 And the idea is to look into the future by way of the past, also, not really the future, but I mean, what can we learn today about what happened yesterday? And I was starting with the inspiration we had at EFI, at the university, where we had Christian Nygård and the Scandinavian approaches as part of our basic development of the EFI, in fact. And the key thing here was his and the Scandinavians approach to system development, which was focused on participatory design and democratic technology development. And there's some traditions back there from working with the unions. It was a project in the 70s with the Christian and actually which led to new working life agreements in Norway, where workers were then, from then onwards, allowed to negotiate the introduction of new technologies. Because at that time, workers and jobs were threatened by new technology. And a typical example is the graphical workers, typographical tools. And a big project in Sweden was linked to making new tools for the graphical workers then. And they developed many methods and approaches for participatory design. And what they actually wanted to develop is what suddenly was there, namely the desktop publishing. So it was not successful because it was overruled by development. Anyway, the hisp and the DHS approach was to adapt the Scandinavian approaches to the context of developing countries. And that was the starting point for the hisp project. And it was more to develop things in the south and empowerment in the south and actually health in the beginning. But health was where this could happen because the health sector is huge. And you have all kinds of use situations and it's very data intensive. So it's actually started in South Africa in that way. Just a couple of words about what is participatory design is on basic principles. Generally, it's about including future users in developing and designing the technical solution. And the idea is the democratic part is then that the future users should have a say in developing the technology. And be part of designing the future working conditions. And to involve users in all parts of the process. That's the key part. And mutual learning is important here in that you learn together while developing things together. And rapid prototyping or prototyping is a very important part of this approach in hisp. Where you can have many different participatory design techniques around developing a real system in real context. And to build working prototypes, that's actually the trademark of the hisp participatory design approach. And that can start with some low hanging fruits and make sure that there are some early results. And thereby learning by doing that's kind of how hisp has accommodated or actually adapted the participatory design approach then. So it started in South Africa when Mandela created, he became president and new South Africa, he was actually part of what was then called Reconstruction and Development Program through being a part. I mean I had a scholarship and worked with a and was actually staying in Cape Town and worked with the University of Cape Town and later also University of Western Cape. And through those contacts we became part of this new Reconstruction and Development Program. And information was seen as key. And the reason why information was key in the new South Africa was that it was a lot of differences and the opposite of equity in all respects between ethnic groups across geographies. And all those differences between racial and ethnic groups that you know and have maybe still remember from what you learned about apartheid. So local use of information was important because that was a way to empower the users, empower those who were kind of oppressed through apartheid. And that should now be empowered through being able to have, let's say, in local governance, that was the idea from the ANC at that time and translated into system development which was about bottom-up design and participatory design. And it was a lot of work, I mean it started in 1994, but the real first version of the database, DHRIS version 1 was tested and implemented around 97 and then in 98 it was a big push in many provinces from there on. And it's developed into national implementation around 2000. So it was a long process and important was that the participants in this process were from the beginning, a lot of people who have been in the anti-apartheid movement. So it was kind of a progressive movement and being part of this RDP as it was called and that was kind of an important part of how the gist of the HISP developed in the beginning. And one thing I became more aware of recently and I wanted to highlight was that the key part of the national health plan for South Africa, I mean the ANC, African National Congress, Mandela's Party's health plan that was to build everything on the foundation of the health districts. The districts were seen as the foundation for decentralized comprehensive primary health care and it should include the district authorities who should then coordinate and manage hospital services, health programs, health centers, community health, etc. And that was then the important part of the changes in South Africa to create these health districts that were created across all these old Bangtustans and homelands that we call these crazy things of the apartheid. And also then of course that's why DHS is called DHS district, but not only district, it's district health system in fact. So this is the background for the naming also and if you look at the visions of how these health districts should transform the health system. You see here just one example from the pilot project, one of the districts in the pilot, in the HISP pilot in the 90s, Atlantis, the typical system was that the data flows were only going out of the districts or no local use of data, it was kind of a very oppressive and depressive system because they were actually disempowered at the district level. In the old South Africa and the idea was then with by creating this district and you should change the data flows and and you should should focus on on say district database and and and district management. This was another old drawing from from the district approach and you see here that the idea was that all this different different programs data from the programs data from community data from from all the clinics, hospitals, all services that should should be integrated through this district approach and what we