Qualitative findings on factors influencing the sustainability of the MCBR system were grouped into three broad themes – individual, technological and management factors [16]. In addition, significant sub-themes were identified (Fig. 2). A summary of key findings on the factors and recommendations provided by study participants is given in Table 2 and Table 3, and are discussed in detail below.
Table 2
Summary of key findings on the factors influencing the sustainability of the MCBR system
Major themes
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Sub-themes
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Findings
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Individual factors
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User satisfaction
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- Technological constraints make users unsatisfied
- Diverse ideas of user preference over PBR and MCBR systems
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System access
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- Technical problems with supported mobile phones
- Data managers lacking suitable computing devices for data access and management
- Financial and logistic burden of mobile phone maintenance
- Financial unsustainability of mobile phone-related costs, especially for national scale-up
- Insufficient mobile internet access
- Areas without internet access to be left out in national scale-up of MCBR
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User support
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- Poor IT literacy of the ICMVs
- Not enough training for ICMVs and stakeholders
- No proper user support system, especially for troubleshooting technological problems
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Technological factors
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System interoperability
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- Use DHIS2 platform endorsed by Myanmar MoHS
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System scalability
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- Financial and technological constraints for nationwide scale-up
- Basic health staff suggested as potential MCBR users
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System relevance
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- Data elements of MCBR reflect those of PBR
- Job-aid function helps ICMVs follow national malaria treatment guidelines
- Stock management module not covering all stocks
- Missing auto-alert system for positive case notification
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System quality
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- Simple, easy to use, and potentially timely
- Software bugs and errors, unsatisfactory system response time, unpredictable and unreliable outcomes
- Inconvenient data management
- Unsatisfactory output data quality
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Technology sustainability
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- Concerns with maintenance and improvement of mobile application (software)
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Management factors
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Ownership of the system
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- NMCP to take sole ownership of the system
- IPs thought NMCP is not currently ready to take over the system due to many constraints
- NMCP believes it is already in position to take over the system
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Human resources
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- Dropout of ICMVs trained for MCBR
- No separate focal person to manage MCBR at all levels in both NMCP and IP
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Policies and operational procedures
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- Lack of standard procedures and policies for proper operation of MCBR
- Mobile phone-based reporting not possible in non-government-controlled areas because of local security issues
- Concerns over standalone use of MCBR without physical documents for future reference
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Financial sustainability
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- Completely donor-funded currently
- Uncertainty about financial support after 2023
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Applicability of MCBR data
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- NMCP and IP do not apply MCBR data for practical applications, relying only on PBR data for such purposes
- Doubtful effectiveness of MCBR for malaria elimination due to many constraints, despite its potential
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DHIS2 – District Health Information System 2; ICMV – integrated community malaria volunteers; IP – implementation partner; IT – information technology; MCBR – Malaria Case-based Reporting (system/application); MoHS – Ministry of Health and Sports, Myanmar; NMCP – National Malaria Control Program, Myanmar; PBR – paper-based reporting |
Table 3
Summary of recommendations for sustainability of the MCBR system as proposed by the study participants
Themes
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Recommendations
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General
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- Resolve all, or at least some, of the existing technical and operational challenges
- Develop and apply policies and standard operating procedures for proper operation of MCBR
- Develop a proper sustainability plan for MCBR
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Better user support
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- Support better mobile phones for ICMVs, and computers or tablets for data managers
- Conduct additional MCBR training for all NMCP and IP stakeholders; conduct additional MCBR and mobile phone use trainings for ICMVs
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Better workforce
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- Deploy a dedicated focal person for managing MCBR at each level
- Deploy a well-functioning user support system with an IT technician in each township or at least in each district, or empower township level staff with MCBR-related IT capacities
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Technology sustainability
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- Approach Myanmar national experts to manage future upgrades, updates, and modification of the system
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Financial sustainability
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- Apply alternative models for system access like “bring your own device” in which the MCBR application is installed on the ICMV’s own mobile phones
- Myanmar MoHS to secure funds for MCBR once (if) support from international donors ceases
|
ICMV – integrated community malaria volunteers; IP – implementation partner; IT – information technology; MCBR – Malaria Case-based Reporting (system/application); MoHS – Ministry of Health and Sports, Myanmar; NMCP – National Malaria Control Program, Myanmar; PBR – paper-based reporting |
Individual factors
User satisfaction
Both ICMVs and stakeholders believed that MCBR would fulfil the purposes they want to achieve with malaria case reporting, especially regarding its timeliness, simplicity, ease of use, and requiring no physical transportation for reporting unlike PBR; in addition, they stated that their use of this modern technology improved their social status. However, they also reported many challenges in using MCBR, such as dependence on internet access, software errors, and data synchronization problems [13]. Among ICMVs, this induced anxiety around their work performance and that of the system, leading some users to feel unsatisfied.
