The District Health Information System (DHIS2): A literature review and meta-synthesis of its strengths and operational challenges based on the experiences of 11 countries

Abstract

Background:

Health information systems offer many potential benefits for healthcare, including financial benefits and for improving the quality of patient care. The purpose of District Health Information Systems (DHIS) is to document data that are routinely collected in all public health facilities in a country using the system.

Objective:

The aim of this study was to examine the strengths and operational challenges of DHIS2, with a goal to enable decision makers in different counties to more accurately evaluate the outcomes of introducing DHIS2 into their particular country.

Method:

A review of the literature combined with the method of meta-synthesis was used to source information and interpret results relating to the strengths and operational challenges of DHIS2. Databases (Embase, PubMed, Scopus and Google Scholar) were searched for documents related to strengths and operational challenges of DHIS2, with no time limit up to 8 April 2017. The review and evaluation of selected studies was conducted in three stages: title, abstract and full text. Each of the selected studies was reviewed carefully and key concepts extracted. These key concepts were divided into two categories of strengths and operational challenges of DHIS2. Then, each category was grouped based on conceptual similarity to achieve the main themes and sub-themes. Content analysis was used to analyse extracted data.

Results:

Of 766 identified citations, 20 studies from 11 countries were included and analysed in this study. Identified strengths in the DHIS were represented in seven themes (with 21 categories): technical features of software, proper management of data, application flexibility, networking and increasing the satisfaction of stakeholders, development of data management, increasing access to information and economic benefits. Operational challenges were identified and captured in 11 themes (with 18 categories): funds; appropriate communication infrastructure; the need for the existence of appropriate data; political, cultural, social and structural infrastructure; manpower; senior managers; training; using academic potentials; definition and standardising the deployment processes; neglect to application of criteria and clinical guidelines in the use of system; data security; stakeholder communications challenges and the necessity to establish a pilot system.

Conclusion:

This study highlighted specific strengths in the technical and functional aspects of DHIS2 and also drew attention to particular challenges and concerns. These results provide a sound evidence base for decision makers and policymakers to enable them to make more accurate decisions about whether or not to use the DHIS2 in the health system of their country.

Keywords

information technology health information technology health information system qualitative research District Health Information System meta-synthesis content analysis

Introduction

The introduction of information and communication technologies (ICTs) into healthcare organisations has often generated controversy. While health information systems (HIS) have the potential to provide many benefits (such as cost saving and improved quality of healthcare) (Nguyen, 2015), there are also potential problems associated with their introduction, implementation and use (Kivinen and Lammintakanen, 2013), so HIS may not always provide essential information to support effective healthcare. Nonetheless, the type and very nature of health information contained in HIS (both health information management related and clinical data) makes it necessary to use technology.

HIS in developing countries

In many developing countries, HIS have evolved in a rather chaotic and fragmented way, with data collected inconsistently and in a disorganised manner. Consequently, information needed for decision-making may be unreliable, irrelevant, ineffective and insufficient (Karuri et al., 2014; Lungo, 2003; Wilson et al., 2001). In countries such as these, barriers to HIS development can exist at every stage of the development process (data collection, comparison, compilation, analysis and reporting), exacerbated by lack of material resources (e.g. cost and availability of IT infrastructure and relevant software) (KrajČA, 2010), inadequate human resources and inconsistent reporting requirements. Lack of data ownership means there is little incentive for health workers at the lower levels of employment to analyse, use and interpret health data (Aqil et al., 2009; Karuri et al., 2014; Kimaro, 2006; Lungo, 2003), and lack of feedback on HIS performance creates additional challenges. Feedback is an essential component of the health information cycle; it facilitates open communication that fosters discussion and resolution of problems. In developing countries, health workers rarely receive feedback on HIS, and where feedback has been provided it has tended to be negative, out of date and unproductive (Garrib et al., 2008; Karuri et al., 2014; Lungo, 2008).

Types of HIS

While there are many different types of HIS, most systems fall into one of two main categories: (i) those for handling data records of individuals (e.g. electronic medical records, electronic health records) and (ii) systems associated with data collection for decision-making and information management, generally referred to as health management information systems. The District Health Information System (DHIS) falls into this latter category (data collection for information management and decision-making).

DHIS

The DHIS evolved from research conducted into HIS programme¹ at the University of Oslo in 1994. The purpose of its development was to aggregate routinely collected data across all of the public health facilities of a particular country, to facilitate analysis of health services provided in that country at the national level, forecast required services for future planning purposes, and to evaluate the performance of healthcare workers (Garrib et al., 2008). The primary goals of the system were to establish a centralised database with reporting capabilities at health centres, define and determine the standards for local and national health centre reports and connect service delivery and other health system input databases (Manya et al., 2012). The basic version of DHIS was based on Microsoft Office Access. It was considered useful as a decentralised and independent database programme. DHIS has been used to collect and analyse data on a monthly basis at local, regional and provincial levels in several countries (KrajČA, 2010). In these particular cases, the DHIS has been installed individually on a number of computers across the country and data saved on these computers.

