Establishing One Health Surveillance Platform for Electronic Integrated Disease Surveillance and Response in Malawi: Action Design Research Study

Abstract

Background: Facing the threats of emerging and reemerging health issues requires One Health surveillance systems to provide information for integrated responses. Malawi started enhancing the electronic integrated disease surveillance and response (eIDSR) system in 2015, progressing with the aim of developing a One Health Surveillance Platform (OHSP) using District Health Information Software 2 (DHIS2) as its technical backbone, thereby supporting the COVID-19 pandemic response more resiliently and impacting the integrated disease surveillance and response (IDSR) performance. Digital solutions are critical components of One Health surveillance; however, evidence of the successful establishment and implementation of adaptive digital One Health surveillance systems is scarce.

Objective: This study aims to report on the establishment of the OHSP in Malawi and how an adaptive digital health solution contributed to strengthening and impacting the country's eIDSR during the COVID-19 pandemic and beyond the pandemic.

Methods: The establishment of Malawi's OHSP was based on the action design research methodology with a transdisciplinary approach. The core team reflected the multiple iterative processes of building the OHSP and formalized its impact on IDSR reporting quality.

Results: The OHSP core team conducted multiple iterative cycles to build the platform, leveraging lessons from previous eIDSR pilots, reusing digital health infrastructure, and developing DHIS2 digital solutions in 2019, right before the COVID-19 pandemic. The initial establishment was to cover 48.3% (14/29) of the country's health districts. Pivoting from the initial plan as the COVID-19 pandemic emerged, the core team swiftly adapted the OHSP to scale up nationwide and assisted the health system in responding to the pandemic. The pandemic shock resulted in a national scale-up of the OHSP and impacted the national weekly IDSR reporting quality from nonexistence in 2015 to 97.8% and 74.5% for completeness and timeliness, respectively, in 2024.

Conclusions: The establishment of the OHSP significantly bolstered the surveillance function for weekly IDSR reporting. Government leadership and good coordination were key to success. Continuous capacity building, enhancement of community-level surveillance with digital innovations, adaptable technical infrastructure, and a reuse strategy can provide long-term sustainability for One Health surveillance. Malawi's experience may apply to other countries with demonstrated value of resilient, government-led digital health interventions. Future efforts should focus on improving interoperability with other One Health domains and investing in infrastructure upgrades with local leadership and domestic funding to prepare for future emergencies.

Keywords: DHIS2; District Health Information Software; IDSR; One Health; One Health surveillance; adaptive digital health system; eIDSR; integrated disease surveillance and response; pandemic preparedness.