Whilst many ICMVs wanted to continue using MCBR if the existing challenges are resolved, others reported that they preferred to use PBR. A few ICMVs reported they liked the idea of using PBR and MCBR in combination, whereas others disagreed because of the added work it created.
Similarly, none of the MoHS and implementing partner stakeholders wanted to discontinue either the MCBR or PBR systems, although they reported technological and operational issues in using them. Although some stakeholders expressed a strong preference for MCBR, provided that the aforementioned challenges are resolved, some stakeholders expressed a preference for PBR, reasoning that it is the most efficient reporting system in the current context.
PBR system is the most efficient one.
PBR has been used for a long time and familiar with both ICMVs and higher levels
“PBR has solid documents and is auditable.”
PBR system is [the only] convenient channel.
PBR is the only available and possible method to use in their area.
(NMCP and IP stakeholders)
Although there were diverse ideas on the standalone use of the PBR and MCBR systems, some stakeholders acknowledged the use of both systems during the transition to an all-electronic mHealth system in the future may be necessary.
System access
Since the roll-out of MCBR, the NMCP and IPs have provided the ICMVs with Samsung Galaxy J1 or Samsung J2 mobile phones with a SIM card and the MCBR application already loaded. According to ICMVs, they were supplied with mobile credit of between 5,000 MMK (~ 3.5 USD) per three months and 10,000 MMK (~ 7.0 USD) per month. However, the ICMVs raised several complaints about the phones, such as small screens, batteries draining too quickly, and poor performance which worsens with time; it was claimed these problems hampered their MCBR reporting considerably.
An NMCP stakeholder reported that data managers who access and manage the data reported through the MCBR system are not equipped with suitable computing devices, such as laptop computers or mobile tablets. Currently, they access and manage large amounts of MCBR data through mobile phones, which is impractical.
“There are, let’s say, hundreds of blood tests reported from one township. So, it is not an easy task to access all these data using a mobile phone.” (Project manager level stakeholder, IP)
Moreover, ICMVs working in the field expressed concern regarding potential loss or damage of the mobile phones, which they did not consider to be their own property, and many ICMVs reported losing or damaging their mobiles. They called for protective accessories like phone cases and waterproof bags.
Stakeholders expressed their concern about the sustainability of supporting mobile phones costs, including mobile handsets, phone credits and maintenance fees. They claimed that the cost is high, and it burdens the supporting organizations in the long run, particularly when the MCBR system is scaled up nationally.
“The office had prepared an additional ten percent stock of mobile phones as a buffer. But we have already consumed this buffer stock and no more lost or damaged phones could be replaced.” (Field supervisor level stakeholder, IP)
With the intention of ensuring sustainability, many stakeholders proposed other models like “bring your own device” where the MCBR application would be installed on the ICMVs’ own mobile phones (if compatible), potentially freeing up budget to support mobile phone credits. Some IP stakeholders reported that they already used this model when they were unable to support any more mobile phones for the ICMVs for MCBR.
“As more and more volunteers have their own phones, volunteers use the app [MCBR] in their own phones.” (Program manager level stakeholder, IP)
Another major concern for MCBR sustainability raised by the ICMVs and stakeholders was mobile network coverage. Despite significant expansion of the network in Myanmar during 2014–16, many ICMVs claimed that insufficient mobile internet access made timely reporting via MBCR impractical, and resulted in additional costs for the ICMVs to travel to places with internet access.
“I cannot upload the data because mobile internet signal is poor in my village. I need to go to the place with a better internet access.” (ICMV, Kayin State)
Mobile internet access problems were identified by ICMVs and stakeholders as a main contributor to data synchronization problems and poor data access in the MCBR system. One stakeholder reported that although MCBR was largely implemented in a remote area, it was not successful because of limitations in mobile internet access. Some stakeholders pointed out that even if the MCBR were expanded nationwide, some ICMVs in remote areas would be unable to use MCBR because of unavailability of mobile networks. Therefore, MCBR can be expected to operate in these areas only after the establishment of a stable mobile internet network.
In addition, electricity is not available from the national power grid in some remote villages; their main power sources are solar panels and generators. ICMVs requested support for power banks and solar panels, especially those living in remote areas.