DHIS2

The DHIS2² version introduced improvements into the system to extend the use of the data and enable ready-made reports to be generated that could cover reporting requirements for health services at all levels, enabling decisions to be made about services at health centres, as well as local, provincial and national health departments (Karuri et al., 2014). The goal was to create a new version of DHIS that incorporated and made use of modern technology, with an independent Web-based platform and database, but with the capacity to work in offline mode as well, in order to facilitate efficient and effective management of national data and act as a “data warehouse.”

DHIS2 is an information system with an open source and few hardware requirements, a generic tool rather than a preconfigured database application and an open metadata model with a flexible user interface that allows users to specify their content without the need for programming. DHIS2 is normally used as the national HIS for the following items: data management and analysis, mapping existing services and recording the facilities, logistics management, monitoring and evaluation of health programmes and mobile tracking of pregnant mothers in rural communities (KrajČA, 2010; Nguyen, 2015).

Comparing DHIS and DHIS2

Both versions (DHIS and DHIS2) are flexible, configurable (easily-set) and open-source systems (Poppe, 2012). However, with DHIS2, data are saved on a central server, accessible via a Web browser and available on several platforms, both offline and online (Vasbotten et al., 2015). Another difference between the two versions is that data in DHIS are only entered via computers in the location of service provision, while DHIS2 data can be input into the system using a variety of tools, including desktop computers, laptops, tablets and smartphones. Although both versions allow service providers to enter data into the respective systems, the major difference with DHIS2 is that the data are immediately accessible to all relevant healthcare personnel. This was not possible in the first version (Vasbotten et al., 2015).

International use of DHIS2

DHIS2 has been selected for use in 30 different countries, across four continents, in preference to any other health information management software. The system has also been used in 46 countries at different levels of their health systems. The widespread adoption of DHIS2 has been facilitated by several features of the system that support its compatibility with the requirements of a number of different countries. According to Manoj et al. (2013: 2):

these features include, customised data entry, indicator defining, data visualising through various types of graphs, web based pivot tabling, integrated GIS module, meta-data importing and exporting, custom data quality checks, user access control, integrating the messaging system and DHIS2 mobile solution.

Figure 1 provides an overview of the DHIS2 system, and Figure 2 highlights key points and processes in the development of DHIS2, from its initial release as an offline Microsoft Access-based desktop software application in South Africa to the DHIS2 application platform that is used today (Gammersvik, 2015; Sahay et al., 2013).

Figure 1.

Overview of the DHIS2 system (source: Manoj et al., 2013: 5). DHIS: District Health Information System.

Figure 2.

Timeline in the development of DHIS2 (source: Gammersvik, 2015: 7). DHIS: District Health Information System.

The current research

Because different countries have had different experiences with the introduction and the implementation of DHIS2, this research sought to gather information about the strengths and operational challenges of DHIS2. The aim of this study was to provide comprehensive and appropriate information for use by policymakers in both Iran and in other countries where the decision to use the DHIS2 system or not has yet to be made.

Method

Research design

This study was performed as a literature review, coupled with a meta-synthesis method because analysing data on the strengths and weaknesses of DHIS2 requires an interpretive rather than a deductive approach (Walsh and Downe, 2005). Ethical approval was obtained from the Ethics Committee of Kerman University of Medical Sciences (approval no. IR.KMU.REC.1395.753).

Data sources, search strategy and study selection

For the purposes of this research, only studies that investigated the strengths and operational challenges of using the DHIS2 were selected. To source these documents, the following databases were searched: Embase, PubMed, Scopus and Google Scholar. Inclusion criteria were articles and reports that dealt with the managerial aspects of DHIS2, published in English, with no time limit (up to and including 8 April 2017). Exclusion criteria included articles and reports not published in English, articles that discussed only the technical aspects of DHIS2, articles discussing previous versions of DHIS (e.g. DHIS 1.4) and articles discussing other HIS.

Due to the high number of findings in Google Scholar, cases were studied as far as they were relevant to the results of the study (a total of 65 pages (650 results)). A combination of the following keywords was used to search “District Health Information System,” “District Health Information Software,” “DHIS2,” “Challenge,” “Limitation” and “Issue.” The following search strategy was used: PubMed: ((((((challenge [Title/Abstract]) OR Limitation [Title/Abstract]) OR Issue*[Title/Abstract]) AND DHIS2 [Title/Abstract]) OR “District Health information Software” [Title/Abstract]) OR “District Health information System” [Title/Abstract]). Scopus: TITLE-ABS-KEY (challenge) OR TITLE-ABS-KEY (limitation) OR TITLE-ABS-KEY (issue*) AND TITLE-ABS-KEY (dhis2) OR TITLE-ABS-KEY (“District Health information Software”) OR TITLE-ABS-KEY (“District Health information System”). Embase: challenge: ab, ti OR limit*: ab, ti OR issue*: ab, ti AND dhis2: ab, ti OR “district health information software”: ab, ti OR “district health information system”: ab, ti.

Citations identified in the search of the four databases were then combined, duplicates removed and the remaining studies reviewed and evaluated in three stages: title, abstract and full text. Literature screening was conducted using EndNote v.7 software. All articles were evaluated by two independent reviewers (HR and FH) at each stage and if opinions differed, a third reviewer (RD) determined the final decision.

Data analysis

In order to identify and extract the strengths and operational challenges of DHIS2, each of the selected studies was read with precision and focus on the details. The content analysis method was used to analyse extracted key concepts. These key concepts were divided into two categories of strengths and operational challenges of DHIS2. Then, each category was grouped based on conceptual similarity to achieve the main themes and sub-themes. MAXQDA (MAXQDA-11) software was used for content analysis.

