led to the creation of a comprehensive COVID-19 toolkit, which encompasses applications, customisable meta-data packages, indicators, and visualisation tools for monitoring and analysis. Additionally, the toolkit includes documentation and training materials. The toolkit and other findings were rapidly disseminated and deliberated through webinars. As depicted in the instances, the process of adapting and translating the toolkit to suit local circumstances was already in progress from March to April 2020, spanning across countries such as Laos and Bangladesh in Asia, and Mozambique, Rwanda, and Togo in Africa. The timely availability of these toolkits, along with the ongoing process of localization, innovation, and further development through webinars and existing contacts, played a crucial role in promoting the agile adoption and implementation of COVID-19 solutions.

The epidemic prompted a swift response, with the establishment of new governance systems to facilitate quick decision-making and flexibility in implementing different measures, including digital solutions. In order to explain something that is, in many aspects, easily comprehensible, we employ Gersick's [39] concept of punctuations and 'revolutionary' periods, which facilitate profound transformations. This model is valuable for comprehending and analysing crucial elements of digital resilience and agility as they occurred, particularly in the initial phase of the pandemic. Romanelli and Tushman[40] utilised the model to comprehend the process of adopting or disrupting technology in response to environmental changes, which are conceptualised as a punctuation that interrupts the existing state of stability and disrupts the established socio-institutional structures [41]. The beginning of the pandemic marked a significant change and was followed by a transformative phase of agile responses, facilitated by efficient governance and rapid system creation using the digital platform method. According to Rigby et al. [42], agile solutions are context-specific and not a result of centralised planning. They are prompted by immediate requirements and rely on novel peer-to-peer frameworks that deviate from conventional bureaucracies. Following the notification of the first cases in China, prompt governance measures were implemented in Sri Lanka, Rwanda, and Bangladesh. These measures involved the initiation of new approaches and the establishment of new collaborations among institutions and individuals to develop effective responses. For example, the hackathon mentioned earlier. Another instance is the utilisation of dhis2 for contact tracing in Norway. Each municipality in Norway had its own system for reporting notifiable diseases internally, and there was no sharing of data between municipalities. However, it was not feasible to implement this in a contact tracing system, as it was required to track contacts in all regions of Norway. As a result, data exchange for these purposes was quickly authorised, and the system was put into operation. Post-COVID, the practice of sharing data between different municipalities for legitimate reasons becomes the accepted standard.

Capacity in countries

Introducing several solutions to a country with limited capability could result in significant sustainability challenges, as evidenced by the lessons learned from the Ebola outbreak [43]. There exist various categories of knowledge and skills improvement within the field of Information Systems. Effective management of information systems (IS) is highly dependent on the capacity to oversee and guide their direction, execution, and coordination. This is achieved through the establishment of standard operating procedures (SOPs) and the establishment of high-level coordinating bodies such as working groups or task forces, which play a vital role. In the context of introducing DPGs that could lead to achieve SDGs, we rely heavily on local capacity of countries to sustain the systems over time.

In the context of Sri Lanka, the first phase of the case study predominantly focuses on building capacity of existing resources in the ministry of health. The starting of the Masters's program was a long-term vision to produce qualified professionals who, in turn, will be able to build capacity at sub-national levels across all types of healthcare staff categories. This proved to be crucial during the phase 2 of the case study in Sri Lanka during the height of the pandemic. This highlights a crucial aspect of implementation of digital public goods which can not only run but also evolve with local resources. Travel restrictions during the pandemic ensured that no external consultant could enter the country at the height of the COVID-19 outbreak. This invariably led to the country-led customization of the dhis2 platform coupled with an accelerated implementation which scaled nationally during the pandemic. This required huge amount of capacity at all levels in health hierarchy for building the system as well as training the healthcare staff to use the system. The existing capacity in the country was an invaluable asset for this. In the phase 3 of the Sri Lanka case study it portrays how the country was able to capitalize on the local capacity to implement the digital health blueprint which not only included dhis2 but several other DPGs.

In the context of global implementations of other countries, the role of the HISP network in the building and dissemination of knowledge for continuous capacity building was salient.