User support
Another major barrier to MCBR use is the poor information technology (IT) literacy of the ICMVs. Some had never used a smartphone before. All MCBR users received training on the MCBR application, including some basics of mobile phone usage. However, some ICMVs and stakeholders reported that the training they received was inadequate. They wanted additional training, such as refresher training on MCBR, training on mobile phone use for ICMVs, and specific training for supervisors, data managers and monitoring and evaluation staff of NMCP and IPs.
The first contact point of the ICMVs for IT troubleshooting is their peer ICMVs and their immediate supervisors, who are usually township level staff, although some ICMVs contact regional-level staff for troubleshooting. The regional-level stakeholders preferred that ICMV troubleshooting of IT issues occurred first at the township level. They voiced the need to build the capacity of field supervisors to solve MCBR-related IT and data management issues. Moreover, it was also pointed out that, for transformation into a well-functioning eHealth system, including for proper management of the MCBR system, at least one IT technician should be deployed in each township, or at least in each district in addition to existing staff.
“We need to do capacity building to township (malaria) focal persons to upgrade their skills. If we can do so, it would be better for MCBR.” (Regional officer level stakeholder, NMCP)
Technological factors
System interoperability
One program manager-level stakeholder noted DHIS2 is an MoHS-endorsed platform, which creates potential for the MCBR system to interconnect with other disease control programs.
“One of the good things about MCBR … it’s basically DHIS-2, which is the chosen platform of the Ministry of Health. So, I think that is a really big plus, because all of the data is going into a system that will be sort of standardized in the way that the ministry wants it.” (Program manager level stakeholder, IP)
System scalability
Most stakeholders claimed that it was possible to scale-up the MCBR system nationally, and some even showed their eagerness for it. However, stakeholders had concerns about the financial and technological constraints which could be exaggerated with national scale-up.
“MCBR still has problems in field implementation. … If we nationally scale up the MCBR, the situation would be worsened in some townships. … So, we better solve current problems and upgrade the current application into a stable one. Then we may think about the national scale-up.” (Team leader, NMCP)
When considering expansion of MCBR to other users, many of the stakeholders mentioned basic health staff such as Midwives and Public Health Supervisors-2, whose geographical coverage and consultation numbers are generally higher than those of the ICMVs. Nevertheless, some stakeholders were afraid the introduction of MCBR would be an additional burden to the basic health staff, who are already busy with many tasks. Conversely, some stakeholders think using MCBR will reduce the burden of their paperwork.
System relevance
The data elements and job aid function of MCBR aligned with the standardized carbonless malaria register and national treatment guidelines, respectively. Both ICMVs and stakeholders reported that it was useful for the ICMVs to follow the national malaria treatment guidelines, and that the data reported through MCBR were in line with the existing data requirements. However, the ICMVs wanted a stock module of the application to include all types of supported stocks, such as paracetamol tablets, multivitamin tablets, and oral rehydration salt packs, in addition to the antimalarial medicines and malaria RDTs.
Many stakeholders suggested that supervisors are not constantly monitoring the DHIS2 database to recognize when a malaria positive case is reported, and called for an auto-alert system in the MCBR, enabling responsible supervisors to be notified directly (e.g., by SMS) when an ICMV reports a positive case through the MCBR application. The lack of such an alert system was criticised as a weakness in reaching the goal of real-time notification and reporting of malaria cases. Currently, MCBR users call their supervisors on the telephone to provide urgent notification of malaria cases.
System quality
Although the ICMVs appreciate the MCBR application for its simplicity and ease of use, many complained that delivery outcomes of their report in MCBR were unpredictable and unreliable, and they sometimes need to confirm delivery status by other methods such as direct phone calling. The stakeholders also reported that the quality of the MCBR data in the DHIS2 database was unsatisfactory [13], undermining its further applicability for program implementation. However, many of the stakeholders expected data quality to improve.
Technology sustainability
Although none of the stakeholders expressed concerns about the technological sustainability of the DHIS2 platform, many higher-level stakeholders were concerned about potential dependence on international software developers for technical assistance, including maintenance and further improvement of the MCBR application. In the long run, such dependence would be burdensome for organizations supporting the use of MCBR; the problem could be resolved if Myanmar national experts could manage the system.
Management factors
Ownership of the system
The stakeholders perceived that everyone working with the MCBR system at different levels – including ICMVs, NMCP and IP staff, policymakers and software developers – shares responsibility for its sustainability. However, all NMCP and IP stakeholders agreed that the NMCP should ultimately have sole ownership of the system. On inquiring about the readiness of NMCP to take overall ownership of the MCBR system, some NMCP stakeholders reported that they were confident to take over MCBR because NMCP had set up its own server, recruited the required number of personnel and trained them properly.