Results/data synthesis

Literature selection overview

The documents examined in this research had their origins in 11 different countries (see Table 1). The study included 20 articles and reports, analysed from the perspective and experiences of those countries that had implemented the DHIS2 system. In the primary search, 766 English papers were found in the scientific databases; after removing duplicate and unrelated titles, 719 articles remained. In the second stage, 238 studies were reviewed based on the abstracts, resulting in a further 205 articles being excluded because they lacked inclusion criteria, and leaving a total of 33 selected articles. Finally, examination of the full texts of these remaining studies led to the selection of 20 eligible studies for inclusion in the study (see Figure 3).

Table 1.

Details of the selected studies.

Authors (year)	Country	Title	Type of document
Manya et al. (2012)	Kenya	National roll out of District Health Information Software (DHIS 2) in Kenya, 2011 – central server and cloud based infrastructure	Article
Nguyen (2015)	Rwanda	User acceptance of instant messaging in DHIS 2	Master’s thesis
Karuri et al. (2014)	Kenya	DHIS2: the tool to improve health data demand and use in Kenya	Article
Lungo (2008)	Tanzania	The reliability and usability of district health information software: case studies from Tanzania	Article
Gammersvik (2015)	Palestine	Balancing institutional needs with generic functionality in information systems: the biography and evolution of the DHIS 2 tracker following two implementations in Palestine	Report
Sheikh and Bakar (2011)	Zanzibar	Open source software solution for healthcare: the case of health information system in Zanzibar	Article
Poppe (2012)	Ghana	Health information systems in West Africa: implementing DHIS2 in Ghana	Report
Berntsen (2015)	Uganda	Enabling participatory design in low resource contexts – a study of distributed software development of DHIS2	Master’s thesis
Manya and Nielsen (2015)	Kenya	The use of social learning systems in implementing a Web-based routine health information system in Kenya	Article
Manoj et al. (2013)	Sri Lanka	Implementation of District Health Information Software 2 (DHIS2) in Sri Lanka	Article
Vasbotten et al. (2015)	Malawi	The use of DHIS2 within Malawi	Report
Al-Nashy (2015)	Sudan	Managing scaling of HIS: implementation of DHIS2 in Sudan	Master’s thesis
Bergum et al. (2015)	Ghana	Deliverable 2 analyzing DHIS2 as an information infrastructure	Report
Jayatilleke et al. (2016)	Sri Lanka	Injury surveillance with District Health Information System 2 (DHIS2)	Article
Sujatmiko (2015)	Uganda	Implementing DHIS2 feedback via short message service: a case study for Uganda WEMR health workers	PhD thesis
Nielsen (n.d.)	Malawi, Kenya and Uganda	Advancing health information systems: experiences from implementing DHIS 2 in Africa	Report
Braa et al. (2010)	Sierra Leone	Comprehensive yet scalable health information systems for low resource settings: a collaborative effort in Sierra Leone	Article
Kiwanuka et al. (2015)	Tanzania	Analysis of the acceptance process of district health information systems (DHIS) for vertical health programmes: a case study of TB, HIV/aids and malaria programmes in Tanzania	Article
Kiberu et al. (2014)	Uganda	Strengthening district-based health reporting through the district health management information software system: the Ugandan experience	Article
Adaletey et al. (2013)	Ghana	Cloud computing for development – improving the health information system in Ghana	Conference paper

Figure 3.

PRISMA flow diagram of the article selection process.

Strengths of DHIS2

The systematic review of the strengths of DHIS2 and meta-synthesis of results identified seven themes and 21 categories, as shown in Table 2.

Table 2.

Strengths of DHIS2.

