Digital Health Barometer

The public health sector in South Africa services close to 83% of the population. With the current population in 2022 estimated at 60,216,602 people, this amounts to 49,9 million people who are dependent on a severely constrained health system. With one of the highest HIV and TB burdens in the world and a struggling health system further crippled by the COVID-19 pandemic, good decision-making to derive maximum benefit from constrained health budgets is more critical than ever. It is important for a health information system to produce high-quality data for stakeholders in the health system to use for making decisions about interventions that are transparent and supported by evidence. However, the availability and ease of access to such evidence are limited, and the information needed by health planners is frequently insufficient, dispersed across numerous locations, and of questionable quality, necessitating the use of a variety of resources by planners and managers in the health sector. Additionally, recent in-depth research and analyses have provided persuasive evidence that climate change is significantly altering our environment and having an impact on health outcomes. In order to respond and prepare for the impact of climate change on health, disaggregated climate-related data is required. There is currently no online platform that provides both health indicators and climate-related information in South Africa.

Due to unequal access to health information, traditional healers, community-based governance structures, and other stakeholders are excluded from formal decision-making processes and their perspectives are not taken into account when planning services. Our solution responds to the need for an accessible, user-friendly and reliable digital platform for key PHC and climate change information for decision-making that is accessible to a wide range of users, including the community.

Our solution is to transform our current  publication

(https://www.hst.org.za/publica... ) into a digital resource that will be an online platform to support equitable PHC decision-making processes. This platform will be built using business intelligence tools (such as Tableau) that can be accessed through a web browser or mobile device via a guided analytics story design. Filters and user-customized options will enable different audiences to explore, interrogate and download content applicable to their context. User-friendly guides in multi-media will empower users to engage with the tool.

The health related data is available from the District Health Information System (DHIS) which the Department of Health collects directly at facility level. The facility level data are aggregated data, available at the different administrative levels in South Africa (i.e. National, Provincial, District and Sub-District). In addition, the DHIS data will be used in conjunction with survey data to develop proxy indicators that have so far been difficult to measure like the measurement of non-communicable disease (NCDs) indicators such as diabetes and hypertension. Our solution will also integrate current and historical climate-related trend data illustrating rainfall, temperature and lightning at a district and sub-district level. We will extract the temperature and rainfall data from near-real time remotely sensed data that is publicly available from the NASA Earth Observation Data platform (https://www.earthdata.nasa.gov...) and we will obtain the lightning data from the South African Weather Service (SAWS). Geographic Information Systems (GIS) will be used to extract and visualize the various indicators across the districts in SA.

We will enrich the health and climate data with a narrative that provides an interpretation of the data compiled by a health journalist in order to ensure that our information is communicated in an accessible manner and disseminated not only on our platform but via social media and news media outlets. In addition to this written narrative we will add podcasts to the conversation created with the often unheard voices in the healthcare system. The target audience of this podcast would include the voices of traditional health practitioners and community health workers who will provide a rich community-based context in terms of what they are experiencing in their communities. We envisage that our solution would provide an informative bridge in which leaders, planners and managers in the health sector, traditional health practitioners and community health workers are able to improve their way of working together in the planning and execution of equitable health services. The more easily accessible health and climate information will give communities an opportunity to obtain information which could aid them participating in decision-making processes that ultimately affect their lives. They can also use this information to advocate for equitable service provision in their area.

Overall, our solution will impact users of the public healthcare system in South Africa. We principally want to achieve this through promoting evidence-based decision making for those who are directly affected by how our public health system operates. The solution will promote improvement in the health of the 83% (49.9 million people) of South Africans who depend on the public healthcare system through better access to critical health data and information for better decision-making, planning, and service delivery.

Health leaders, managers, planners & policy-makers: By using the online DHB they will be able to access valuable and useful information for decision making and planning and save time not having to search across a wide array of sources to find the information they need. They can download useful graphs and tables for their reports and read the accompanying analyses to ensure allocation of equitable health resources.

Community accessing the public health sector: The community in South Africa do not have access to health service information other than through news articles and other media. Therefore, accessing the information on the online DHB will enable the community to source information relevant to their districts that can be used for advocacy and decision-making purposes. For example, they can see the number of facilities in their sub-district and where they are located, the immunization coverage or even key information on lightning strike occurrences or flooding in their area over the past year.

Community health workers and Traditional health practitioners can use the information to better plan for services for their communities by understanding which services to prioritize for their respective community’s needs.

Researchers and journalists can use the DHB platform as a valuable resource for researching and writing health related articles, and are reassured that all the information is current, accurate and validated.

Since its establishment in 1992, The Health Systems Trust has contributed significantly to the development of the South African national health system. Our strength lies in the knowledge, insight and experience we harness through synergizing our research and implementation outputs through close collaboration with the Department of Health, therefore our approach is highly consultative in nature across all the levels of the health systems including the communities we work with. Over the past 30 years these activities have provided a deep understanding of the needs within the South African health system. We have various projects that are entrenched at the community level where we are providing HIV and TB services where we have close ties to the communities that are directly affected by decision-making processes taken by health managers and policy-makers that we would be equipping with our platform. 