The contact tracing teams in Norway have comprised diverse and multidisciplinary groups, including medical professionals such as doctors, nurses, and physiotherapists, as well as individuals from various other fields such as pilots, flight attendants, police detectives, and shopkeepers, among others. Their diverse backgrounds and experiences have shaped their perspectives on contact tracing protocols and procedures, including the functions of the systems. Contact tracers lacking experience in the healthcare industry frequently challenge statements such as "this is how it has always been done" or "it is not feasible to digitise this process." Instead, they propose alternative solutions or implement changes independently. According to Walker and Salt [13], resilient individuals who possess a positive capacity tend to focus more on finding solutions rather than dwelling on problems.

Most of the countries in the study group have extensive expertise in developing digital information systems in the healthcare industry using the dhis2 platform, which is free and open-source. The adoption of open-source solutions may be driven, in part, by limited financial resources to acquire and sustain proprietary systems. Both case studies indicate that both countries had prior experience utilising the dhis2 platform for other purposes. Additionally, there was a strong presence of local expertise at all levels of the health hierarchy, which facilitated the design, customisation, and utilisation of the platform for routine health data needs. Therefore, despite the limitations on global travel imposed during the initial stage of the COVID-19 pandemic, both countries managed to develop and implement a digital system to handle COVID-19 data needs using local resources. Despite the significant strain on resources caused by COVID-19, countries managed to develop and deploy a digital system nationwide by leveraging existing local resources.

Networking in COVID-19: Transnationally mandated network of support

The COVID-19 toolbox, developed through collaboration in Sri Lanka and disseminated via the HISP and dhis2 network, had a crucial role in the swift adoption of the toolkit worldwide. The toolkit was distributed via the existing channels and established procedures of the health program-specific toolkits produced in collaboration with dhis2 and WHO [37], which gave credibility to it. According to an informant in the Ministry of Health in Rwanda, the approval of the metadata package by the World Health Organisation (WHO) has significantly reduced the time spent on discussing data element standards. This is because the WHO standards serve as a starting point, allowing for the addition of specific requirements without going through the usual time-consuming process. This exemplifies Pacey's [44] notion of dialectic dialogue occurring as countries and cultures embrace novel technologies. This concept is derived from the analysis of 1000 years of worldwide technological advancement. We employ Tiwana's [45] concept of 'partitioned innovation in open-source networks' to examine the transformation of digital solutions as they traverse across different countries. As demonstrated by the cases, the metadata and other components of the toolkit underwent substantial modification and localization through discourse in the respective nations. In the situations of Lusophone and West Africa, we have observed that the process of translating to Portuguese and French languages, as well as adapting to the African cultural setting, involved significant adjustments, modifications, and novel developments. Subsequently, upon the arrival of the Portuguese version in Guinea Bissau, other modifications and advancements were necessary. These included the implementation of measures to reduce waiting times at border crossings and testing sites, achieved through the development of self-registration and appointment scheduling systems. In many countries, such as Burkina Faso and Guinea, the Francophone version was used with few modifications. However, in more developed countries, the initial metadata set was utilised as a preliminary design guide.

In Chile, the sharing of design ideas related to free and open-source software sparked the intervention and creation of a system for overseeing ICU beds, units, and patients using dhis2, starting from the beginning. They discovered DHIS and its accessible solutions online. They obtained the software, instructions, and tutorials for dhis2 and used them to construct the system.

Several apps underwent iterative improvement and development across several countries, exemplified by Rwanda's adoption of COVID lab result certificates from Uganda. Subsequently, as a result of policy modifications, it became necessary for them to create an internet-based citizen portal that would allow anyone to access certificates. HISP Rwanda was deliberating on data flows and design when HISP Mozambique introduced their comprehensive online model during a webinar. Through collaboration, this model was subsequently adopted as the new online solution for Rwanda. Subsequently, this solution was brought to Chad, where they proposed the inclusion of a certificate verification functionality that would provide a green indicator for valid certificates and a red indicator for invalid ones. After its development, this innovative approach was introduced in Rwanda, and subsequently expanded to Uganda and Tanzania. This example demonstrates the practical process of developing and disseminating inventions inside open-source networks [45]. The availability and exchange of digital solutions at this level of advancement would not have been achievable without the utilisation of free and open-source software. The term 'free' is significant since it signifies a minimal requirement for testing, piloting, and potential deployment. On the other hand, the term 'open' facilitates the sharing of the software among different countries and allows for local development.