Theme	Category		Subcategory
Technical features of software (12 of the 20 included papers)	Capabilities of proper data analysis and reporting		Predefined analytics tools of software (Manya et al., 2012) Incentive to use health data (Karuri et al., 2014) Increasing productivity of reporting and providing feedback (Sheikh and Bakar, 2011)
	Ability to appropriately visualise data using the software		Ability to define dashboard by user, geographic information system interface, the ability to make charts and reports (Manya et al., 2012; Sheikh and Bakar, 2011)
	Possibility of using the software offline		Possibility to use software in an intranet offline environment (Bergum et al., 2015; Manya et al., 2012)
	Web-based software		The possibility for any user to use information in any place because HIS software is Web-based (Karuri et al., 2014; Kiwanuka et al., 2015) Access to all software functions via the Web, including data entry or reporting from the mobile phone or PC (Manya and Nielsen, 2015) Support the software and international authorities support (Gammersvik, 2015; Manya and Nielsen, 2015)
	Open-source software		Open-source software (Gammersvik, 2015; Jayatilleke et al., 2016; Kiwanuka et al., 2015; Manya and Nielsen, 2015; Sheikh and Bakar, 2011)
	The ability to send SMS		SMS sending possibility through software and support different types of messages gateway (Nguyen, 2015; Poppe, 2012; Sujatmiko, 2015) The relationship between users and the backup system via SMS messenger in DHIS2 (Manya et al., 2012)
	Software support and international authorities support		Approved by the WHO (Sujatmiko, 2015) Supporting the establishment of international network of users and software developers (Manya and Nielsen, 2015) Sponsored by the Centre for International Cooperation in Higher Education of Norway to train DHIS2 (Manoj et al., 2013)
Proper management of data (9 of the 20 included papers)	Integration and aggregation of health information		Connecting with other e-health systems (Sujatmiko, 2015) Integration of data collection and integration of them (Poppe, 2012) Increasing coherence in the database and thus reduction of the diversion of metadata (Nielsen, n.d.) Maintenance of software centrally by a dedicated team (Nielsen, n.d.) Resolving the problems, being apart the previously used systems and consolidating them (Sheikh and Bakar, 2011) The establishment on a central online server (Manya et al., 2012) Availability of a central data warehouse (Adaletey et al., 2013; Poppe, 2012)
	The possibility of data entry at the operational level of the service provision		The possibility of data entry at facilities and health centres levels (Manya et al., 2012) Ability to collect and use the data in operational and regional levels (Manya and Nielsen, 2015)
	Increasing the quality, timeliness and completeness of data		Improvement of the quality, timeliness and completeness of data (Al-Nashy, 2015; Kiberu et al., 2014; Poppe, 2012) Reduction of distortions in the metadata challenge
Application flexibility (8 of the 20 included papers)	Ability to add new modules to the application		Flexible user interface (Manya et al., 2012) Ability to add ready modules and their development (Bergum et al., 2015)
	Ability to customize software for local needs		The appropriate localisation of software (Jayatilleke et al., 2016; Manoj et al., 2013)
	Application flexibility		High flexibility of the software (Berntsen, 2015) Taking advantage of free metadata model (Manya et al., 2012) Designing the contents of a particular information system without the need for programming (Braa et al., 2010) Ability to add new features to the software depending on user needs (Gammersvik, 2015)
	Possibility of using software tools		The possibility to use tools (such as PDF and PNG) and legacy systems (mostly Excel and Access) and Web-based services (like Google Maps) (Adaletey et al., 2013; Bergum et al., 2015)
	Sustainability of software		The ability of resistance even with the problems of access to electricity and the Internet (Berntsen, 2015)
Networking and increasing the satisfaction of stakeholders (4 of the 20 included papers)	Increased satisfaction of stakeholders	Increased employee satisfaction	Increasing workers’ satisfaction using the application (Berntsen, 2015; Poppe, 2012) Reception of all managers and employees from software (Manya et al., 2012) User-friendly software and easy to use (Manya et al., 2012)
	Increased satisfaction of stakeholders	Support of various stakeholders	Rapid and successful development of DHIS2 has received large support from stakeholders (Manya et al., 2012)
	Networking opportunities		The formation of a large network of developers, local users, the Ministry of Health, NGOs and universities (Bergum et al., 2015)
Development of data management (2 of the 20 included papers)	Increased responsibility sense for production qualified data		Upgrading data and system ownership (Manya et al., 2012)
	Encouragement of the use of data for decision-making		Encouragement to usage culture of information for decision-making (Manya et al., 2012) Providing conditions for necessary support for the use of data
Increasing access to information (4 of the 20 included papers)	Increasing access to information		Better access to data and information (Manya et al., 2012; Sheikh and Bakar, 2011) Support of transparency by granting peers access to data Increasing use of information with generating accessible and more understandable data (Poppe, 2012)
Economic benefits (2 of the 20 included papers)	Cost-effectiveness of software		Cost-effectiveness of application for countries with limited resources (Jayatilleke et al., 2016) Removal of the shipping cost for physical (paper) and logistics data (Poppe, 2012)

DHIS: District Health Information System; PC: personal computer; PNG: Portable Network Graphics; PDF: Portable Document Format; WHO: World Health Organization.

Technical features of the application

Results showed that the DHIS2 application has strong technical capabilities. According to the reports from Kenya and Zanzibar, DHIS2 has the ability to properly analyse data, provide reports and provide feedback. The software also has the ability to visualise data. Although the DHIS2 is Web-based, it is possible to use it offline. As DHIS2 is an open source, it is sufficiently flexible for users to make changes based on their needs. This feature of the software reduces the cost of application preparation and dependence on the software company and encourages and strengthens innovation among staff to promote the software. Another technical feature of the software is its ability to send text messages, which effectively reduces the impact of distance between users in different parts of the country. There is also strong international support for software deployment.

Proper management of data

Due to the deployment of this software on a central server and the presence of a data warehouse, health information can be collected and integrated. The DHIS2 system provides the option to enter data at the operational level, which may enhance the quality, timeliness and completeness of the data (Al-Nashy, 2015; Kiberu et al., 2014; Poppe, 2012).

Flexibility of DHIS2 application

The ability to add new modules to the software based on the needs, localisation capabilities in different countries and the use of tools such as Access and Excel has made the DHIS2 software flexible. The software also has a high stability despite difficulties relating to access to electricity and the Internet in some locations, such as Uganda (Berntsen, 2015).

Networking and increasing the satisfaction of stakeholders

Evidence shows that DHIS2 is user-friendly, increases employee satisfaction and has been well received by management executives (Manya et al., 2012; Poppe, 2012). Additionally, the software has enabled users to form large networks made up of satisfied supporters and users, developers, local users, health ministries, non-governmental organisations (NGOs) and universities.

