Sao Tome and Principe is a Least Developed Country (LDC) as well as a Small Island Developing State (SIDS), with a fragile and externally dependent economy and high poverty rates.[1] The
country witnessed an epidemiological transition, with a double burden of communicable and non-communicable diseases that coexist with high burden of neonatal disorders.[2]
As in many countries around the world, until recently Sao Tome and Principe faced issues with good quality data collection, validation, and decision-making due to the lack of a single health information system meeting international standards.
There existed several parallel information subsystems, mostly paper-based, related to different health programs and health facilities. Consequentially, without full integration, data collection efforts were duplicated, leading to in lower data quality
and usability.[3]
To address this structural weakness and to improve routine health data collection, data quality, and data analysis, across the entire health system, the Ministry of Health (MoH) of Sao Tome and Principe decided to officially adopt and expand
the District Health Information Software (DHIS2) platform.[4] World Health Organization (WHO) and United Nations Development Programme (UNDP) provided technical and operational
support to the government of Sao Tome and Principe on the launch of DHIS2.
After the initial implementation of the aggregated data module for the programs funded by the Global Fund and GAVI, the DHIS2 individual tracker was, in 2020, customized to several other health services and programs, and implemented for individual data
reporting and patient registry for many areas. These include single patient registry at primary healthcare (PHC); emergency consultation at PHC; death registration; HIV testing and treatment; tuberculosis treatment and monitoring; malaria investigation;
reproductive, maternal, infant, and adolescent health; immunization; reporting of laboratorial results for COVID-19; COVID-19 vaccination, and monitoring of adverse effects (AEFI tracker).
WHO trained healthcare personnel on reporting, validation, and analysis of aggregate and individual data, at the national, district, and facility levels, while UNDP purchased the equipment and tablets needed to implement the system.
WHO’s technical support was essential for strategic planning and coordination of the DHIS2 expansion project across the various institutions involved. WHO is the co-chair of the Country Coordinating Mechanism (CCM) as well as the Health Information
System Steering Committee, composed of MoH, different agencies and technical partners, such as the Global Fund, Gavi, Republics of China, Portugal, Brasil, some national non-governmental organisations and the civil society. Partners rely on health
data that is generated through DHIS2 to identify priority investments in health sector and to monitor these investments’ progress and results.
Currently, WHO and other UN agencies are implementing a UN Sustainable Development Goals (SDG) Joint Programme entitled Reaching the furthest behind first: A catalytic approach to supporting the social protection in Sao Tome and Principe
[5]. Through this project a special DHIS2 module has been developed to ensure that the MoH information system can monitor access to health services for all, and particularly for the most vulnerable people. This universal health
coverage pilot project will enable the most vulnerable to benefit from subsidized access to essential health services, and DHIS2 is the health information platform that will enable to monitor progress and impact by linking-up the health services
with the social registry. WHO is the leading agency providing technical support to MoH and to Ministry of Labour and social protection and services in this project.
In addition, Sao Tome and Principe used DHIS2 in its COVID-19 response, most notably, for daily reporting and monitoring of COVID-19 cases and subsequently vaccination and adverse effects.
These efforts need to be continued for a sustainable implementation of DHIS2 at all levels of care consolidating the currently implemented modules and expanding to the national programs not yet in the system. A great focus is given to data generation
for policy making, strategic decision-making, health planning, performance and program monitoring and evaluation, with the goal of improving the provision of quality essential health services and universal health coverage.
[1] In 2020, an estimated 68% of the population lived below the poverty line for lower middle-income countries ($3.2 in 2011 PPP); World Bank (2020). Macro Poverty Outlook - Sub-Saharan Africa. Washington DC.
[2] Abbafati C, et al. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020
[3] As an example, to improve the surveillance and monitoring and evaluation of the HIV / AIDS, Malaria and Tuberculosis programs, the National Endemic Center in 2018/2019 created its own information subsystem, similarly to what happens in the Healthcare Directorate in relation to diseases of mandatory reporting and to the Program of Reproductive, maternal, infant, and adolescent health, and immunization. Simultaneously, most of the system remained largely paper-based and highly fragmented in nature.
[4] This decision falls under the purview of a wider National Health Information Management strategy which aim is to ensure that DHIS2 becomes the sole health information platform
to inform the MoH policymaking and planning.
[5] Total budget of the project is $US 2 394 799; UN Agencies: UNICEF, ILO, UNDP, WHO; National Partners:
Ministry of Labour and Social Affairs, Ministry of Health, Ministry of Youth, Ministry of Education, National Statistics Institute, National Social Protection Council; Duration: 1 January 2020 to 31 December 2021.
Photo caption: DHIS2 individual tracker is being used to report and monitor the first phase of COVID-19 vaccination.
Photo credit: WHO