“So, with our current conditions, it is possible (for the NMCP to take over the MCBR ownership). First, the server is ready. Next, the manpower. In the townships where the MCBR is operating, we have already appointed data focal persons such as data assistant. Team leaders and regional officers have received trainings for MCBR.” (Team leader, NMCP)
Nevertheless, IP stakeholders suggested that NMCP ownership is currently impossible, and that the NMCP would require more time to completely take over MCBR given current human resources, technical, technological, and financial limitations of NMCP, although its capacity is improving.
“I definitely think it's possible [that NMCP totally takes over MCBR]. Like I said, it's just about making sure the requirements [for managing MCBR] are known and that they're ready to take over. … I think we need to do it carefully in a planned way, in a phased manner, which is what we're trying to do.” (Program manager level stakeholder, IP)
Human resources
Although some NMCP stakeholders reported they had the required human resources, other NMCP and IP stakeholders reported human resource problems regarding the MCBR system, such as attrition of trained ICMVs, and inadequate number and capacity of personnel at the management level. NMCP and IPs lack dedicated focal persons for managing and monitoring the MCBR system at all levels. Instead, the focal person for the PBR system is responsible for managing the MCBR system, including monitoring, supervision and providing feedback to all respective ICMVs. In the NMCP, some of the ICMV supervisors have to take responsibility for other vector-borne disease control activities. They cannot focus on MCBR during the rainy season, because they need to work on outbreaks of other infectious diseases, such as dengue.
“If we can have a separate person for this purpose [for monitoring the MCBR system], it would be better. … Now the existing staff here have to do these [MCBR-related] tasks. In the dengue season, the malaria positivity is also high. Then, we all get crazy.” (Regional officer level stakeholder, NMCP)
Both NMCP and IP stakeholders pointed out that a dedicated focal person for managing MCBR is necessary to maintain the database and to make sure everything is really working in the MCBR system. The NMCP stakeholders stated that, for NMCP, it is preferable that this focal person be an internal staff member rather than a seconded staff member, and ideally should be posted at the township level.
“The best situation is having an IT focal person in each volunteer-occupied township. … That’s why I prefer to train our own staff who are young and have familiarity with IT.” (Regional officer level stakeholder, NMCP)
Policies and operational procedures
Some participants highlighted the lack of standard procedures and policies to guide the proper operation of the MCBR system. Identifying the entity responsible for the cost of replacing or repairing a lost or damaged phone was also a common problem among the managing stakeholders. Without an agreed-on policy, the stakeholders had to balance the ICMVs’ careless use of MCBR phones against their reluctance to use the devices because of the potential financial burden on them. Currently, this problem is solved in various ways, such as ICMVs paying for phones they lose or damage, all peer ICMVs sharing the cost of new phones for ICMVs who lose or damage them, or, most frequently, the managing organizations paying for replacement or repair (creating a financial and logistical burden).
Another barrier to the geographical scaling up of the MCBR system is that armed forces who manage non-government-controlled areas reject implementation of the MCBR system in their areas because of local security issues associated with the use of mobile phone GPS capability. Despite these areas being high malaria transmission areas with many ongoing interventions, MCBR cannot be used to report these activities.
Although the ICMVs and stakeholders had diverse ideas about totally replacing the PBR system with MCBR, both expressed concern about using MCBR for malaria reporting without the physical documents associated with the PBR system and the loss of this reference source for data quality validation and donor audits.
Financial sustainability
Currently, MCBR is almost completely funded by an international donor agency, including the costs for its development, hosting and maintaining the server, procurement of mobile phones, and supporting volunteers with phone credits. Some stakeholders expressed concern about the sustainability of MCBR after 2023, when they believe funding may cease. Although some funding gaps are foreseen, stakeholders hope that MoHS will allocate some funds to ensure future sustainability of the MCBR system. However, a proper sustainability plan for the MCBR system is yet to be developed.
“… I know that the Union Minister [of MoHS] is very supportive of our electronic health information system. So, I hope that the ministry will be able to find some funds for sustaining the operation of MCBR in the future.” (Program manager level stakeholder, IP)
Applicability of MCBR system (net benefits)
All stakeholders reported that, for the time being, they could not apply the MCBR data from the DHIS2 database for their decision-making, resource allocation or program management due to poor perceived data quality [13].
On asking about the potential usefulness of the MCBR system to the malaria elimination program, some ICMVs reported that MCBR is an effective reporting method for malaria elimination, but some disagreed, mentioning factors such as the lack of timely positive case notification. Many of the stakeholders expected MCBR will become a better surveillance system for malaria elimination than PBR if current obstacles and constraints are resolved.