Development of data management culture

DHIS2 users’ access to their data increases the feeling of responsibility for production of quality data. In this way, the attributes of the DHIS2 system enhance a decision-making culture in relation to the use of data.

Increased access to information

Based on the literature reviewed in this study, the DHIS2 software has also increased data access. For example, DHIS2 supports and protects transparency by giving peers access to data.

Economic benefits

The system has also been shown to be cost-effective. For example, the DHIS2 application had led to the elimination of the cost of transporting paper reports.

Operational challenges

Operational challenges of using this software included 11 themes and 18 categories, which are shown in Table 3.

Table 3.

Operational challenges of using DHIS2.

Theme	Category	Subcategory
Funds (3 of the 20 included papers)	Sufficient financial sources	The need to determine the financial needs and being observed in the ministry’s annual plan (Manoj et al., 2013)
Funds (3 of the 20 included papers)	Stable financial sources	The need for sustainable financing for the implementation of DHIS2 (Al-Nashy, 2015; Bergum et al., 2015)
Appropriate communication infrastructure (7 of the 20 included papers)	Appropriate Internet	Development of ICT infrastructure across the country to support the application (Poppe, 2012) The existence of previous appropriate foundations for setting up a system to coordinate existing data (Poppe, 2012) Need to develop government policies to create more opportunities related to the Internet Restrictions in some areas for Internet connection (Berntsen, 2015; Poppe, 2012; Vasbotten et al., 2015) Poor Internet connection is a barrier to connecting Excel to DHIS2 databases (Poppe, 2012; Sujatmiko, 2015)
	Other communications infrastructure	Lack of access to some areas to mobile and electricity (Karuri et al., 2014) The need for appropriate ICT and connectivity to set up the system (Al-Nashy, 2015)
The need for the existence of appropriate data (3 of the 20 included papers)	Sufficient data	The necessity of data availability in the region (Karuri et al., 2014)
	Qualified data	The need to improve the quality and completeness of data (Karuri et al., 2014) The need for qualified health data for comprehensive usage in DHIS2 (Karuri et al., 2014) The lack of basic information system (Poppe, 2012)
Political, cultural, social and structural infrastructure (7 of the 20 included papers)	The impact of social factors on the implementation of the software, such as infrastructures, organisations and political factors (Gammersvik, 2015) Political challenges (political instability) (Bergum et al., 2015; Poppe, 2012) Lack of stability over time (Berntsen, 2015) Linguistic challenges (lack of familiarity with the English language) (Poppe, 2012; Sujatmiko, 2015) Challenges related to the regional cooperation (Poppe, 2012) The disintegration of the health system (Al-Nashy, 2015; Karuri et al., 2014) Poor infrastructure (Al-Nashy, 2015) Technical-economic challenges: uncertain and unpredictable environment of public health systems, uneven development of infrastructure (Karuri et al., 2014)
Workforce (8 of the 20 included papers)	Workforce shortage	Lack of human resources capacity (Karuri et al., 2014; Kiwanuka et al., 2015; Nielsen, n.d.) DHIS2 success dependence on human capacity, competence of staff (Al-Nashy, 2015; Gammersvik, 2015; Karuri et al., 2014) Human capacity building as the main prerequisite for running the application (Al-Nashy, 2015; Manoj et al., 2013) The high volume of employees as a potential obstacle to all software personnel (Berntsen, 2015)
	Competence and accuracy of workforce	Poor competence of human resources in different areas (Karuri et al., 2014) Human error in relation to reporting data (the omission of a patient in the patient list) (Vasbotten et al., 2015)
	The need to change the viewpoint to the reporting staff	Interests of few individuals on reporting at the regional level (Berntsen, 2015) Lack of motivation or reluctance to use new systems such as DHIS2 (Vasbotten et al., 2015)
Management/leadership (13 of the 20 included papers)	Proper planning for establishment	The need to determine the need to run the software, and detailed planning for the implementation of the project (Al-Nashy, 2015; Manoj et al., 2013) Considering the non-static and changing state of the DHIS2 system (Bergum et al., 2015)
	Maximum internal participation	Ensuring the participation of all stakeholders in the implementation of software (Karuri et al., 2014; Manoj et al., 2013) The important role of prominent individuals at the local level (Sheikh and Bakar, 2011) Participatory design leads to attention to all aspects and implementation of the programme with maximum collective satisfaction (Berntsen, 2015) Achieving support of key stakeholders (Adaletey et al., 2013; Manya et al., 2012)
	The importance of logical connections with institutions developed system	Signing a memorandum of cooperation between the University of Oslo and some applicant areas to facilitate the implementation of software (Manoj et al., 2013) Designing and implementation of the study with the help of numerous partners such as the Oslo office, the centre of global DHIS (Berntsen, 2015; Gammersvik, 2015; Manya and Nielsen, 2015)
	The need for protection rules	The need for policy frameworks to implement the software Lack of facilities and equipment and also lack of cooperation from excellent organisations to provide needed equipment (Berntsen, 2015)
	Perceptions of senior executives	Lack of proper understanding of the subject as a barrier for establishment of software (Manoj et al., 2013) The importance of attitude and readiness of policymakers and managers to the process of change (Karuri et al., 2014)
	Senior management support	Gaining support from senior levels of the national and provincial levels for appropriate implementation of the system (Karuri et al., 2014; Manoj et al., 2013)
	Avoidance of precipitance	The need to spend more time especially on planning and practising (Berntsen, 2015; Kiberu et al., 2014) Lack of time for practical exercise (Poppe, 2012)
	The definition of administrative structure	The necessity of formation of the country team by the Ministry of Health in the early stages of implementation of DHIS2 (Manya and Nielsen, 2015) Lack of proper organisation to coordinate the operations of NGOs and governmental organisations (Vasbotten et al., 2015) Lack of guidance policies for human and information structure (Karuri et al., 2014)
Training (12 of the 20 included papers)	Training requirement	Lack of technical knowledge to DHIS2 and working with it by staff (Karuri et al., 2014; Poppe, 2012; Sheikh and Bakar, 2011; Sujatmiko, 2015) Concerns about reporting skills and competencies of healthcare staff (Al-Nashy, 2015) Personnel without proper training (Vasbotten et al., 2015) Lack of interpretation skills and application of DHIS data (Karuri et al., 2014) The need to hold training classes for users and other stakeholders (Adaletey et al., 2013; Al-Nashy, 2015; Berntsen, 2015; Karuri et al., 2014; Kiwanuka et al., 2015; Manoj et al., 2013; Nguyen, 2015)
Training (12 of the 20 included papers)	Training methods	Job training workshops and meetings with social learning through the formation of groups of software users (Manya and Nielsen, 2015) User feedback via text messaging to other users of DHIS2 software, the central core of national and international consultants (Manya and Nielsen, 2015) Having the ability to use computer and training to apply the software before using the software in the system (Lungo, 2008) ToT approach and cascade training to lower levels (Manya and Nielsen, 2015) Formal education in the university system and through the biomedical informatics course (Manoj et al., 2013) Development of DHIS2 Academy to provide the necessary capacity to strengthen at national and regional levels (Sujatmiko, 2015) Response to users’ questions by phone and email software (Manya and Nielsen, 2015)
Definition and standardising the deployment processes (1 of the 20 included papers)		Using a biomedical informatics graduate for the localisation of system (Manoj et al., 2013) Cooperation of WHO Collaborating Centre in the field of public health education (Manoj et al., 2013)
Application of criteria and clinical guidelines in the use of system (1 of the 20 included papers)		Providing certificate indicators used in the system (Gammersvik, 2015) Use of clinical guidelines to achieve the common language among various stakeholders (Gammersvik, 2015)
Data security (3 of the 20 included papers)		Human or systematic error at data entry into DHIS2 (Vasbotten et al., 2015) Concerns about granting access to all health units as well as external stakeholders based on the philosophy of open data (Nielsen, n.d.; Poppe, 2012)
Stakeholder communications challenges (2 of the 20 included papers)		Lack of coordination between the NGOs and the Ministry of Health (Vasbotten et al., 2015) Communication challenges among various stakeholders (Gammersvik, 2015)
Necessity of establishment of pilot system (2 of the 20 included papers)		The need to implement software as a pilot programme for multicentre/province (Al-Nashy, 2015) The need for preparedness at various levels including local and regional levels before implementation (Sheikh and Bakar, 2011)