The DHB is designed in collaboration with the National Department of Health. Each publication involves continuous engagement with key stakeholders which entails the formation of a technical working group of managers from the National Department of Health, the Health Information Systems Program and the Health Systems Trust. This technical working group interrogates the current public health priorities of the country for that specific year in order to arrive at a consensus on which health indicators need to be included in the barometer for that year. An electronic survey is also developed and sent to various users of the platform where they are given an opportunity to rank the different priority areas to ensure the information the DHB provides is responsive to the needs of the users. This edition the DHB  will also include collaboration and consultation with the missing voices of the community, traditional health practitioners and CHWs.

The vision of our organization is improved health equity in a healthier Africa and our approach is based on the primary healthcare philosophy and generating evidence-based interventions as well as innovations for improved service delivery and quality improvement. In our quest to achieve this we have been supporting health systems in South Africa since 1992 however since we are a non-profit organization we are fully reliant on funding from donors in order to advance our work which is the primary reason that we are applying to this challenge. In the past this particular solution was funded initially by Atlantic Philanthropies and then by the South African National Department of Health. However, due to the need for the Department to shift funds towards the fight against the COVID pandemic in the country it has not been possible for the publication to receive government funding and our organization supported them in other ways. By applying to this solution we are also hoping to use the funding in order to obtain the technical expertise needed in order to transform our publication into a fully digital resource used by a wider audience with additional useful climate change indicators. We are confident in our publication and the need for this growth and are therefore also happy to co-fund a component.

We are also eager to also participate in the WFP Innovation Accelerator programme so that we may gain knowledge and expertise in how we can develop our solution.

Our solution is innovative in the South African context as there is no other resource like it that currently exists. Our platform will also be unique because there is no other platform currently available that houses indicators across such a wide spectrum (i.e. burden of disease, socio-economic, finance and environmental variables). The Health Department’s DHIS is not available to the public.  We envisage that through this platform, we are able to provide not only a useful range of aggregated health and climate change indicators, but also present analyses and interpretation in a manner that will enable users to engage with public health data in an inclusive and accessible manner through data visualizations that are easy to understand. We anticipate that the online and interactive DHB will be the go-to space for sourcing integrated information for decision-making and planning purposes across different sectors and for communities to have information for advocacy and resource mobilization purposes. Our solution will also be adaptable to evolve as we continue to consult with the various stakeholders in shaping the information and indicators presented.

In the short term we envisage an outcome of enhanced decision-making and use of information for planning with users being able to interrogate health and climate data. Indicators are used to inform equitable resource-allocation and policy decision processes with more inclusive public discourse on health and climate change related issues through the engagement by a wider audience from various sectors such as community health workers and traditional health practitioners.

The impact we aim to reach within 3-5 years is the use of the DHB as the preferred platform for health and climate change data for decision-making and planning will lead to improved quality and more equitable services in the public sector and a more proactive and informed response and understanding of the effects of climate change and health. Furthermore, with greater collaboration with other sectors such as housing and social development and agriculture, we hope that there will be increased room to study disease trends in relation to climate change and health. The relationship between temperature excesses (heat waves) and mortality due to respiratory and cardiovascular diseases and heat stroke is another example.

We will measure progress towards our goals using the following indicators:

• The number of users engaging with the digital platform and the number of downloads of the data from the platform which we will track using Google Tag Manager. This will enable us to understand what our audience is responding positively to which will aid our ability to continue to provide high-value content to our users.
• The number of citations will enable us to see to what extent academics/researchers are engaging with our work and in which way.
• The number of press articles referencing data and information from the DHB
• The number of multi-stakeholder engagement workshops held annually 
• The number of decision-makers and range of sectors represented at workshops will measure inclusivity and equity.
• Proportion of positive feedback surveys completed by attendees will measure usefulness and acceptance of the information shared.
• Number of annual district health plans that use the DHB information for planning
• The number of email requests we get via our dedicated mailbox for more advanced analysis or queries on the information presented on our platform will also enable us to determine whether people are engaging with the platform.
• Number of podcasts shared on the platform with community health workers and traditional health practitioners.

Our theory of change is grounded in the recognition that new approaches are required to assist users to more easily measure equitable primary healthcare performance. Furthermore, we will incorporate the often unheard voices in the public healthcare system who also have an influence on the health outcomes of the majority of the South African population who are seeking healthcare. Our long term outcome for this solution is improved quality and equitable services in the public health sector and a more proactive and informed response and understanding of the effects of climate change and health.

In order to achieve this our team proposes that the key drivers for change would be to:

1. Transform the current district health barometer into an interactive digital platform to support optimal PHC decision-making,
2. Upgrade the DHB to integrate health and climate change indicators,
3. Facilitate wide engagement with the platform ensuring increased access for key and vulnerable populations to interact with health and climate information.

