structures

reduction and a surprisingly short turn-around time to revise and resubmit ... leaving little or no room for negotiation backed by specific data. (Smith 2015; pp. 24 - 25)

Lack of attention to gender, equity and other inequalities in Malawian (and other) health system decentralization processes is significant.

'Gender responsive health systems' can be defined as health systems that 'address the gender determinants of health, the gender factors at work in the health system and the resulting gender inequalities'. Achieving gender-responsive health systems requires the integration of gender into decentralization processes and health system governance. ' (Pendleton et al 2015).

The WHO Health Equity Monitor states that: Monitoring health inequalities is essential for achieving health equity. Health inequality monitoring uses health data disaggregated by relevant inequality dimensions ... in order to identify differences in health between different population subgroups. Disaggregated data provide evidence on who is being left behind and informs equityoriented policies, programmes and practices.

2.4 Digital health in Malawi: national instruments and their relative attention to decentralized structures

Literature review

• Key documents relating to digital health are the National Health

Information Systems Policy (2015) + the Monitoring, Evaluation and Health Information Systems Strategy (MEHIS), 2017-2022.

The 2020-2025 National Digital Health Strategy has recently replaced the 2011-2016 National eHealth Strategy.

• The NHISP: guiding principles include the need to generate locally relevant data; disaggregation by sex, age, geographical areas, income groups so as to 'achieve greater equity, efficiency and quality'; development of data use; holistic approach; robust [e-Health] systems. Stated barriers to effective use of data include: vertical +/or parallel data systems; lack of interoperability; lack of data sharing; too few trained in data management.

• MEHIS (not solely e-Health): Reference to lack of co-ordination of MEHIS activities, e.g. multiple teams separately organizing supportive supervision and performance reviews. Despite recent efforts to harmonize systems, major weakness of the HIS is existence of vertical/parallel reporting systems. Development partner support concentrates HIS resources in individual programs, ignoring/weakening national HMIS. Despite such discussion, MEHIS does not refer to decentralisation in the context of digital data.

• The NDHS: this comprehensive strategy addresses Districts primarily in terms of resource gaps; ownership + leadership in relation to digital data receive minimal focus. No real discussion of the role of DHIS2; the same is true for decentralization + its ramifications + impacts.

• A Kuunika deliverable is development of Standard Operating

Procedures 6. MEHIS states 15 are to be completed; 12 are at various stages of development.

Key informant interviews

• Many of the key documents that are supposed to underpin digital data systems are great on paper but weak on implementation - and all too often far too ambitious in terms of indicators. This is especially true at decentralized levels. (National level key informant)

• There are now Government and MoH guidelines and strategies, but those tend to leave out the District level it's as though they are the 'missing middle'. But any national strategy needs to include all levels in planning for use of digital data, otherwise why bother to collect all that information? (National level key informant)

• There are documents, national strategies, the

MEHIS - but none of those really thinks about the role of the District, or the Health

Facilities. The focus is always on the national level, while most of the health sector work is in the Districts (DHO staff

6 See Annex 3 for full review of the SOPs specific to relative focus on decentralized structures and District role and responsibilities.

o None of the SOPs under development include detailed attention to decentralized health structures + the role of edata within such a system.

o Only two SOPs refer explicitly to Districts' roles + responsibilities: User Support and DQA.

o E.g. the SOP Guidelines for the Development and Revision of HIS Standard Operating Procedures (no number) defines what a SOP should be, their relevance. The section on roles + responsibilities does not include District structures, while e.g. development partners are addressed. Districts are not explictly mentioned as part of the 'secondary audience' for the SOPs, while donors, CSOs, universities, etc. are.

o There is no reference in any of the reviewed SOPs to Data

Clerks or HMIS Officers, the cadre of health worker who are tasked with data entry.

o SOP 11 - Introduction of new e-Health in the HIS landscape of MoHP Malawi sets out an MoHP defined hierarchy of expertise + 'end users'. Districts + lower levels are in the latter group. member, non-Kuunika District.

• One big thing Kuunika has done is to support the development of the 20202025 National Digital Health

Strategy. That's important and a major step. But it could have looked more at the

Districts, what we can't do, what we could do and how we get from A to B. (DHO staff member, Kuunika District)

The extent to which Malawi's digital data architecture and systems support effective collection and use of disaggregated data at District level - and why this is important - will be considered in the review of the District Implementation Plans (see 4.3 below).