DHIS: District Health Information System; ICT: information and communication technology; NGO: non-governmental organisation; ToT: Trainer of Trainees.

Financial sources

Reviewing the experiences of operating countries shows that one of the main challenges for the DHIS2 implementation is adequate and stable funding.

Appropriate communication infrastructure

Based on the literature review, one of the greatest challenges is proper communication infrastructure. Given that the DHIS2 is a Web-based application, ICT infrastructure is essential to support the application. Additionally, the presence of a previous foundation for setting up a system and coordinating the existing data are the prerequisites of the DHIS2. Experiences of other countries demonstrate that restrictions on connecting to the Internet can develop problems for the installation of the software.

The need for the presence of appropriate data

Reviewing the experiences of other countries demonstrates that the DHIS2 deployment requires adequate data for reporting and high-quality data. Although all countries have data quality issues, some countries experience considerably greater problems with the adequacy and quality of data than do others.

Political, cultural, social and structural infrastructure

In addition to the proper communication infrastructure, there are challenges in the political, cultural, social and structural infrastructures, which can affect the successful implementation of the DHIS2.

Human resources

One of the key issues in the implementation of the DHIS2 is workforce capacity (both numbers of personnel and their ability, knowledge and experience). The results of this study demonstrate that some countries are facing a shortage of adequately trained personnel. Additionally, due to the lack of adequate motivation in personnel to use the new systems, it is essential that the personnel approach to reporting be changed.

Management/leadership

Senior managers play a critical role in the implementation of DHIS2. Lack of appropriate and timely planning for the introduction of new software, for example, is one of the challenges to its success. Failure to source adequate technical support at the local level, combined with a failure to liaise appropriately with software companies to maximise the potential use of their resources can result in wasted opportunities. Local laws that do not support the implementation process, managers with negative perceptions and attitudes towards the implementation of new technology and administrative structures that are unsupportive of change can all affect the successful implementation of new software. The absence of a well thought-out plan can also lead to rash decisions being made at the last minute, which may not be in the best long-term interests of the organisation.