The imposition of travel restrictions had a direct influence on the digital solutions that countries had to adopt, and it influenced their overall decision-making and comprehension of the pandemic. Tanzania stood out significantly by deviating from the worldwide consensus on COVID-19 and implementing a 'business as usual' approach due to concerns about potential starvation, resulting in a discouragement of testing. Nevertheless, Tanzania was compelled to adopt similar measures after Kenya executed their mandate for negative tests to cross the border. In late 2020, HISP Tanzania, in collaboration with the Ministry of Health (MoH), introduced the COVID-19 test and certificate applications for facilitating border crossings. In March 2021, following the death of the president, the new president synchronised pandemic measures with the recommendations of the World Health Organisation (WHO). In general, the establishment of worldwide standards for mandatory COVID-19 tests limits the extent to which local authorities can adapt their digital responses.

Flexible free and open-source software

The software platform of dhis2, as well as its open API that allows for modularity and adaptability, played a crucial role in developing the digital COVID-19 response ecosystems detailed in the instances. The dhis2 platform features facilitated the development of a multitude of digital solutions to address various COVID-19-related issues and initiatives. The availability of an open API facilitated the construction and integration of diverse applications and systems, including laboratories, public testing and certificate services, and immigration authorities around the country. The platform characteristics provided the necessary adaptability and facilitated the creation of several solutions within a brief timeframe, as demonstrated in Sri Lanka where 8 modules and apps were produced in just 2 months. Analogous progress occurred in other nations. The COVID-19 platform strategy is characterised by the extensive participation of diverse users and user organisations, who share and utilise data from one another. In Bangladesh, dhis2 served as the key component of the surveillance system, with third parties developing most of the peripheral apps and systems. The wider ecosystem consisted of pre-existing technologies. The dhis2 served as an integrator for previously segregated systems and data sources. In Rwanda, the majority of the applications were developed by HISP using the characteristics of dhis2 or directly on the dhis2 platform, unlike in Bangladesh.

Our cases aligns with Gawer's [46] viewpoint on platforms as dynamic meta-organizations that facilitate networking and interactions among users on both the demand and supply sides. The platform facilitates new relationships both between and within users, causing the traditional difference between supply-side and demand-side users to become less clear. Data suppliers are both consumers and providers of data, which is shared and utilised throughout the platform ecosystem. The scenarios we present align with the conclusions of a study conducted by Floetgen et al. [47] on mobility platforms. The study found that both digital and non-digital elements have a role in the resilience of these platforms and its ecosystem as socio-technical entities. Furthermore, the study emphasises that resilience is developed through a combination of social and technological factors. Returning to the inquiry posed by Heeks and Ospina [16] regarding "resilience for whom?", are they referring to the Information System (IS) or the system being targeted? With the socio-technical perspective, the answer is "both".

The platform played a vital role in facilitating the global distribution, testing, and development outlined in the cases. Many nations in the Global South have adopted the dhis2 platform and have established significant expertise in operating the system. Consequently, the process of testing, modifying, and integrating new applications could occur either within or in addition to the current dhis2 platform. Another crucial matter is that the lack of licencing restrictions on the open-source dhis2 facilitated the exploration and development of new features without any hesitation and at a rapid pace. Zoom-based webinars and training approaches have facilitated worldwide cooperation, sharing of solutions, design, and learning. They have also made training and capacity building feasible in many regions. Digital platforms provide networking on several scales, encompassing both global and national levels, hence enhancing the variety of solutions and use cases.

We emphasize that while digital public goods are free and open-source software, they also needs to be flexible and customizable for rapid adoption across countries transnationally. The case studies shows us that a majoe reason for rapid adoption of the dhis2 platform is its simple, customizable, flexible nature that aligns with the level of capacity available in many LMICs. In addition, digital solutions which has platform capacibilities, that nurture extensibility and interoperability also promotes adoption across nations due to their ability in surviving in a digital ecosystem with a plurality of technologies.

This article presents evidence that the open-source digital tools created on the dhis2 platform were widely distributed across nations, shared, improved, and used in various country projects. The existence of these digital tools, along with the knowledge and skills gained through the network, played a role in enhancing digital resilience in countries worldwide.