A key requirement for the development of the DHB is the access to the DHIS data which is not publicly accessible. However, HST has been given access to this data for the past 17 years to produce the DHB and we are confident that we would be given continued access for the new platform. The climate change data are easily accessible through the free-to-download NASA Earth Observation platform. A key component of the platform is engagement with missing voices because there is a need for them to improve their understanding of health and climate change in relation to the communities for health service advocacy. We will be able to collaborate with the missing voices through our already established community linkages in our health systems strengthening projects.

The selection of indicators will be conducted in collaboration with various stakeholders (NDoH, policy-makers, academics, planners, healthcare workers and researchers) that comprise the Technical Working Group which is formed on an annual basis. The data will be analyzed and visualized with an accompanying narrative for each indicator to provide key insights. Previous publications included information on a wide range of health services and encompassed 30 indicators. These indicators covered areas such as:

• Reproductive, maternal, newborn & child health
• Infectious disease control (HIV & TB)
• Non-communicable diseases
• Service capacity and access
• Universal health coverage
• Burden of disease

Our solution will work with stakeholders, who we already have established linkages with, in conjunction with new voices in the form of traditional health practitioners, climate experts and community health workers, in order to ascertain which areas should be prioritized on our digital platform. Our solution proposes that we will see improved health outcomes in our communities when the indicators are used to inform equitable resource-allocation and decision-making processes by policymakers and the public who could use the health and climate information to influence their behavior in relation to their health outcomes and climate-related event exposures such as flooding and air quality. 

Our solution will be powered by a business intelligence tool called Tableau that can be accessed through a web browser or mobile device via a guided analytics story design. Tableau is a visual data analytics platform that improves the flow of analysis and makes data more accessible to people through visualizations. Our organization has been using Tableau to produce visualizations for our publication however we will now be tapping into its interactive and digital story design capabilities to share our solution. Instead of building a custom website that would require a lot of money we are going to leverage Tableau's embedded analytics capabilities to integrate the data visualizations we build into our current website. By integrating a widely-used leading analytics solution we will be able to develop and launch our solution much quicker and with less costs. We will procure two Tableau Creator licenses which will be used by our data scientists. Users of our platform will be able to export the data they are interested in as spreadsheets for their own use and credit our system as a source.

The primary healthcare data is collected at facility level by the Department of Health’s data capturers who are stationed in the facilities. Data is collected directly in the clinics from patient files and uploaded to the District Health Information System (DHIS). The Department of Health have over the past 17 years provided HST with permission to access the DHIS data, provided the indicators are presented publicly as aggregates at sub-district and higher levels.

The Health Systems Trust is committed to gender equity and takes the ultimate goal of gender equality into account in its employment strategies when designing and implementing health and development projects. We aim to provide equality and fairness in all of HST’s endeavors. Our current employment status is reflected in HST’s staff makeup as it relates to the demographics of South Africa’s population; embracing disadvantaged groups, LGBTQI populations and disability. Furthermore, 78% of management positions across the organization are occupied by women. The team for our solution is predominantly made up of women, with the lead (project manager) being a young black woman. HST’s work is effected through an equity lens and includes services and support to pregnant women, children, adolescent girls and young women (AGYW), men, older people with comorbidities, rural and economically disadvantaged communities and people with disabilities.

Our solution will provide easy access to comprehensive key health and climate change information that is not currently available on any public platform in South Africa. Our platform will be web-based and accessible via mobiles. We will also be utilizing a dedicated mailbox where people can send in further requests for information related to the content presented on our platform. All the information on the site will be available for free but we will charge a fee for service for requests to do more advanced analyses with the available information. We will also be hosting information and policy briefing workshops held with various governmental departments to facilitate collective decision-making, communication and planning. Through targeted marketing, workshops and the utilization of popular engagement platforms (i.e. social media and podcasts) we will increase the visibility and hence the users of the platform. This will enable us to continue to source funding from stakeholders for not only the maintenance of the platform but also to enhance its offerings as the platform expands with use.

Over the years the DHB has been funded by the National Department of Health.  We believe that once the DHB has been transformed to a digital platform and has been adequately demonstrated and marketed to the Department, this will entice their use of the platform on a regular basis for decision making and planning and they will be inclined once again to fund us to continue the work. In addition to that we will also continue to seek other funding sources and submit proposals to other funders. We will also be charging a fee to those that want more advanced analysis of the information presented on our platform as a form of revenue generation. HST is also prepared to self-fund part of the deployment of our solution.

Funded by the Atlantic Philanthropies, the DHB began as a pilot project in 2003 as a unique publication which provided a visual representation of a selection of health indicators that demonstrated how well and equitably the public health sector provided primary health care to the population across all its districts in South Africa.

The publication was well accepted, expanded its presentation of information and gained traction with the target market (Department of Health Managers). The Atlantic Philanthropies continued to fund the DHB for the next 5 years (2005-2010) at approximately $136000 per annual publication. Thereafter, the National Department of Health was approached to fund the Barometer as they used the information extensively for their planning purposes (annual district health plans). The Department funded the DHB for the next 9 years between 2011-2020 at approximately $166000 per annual publication. Rather than accessing a hard copy publication for information, and with the advancement of technology and the speed of decision-making, it is felt that the National Department of Health would be more inclined to fund and use a digital resource in the future.