Education and training

One of the most challenging issues in the implementation of DHIS2 software is education. Despite the fact that the DHIS2 needs less technical support compared to the previous software, lack of technical knowledge in personnel leads to problems in the implementation of the software. Therefore, educating and training users on how to operate the system is one of the key challenges in the establishment of the DHIS2.

Attention to the role of clinical criteria and guidelines in the software usage

One way to achieve a common language among various stakeholders is the use of clinical guidelines in the application usage. Also, in order to facilitate the administrative process of the software, certificates of indicators used in the system are necessary (which indicator, by whom, data source, etc.).

Data security

The development of DHIS2 was based on the premise of open data, which has been granted to all health system units as well as external stakeholders and other interested individuals. For this reason, data imported by individuals at the district level may be altered or deleted by other users at different locations (Poppe, 2012). Therefore, the open data feature of the software has created concerns in some countries. Thus, data security is a key issue in this application, needing to be considered. In this regard, governments should understand the competency of open information and assign supportive policies (Nielsen, n.d.).

Stakeholder communications challenge

The experience of DHIS2 in Malawi demonstrates that activities of the Ministry of Health and those of NGOs are not necessarily synchronised (Vasbotten et al., 2015). In Palestine, communication difficulties between internal users, representatives of the World Health Organization (WHO) and software providers have also been observed (Gammersvik, 2015).

Necessity of establishment of the pilot software

Lack of preparedness at various levels, including local and regional levels, prior to implementation and failure to implement a pilot programme to pave the way for implementation was a challenge in some countries. The experience of other countries has demonstrated that before the application is run globally, the entire process (installation, adjustment and correction of manual and electronic forms) should be trialled first as a pilot programme in multicentres and provinces.

Discussion

The main objective of this study was to gather appropriate information about the strengths and operational challenges of the DHIS2 and make it available to policymakers and decision makers of Iran’s health system and those in other countries considering implementing this system.

Advantages of DHIS2

The reported experiences of countries that have used DHIS2 have shown this application to possess technically greater capabilities than the previous DHIS. This updated software could both analyse and report on data, and since the DHIS2 is Web-based, it could also assist users to access information in the system from anywhere provided there is computer and Internet access. Other technical features of the software include the ability to use the application offline, send SMS messages and open sourcing software.

The DHIS2 can assist with the appropriate management of data in the health system through integration and aggregation of information, as well as facilitate data entry at the operational level of services provision. In Zanzibar, for example, DHIS2 enabled consolidation of the country’s previously separated systems, eliminating many of the inherent problems involved in operating a number of different systems (Sheikh and Bakar, 2011). In addition, DHIS2 may facilitate the improvement of the quality, timeliness and completeness of data by providing tools for checking data quality, facilitating feedback and self-assessment for reports and identifying facilities that do not report (Poppe, 2012).

Another strength of the DHIS2 is the flexibility of the software. The DHIS2 allows for the possibility of adding new modules. Thus, DHIS2 can be honed to the local needs of each country. The use of this application has been shown to increase employee satisfaction and gain the support of stakeholders. Experiences of Ghana, Uganda and Kenya have demonstrated that due to the highly efficient reporting capabilities of DHIS2, the workers’ satisfaction with this software was enhanced (Berntsen, 2015; Manya et al., 2012; Poppe, 2012).

One of the problems facing health systems in developing countries is the lack of information usage for decision-making. In some countries where the DHIS2 has been used, the culture of information usage for decision-making has been encouraged and developed. Additionally, since users have access to their data at any time and place, a sense of data ownership and system ownership has increased. This sense of ownership has generated an increase in the sense of responsibility for production of quality data. Since the DHIS2 is based on a central server, it could not only increase access to information but also provide economic benefits for countries that face resource constraints.

Operational challenges

Despite the positive advantages of the DHIS2 application mentioned above, using this system in different countries has presented a number of different challenges. Recognition of these challenges can assist policymakers to take these considerations into account before they make decisions and take steps to ensure such obstacles are removed before the system is implemented.

Challenges identified from the experiences of other countries have demonstrated that these challenges are mainly infrastructure and system related. As Lippeveld has pointed out, HIS infrastructure is weak in most developing countries (Al-Nashy, 2015).

Thus, challenges falling into this category can be prevented by attending to these aspects. One issue that can trigger other challenges in the implementation of DHIS2 is insufficient attention to staff training. Lack of knowledge of the DHIS2 software and its use posed a serious challenge in Ghana (Poppe, 2012). Lack of technical knowledge on the part of personnel in information management units caused problems in the implementation of the DHIS2 in Zanzibar (Sheikh and Bakar, 2011). Therefore, adequate attention should be paid to staff training during the implementation of the DHIS2.

The countries examined in this study used different methods for training users. Kenya followed Trainer of Trainees approach for appropriate training. First, a limited number of teachers were selected and trained. Training was then transferred to lower levels following a cascade model (Manya and Nielsen, 2015). Kenya made use of DHIS2 functionality to send SMS messages, allowing the experiences of some users to be shared with others. Another approach to training in Kenya was on-the-job training. Using this approach, visits were made to different parts of the country and the software was examined specifically at the workplace of users while providing coaching and mentorship services (Manya and Nielsen, 2015).