We contribute to the field of policy and implementation by providing empirical evidence on sustainable implementation of digital public goods such as dhis2 in dynamic environments, particularly in difficult conditions. We enhance the theory and conceptual domains by defining the specific attributes of digital platforms that enable them to be effective in adapting to different situations. These attributes are what we refer to as the factors that determine the resilience of a digital platform. We want to emphasise that these determinents are not only technological, but also comprise non-technical boundary resources.

As the COVID period, which had a significant impact on all of us, fades into the past, it is now necessary to examine whether there are any enduring effects of the digital mediation that were put into place. Resilience, as described by Folke [12], encompasses the ability to not only bounce back from quick shocks but also to undergo metamorphosis, where these newly robust aspects become the new standard. Are there any enduring 'new normals' evident in our cases? We can examine the digital solutions that have been created and put into use to determine if they have become the prevailing practice. Examples include the surveillance systems in Norway that operate across municipal borders, as well as the digital Master client register and vaccination register being implemented in Laos, which originated from the COVID-19 vaccination registers. Alternatively, it could be more advantageous to examine the enduring influence and cultural shifts at a broader level, such as the heightened embrace of open-source software or of Digital Public Goods (DPG). The open-source capabilities of the DPG idea have played a crucial role in facilitating network-based design and "partitioned" innovations [45]. Additionally, they have empowered countries to take ownership of digital solutions by allowing them to "own" the source code and create their own systems.

A key measure of long-term influence and durability will be to assess if national policies are increasingly embracing open-source approaches and promoting collaboration across organisational boundaries. In Sri Lanka, after conducting a hackathon and engaging in collaborative efforts to produce open-source software implementations, they are currently working on creating a digital health blueprint. This blueprint will build upon the country's existing capabilities and strong digital public goods.

Ethics approval and consent to participate

Ethics approval has been granted for the study from both the Ethics Review Committee of Postgraduate Institute of Medicine, University of Colombo Sri Lanka and the Norwegian Centre for Scientific Data (Sikt: https://sikt.no/en/home). Informed consent has been obtained from all participants of the study. We confirm that all interventions including data collection were performed in accordance with relevant guidelines and regulations (such as the Declaration of Helsinki) enforced by the ethics committees of University of Colombo and Norwegian Centre for Scientific Data.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available since they are not being permitted to share interviews due to privacy concerns highlighted in ethics approval. However, analysed categorised data could be shared upon request.

Please contact corresponding author, Pamod Amarakoon ([email protected]) for any clarification and data requests.

Consent

Informed consent was obtained from all the participants of the study for the collection of data for analysis and publication without revealing their identity.

Competing interests

There are no competing interests for any authors.

Author Contribution

PM: data collection, review of literature, data analysis, writing of manuscriptJA: review of literature, writing of the manuscript

Acknowledgement

Hannan Khan, Andrew Muhire, Edem Kossi, Marko Garcia, Ragnhild Gundersen, Anne Thorseng, Wilfred Senyoni, Zeferino Saugene

Data Availability

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No competing interests reported.

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Implementation of Transnationally Mandated Resilient Digital Public Goods - Learnings from COVID-19 Pandemic

Status:

Version 1

Abstract

Figures

Introduction

Conceptual Framework

Resilience

Methods

Study Setting

Data Collection

Data Analysis

Case Studies

Sri Lanka

Phase 1: Building capabilities

Phase 2: Period of adaptability of processes

Phase 3: Post-pandemic Routinization

dhis2 open-source platform and HISP network

dhis2 Health Data Toolkits

Country cases: comprehensive platform ecosystems in Bangladesh and Rwanda

Bangladesh

Rwanda

Networking cases: Lusophone countries and West and Central Africa

HISP Mozambique, Lusophone countries and Guinea-Bissau

West and Central Africa

Outlier cases: Tanzania, Norway and Chile

Tanzania case

Norway

Chile

Discussion

Agile Governance and Development

Capacity in countries

Networking in COVID-19: Transnationally mandated network of support

Flexible free and open-source software

Conclusion

Declarations

Author Contribution

Acknowledgement

Data Availability

References

Additional Declarations

Status:

Version 1