Harari Region’s Experience Implementing an Electronic Community Health Information System (eCHIS)

In 2019, in an effort to strengthen evidence-based decision-making and health system performance, the Ethiopian Ministry of Health (MOH) launched an electronic community health information system (eCHIS). The mobile platform and tools improve data quality and accessibility for decision-making at the community level, improving service delivery for community members. During its first rollout, which was part of a larger effort to digitize the country’s health information management system (HMIS), eCHIs was implemented in more than 1,000 health facilities across the country. Observing the benefits that it brought to these sites, including improved performance of health extension workers (HEW) and enhanced referral linkages between health posts and centers, the MOH expanded implementation, which included the Harari Region in eastern Ethiopia in May 2021.

For implementation in Harari, the MOH and the JSI-led Ethiopia Data Use Partnership (DUP) conducted an eCHIS training-of-trainers (ToT) for 16 supervisors from the region’s Planning, Monitoring, and Evaluation Directorate, health promotion, and disease prevention departments, and woreda health offices. Subsequently, this group of people provided implementation and application training for 70 HEWs, supervisors, and leaders between May 27 and June 5. In addition to familiarizing the wider regional health workforce with the digital health tool, the training sessions also served as an implementation planning platform.

Prior to wrapping up regional capacity-building efforts, the MOH and DUP organized a one-day orientation to raise awareness among the regional health bureau (RHB) senior management team and ensure a common understanding of the next implementation steps, which enabled the RHB to develop and roll out a targeted plan to implement eCHIS in 26 health posts and 9 health centers. The first task was to register profile information on all households and the population in the eCHIS app through a 30-day campaign, which started in July. DUP led and coordinated the resource mobilization efforts. In support, the MOH, in collaboration with its health information system partners including the USAID Digital Health Activity, provided 87 eCHIS tablets along with power bank tools. “Implementing partners have been very useful in health information system implementation. DUP has remained a trusted partner and played a unique role in organizing and executing this campaign,” said Fathi Mahdi Idris, deputy head, Harari health bureau.

Regional health workers were grouped such that each campaign team comprised a diverse group of experts from different units, including information technology, health programs, HIV, etc., who were also heavily involved in the campaign design and inception phases. Besides the diversity of health workers involved, the commitment and engagement of RHB leaders were crucial for closely monitoring and supporting household registration and soliciting implementation coordination and support from political and community leaders at various levels. They also devised strategies to efficiently collaborate with different actors at regional, district, and community levels, which reduced implementation hurdles and smoothed the overall processes.

By July 20, 2021, the Harari RHB started digitizing family folders. Teams traveled from house to house, talking with community members and registering their profile information by day, and entering and synching the data to the central eCHIS server by night. As the teams conducted home visits, many community members, including pregnant women who had gone without antenatal care services and others requiring essential health services, were linked to the care they needed. Leaders reviewed and evaluated team performance and gave feedback through a Telegram group created to certify and accelerate information exchange among those involved in the campaign.

Household and population profiling concluded on September 5, ahead of the allotted time. Of the region’s 26,276 households, 25,112 were registered, as were 99,181 (99%) of its 99,848 people (this rate was the highest of any region in Ethiopia, including those that started using eCHIS in 2019). “Completing registrations within the planned period is very impressive. It was a new record and experience for us. An important lesson we go home with is that we can achieve a lot more than what we have accomplished if we are able to act in unison towards a common goal,” said Mr. Idris.

The following factors also contributed to Harari’s success:

• Strong leadership engagement and support. Leaders at all levels of the region’s health system supported the plan and were actively involved in the planning, preparation, and implementation process. Political leaders at different levels also demonstrated commitment by assisting and availing crucial resources to see its fruition.
• Highly motivated and determined campaign teams bolstered by daily monitoring and feedback mechanisms. Team members worked overtime, traveled to remote places, and performed laborious tasks under harsh conditions, but still produced high-quality work in less than the allotted timeline. Team performance was evaluated almost daily, where data quality was verified, mistakes corrected, and challenges addressed. Evaluators used a messaging app to publicly rank teams and acknowledge the best performers, which energized the teams to achieve more. “Regular feedback and acknowledgment from the leaders have been very motivating. Daily best performer recognition and a thank you message also yielded a positive competitive spirit that incentivized the teams to do more,” said Mohammed Muhadin, a representative of the Planning, Monitoring, and Evaluation Directorate.

The lessons extracted from the region’s eCHIS implementation demonstrate the significant influence of leadership commitment and ownership on staff engagement and resource availability. Creating a culture that incentivizes and encourages high performance is another lesson that could be expanded on further and applied to other efforts in the sector seeking to digitize health management information systems and incorporate digital health tools to improve health outcomes.