The international DHIS2 Academy³ has been created to provide the necessary capacity to empower design, establishment and maintenance of the DHIS2 at national and regional levels (Sujatmiko, 2015). In addition, the DHIS2 was introduced to Sri Lanka through the MSc in Biomedical Informatics course at the University of Colombo. These students have become “a strong network for health information systems implementation” (Manoj et al., 2013).

Accurate planning of all requirements, with the participation of all stakeholders, is needed for the successful implementation of the DHIS2. A very important factor in this success is the participation of local expert people. Zanzibar’s first experience, which focused on delivery by international consultants, failed. However, in the subsequent attempt which involved the participation of local employees, the DHIS2 was successfully implemented (Sheikh and Bakar, 2011). Therefore, engaging all stakeholders in the country should be ensured.

In order to facilitate the implementation of the DHIS2, in addition to active participation of local people, reasonable relationships should be established with the trustees of the software system (especially the University of Oslo). The implementation of the system needs the protection of governance. Also important are the attitude and readiness of policymakers and senior managers towards the change process and execution of the system. These should not be underestimated. In Sri Lanka, lack of proper understanding of the senior managers was identified as the most important obstacle to the system deployment (Manoj et al., 2013). Lack of support from senior management, haste in the implementation and lack of clear definition of the special executive structure were other challenges that have caused countries to face problems in the implementation of the DHIS2.

One of the main prerequisites for implementation of the DHIS2 application is the availability of appropriately skilled personnel. Lack of staff who have competent computer skills and the high volume of work associated with implementation are potential barriers for acceptance of the DHIS2 by personnel (Karuri et al., 2014; Kiwanuka et al., 2015; Nielsen, n.d.). Lack of interest in reporting by some individuals on staff and lack of motivation to use new systems (such as DHIS2) can also contribute to problematic implementation experiences (Vasbotten et al., 2015). Therefore, modifying the attitude of employees towards reporting and encouraging them to use new systems seem essential.

The availability and quality of data are factors affecting the installation and usefulness of the DHIS2. Therefore, foundations should be established for requiring that data are entered into the system so that there are sufficient data for reporting and that the data are of high quality. The availability of information for other users (users who have access to data entry) and the ability to change it also create concerns (Poppe, 2012). Hence, at the time of implementation of the DHIS2, special attention should be paid to the issue of data security.

Another key point in the implementation of the DHIS2 is building communication among stakeholders. In the implementation of the software, Malawi faced the challenge of the lack of coordination between NGOs’ operations and the operations by the Ministry of Health (Vasbotten et al., 2015). Given that most countries used the help of external consultants for the DHIS2 implementation (the University of Oslo, representatives of WHO), communicating with these organisations is very important. Therefore, if external consultants are required, communication pathways with these groups should be predetermined.

The use of the DHIS2 has political, cultural, social and structural infrastructure considerations. For example, the government may carry the decision to implement the DHIS2 or to cease its operation for some reason. Another infrastructural challenge that developing countries have faced is the lack of integrity of the health system, in that their HIS may have developed in a fragmented manner. Failure to share information, collecting duplicate data, improper use of data and disruption in providing health services are the consequences of fragmentation in the HIS (Al-Nashy, 2015; Karuri et al., 2014).

Since the DHIS2 is Web-based, communication infrastructures are of particular importance in the implementation of this software because in some countries, restrictions on access to the Internet in some areas have created difficulties in the initial software installation.

The use of the DHIS2 requires stable financial resources (Al-Nashy, 2015; Bergum et al., 2015). Sustainable financing is required to run the DHIS2 and should be considered in the annual budget (Manoj et al., 2013). The experiences of some countries demonstrate that the system should primarily be implemented as a pilot in multicentre/provinces so that possible problems and challenges are resolved before the system is extended regionally or nationally.

Lessons learned

The software has appropriate functionality and can have positive effects on the health system in terms of increasing access to information, development of data management and also increasing the satisfaction of stakeholders, but it should be implemented considering the following points:

appropriating sustainable funding to execute and continue working with the software;

obtaining support from senior managers to implement the software;

training staff and software users before implementation;

development of communication infrastructure; and

the necessity to provide prerequisites to implement the software.

Strengths and limitations of the study

One of the strengths of this study was the broad range of countries that were included in the review, which makes it possible to generalise results to other similar countries. Thus, the results of the study will prove useful to Iran’s Ministry of Health as well as governments of other similar countries, which can all benefit from the findings when considering the introduction of DHIS2 for supporting practice and policymaking. A limitation of the study is that the meta-synthesis was limited by search criteria that deliberately focused on the challenges and strengths of DHIS2 implementation. Technical aspects of this software were not covered in this meta-synthesis and should be reviewed in the future. The findings of this meta-synthesis were also limited by the selection of databases searched and the inclusion of only those texts that were published in English. Some studies may exist in other databases, and the grey literature, which are particularly old (but may have useful observations) or exist only in languages other than English, and were therefore not included in the analysis.

Conclusion

According to the results of this study, the DHIS2 has its own strengths in technical and functional aspects of the software, but alongside these strengths, particular challenges and concerns also need consideration. This study provides evidence for decision makers to consider when contemplating the usefulness of implementing the DHIS2 in the health system of their country.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by Kerman University of Medical Sciences (KMU) (grant no. 95000570). The funder had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Notes

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