learned when we when we try to. Look closer at how the district used the HIS here just before the COVID started in Irwanda, Mozambique, etc. We saw we found actually that data was used but they were not really able to do these things of of. Combining data from different sources calculated calculating calculating indicates, etc. And I will come back to that that later I mean the facility profile is one one thing that is not that easy to to carry out in the current situation in the HHS and in the countries and maybe more importantly than that. We don't really have this cross program dashboards and we don't really have good denominator to calculate indicate so that is one of the reasons why I mentioned that it's possible to look into the past in order to learn what we can do now around. This exact this this area, so if we go back to the movement of the history and the details first version move to India and Mozambique mainly from 2000 and. Also other countries in in Africa from them because at the same time we were able to recruit a lot of his purse to a northern program for developing masters in Mozambique, South Africa, Malawi, Tanzania, Ethiopia, and Sri Lanka and a lot of students very enrolled in this this programs and. Once finished with their master they started with the PhD etc to run these master programs and all of these students were engaged in various starting various the tries pilots in in their home countries and in other countries so that's kind of a big, big, big movement, many, many pilots and. And but they were very difficult to to sustain and scale in countries in this pre online period, because of course this this were Microsoft office and standalone system and. Sometime around 2000 and a bit later. 2003 for something was a secret evaluation in South Africa and Mozambique with a I mean the enemies of the tries criticized it for not being treated and not professional etc etc which then led to. To the start of the details to the web based the details to and we actually created the open source master course at iffy in 2004, which then read a foundation for for the development of the details to. For a long time in fact. And at this period and the research and education and working with all these countries were very important part of what he's doing, and we had what we normally call. I mean the three pillars and one is to work and do research on on health information systems that is about integration standards architecture use of information for decision making etc. Then there is free and open source software. That's the DHS to and how to share it and how to include the groups in the countries his groups in the countries to take part in the development to the part take part in the implementation and of course education and research. The basis for for for the work at the university with masters PhDs training and courses etc. And what kind of emerge out of this situation and was that the DHS to actually got funded from ill to something called the sixth framework program in the in the. Around 2006 2009 or around there and we called it the business. And that was a building Europe Africa network in information system. I think it was. It was a requirement to have a fancy acronym and that was fancy enough. And the first DHS to started out with the overall conceptual design of the of the what was then the DHS 1.4 which was an overhaul of previous DHS one versions. And it was actually implemented first on a big scale in San Sebastian. Ola knows everything about it because he stayed there for one year and working in that program project. And when you come to the. DHS to the first pilot in Carolina in January 2006. And it's still I mean the improvement from the DHS. Microsoft standalone was not that significant in that there were no online web based system yet possibilities I mean the internet was not that strong. So the ongoing debate with Colin and the team in South Africa when they claimed that their standalone version was actually better. They were probably very right in that because for every every implementation you had to then implement servers etc in the PCs around in the district. So anyway it was. It was the DHS to it was very best. Although not having good enough internet to benefit from that. And at the same time then. We increased our profile significantly by working with the doubly show and health metric network. Which health metric network HMN was an important part in the development information system in the global south. Starting I think 2007 2006 until 2010 when it's 2010 I think it broke down because they were disagreeing between HMN and the doubly show who should get the money and all that so. But it did some great work during its existence and actually they they initiated and conducted assessment and strategic planning in 50 or more countries in Africa and all over the world. I think it's actually much more than 50 but Johan is the one who is actually knowing everything about that so we need to get the concrete figures from him. And that's an important part because we had our well-known hispish Ola Knut and Johan working with and at this HMN and doubly show. And very important also is that the HMN architecture was very well aligned with the digital to conceptual design so it was very easy when we got the question then in 2007. Whether we could use DHS to pilot this new architecture data warehouse architecture data repository architecture in Sierra Leone and of course we said yes no problem. And this is the HMN architecture which I think was extremely productive for for the DHS to roll out and scaling across the globe because it's it's it's very similar to to the conceptual design of the DHS to take data from different different sources. And you put it into a repository and you produce graphs and dashboards and all that and we produce this drawing then to show them that actually this was more realistic version of their own architecture. So I think that's that was a very, very important step forward and you can say that at this point in time. The standing of DHS 2 was quite significant. I mean I mentioned that we had people like Knut and Ola and Johan working in Geneva and was part of this and for actually some time and I think that this has been very important in the success of the DHS 2. And when HMN closed into having to close down then they declared the DHS 2 in Sierra Leone as a big success. Mainly maybe because they were not so many successes they had to brag about so they declared it anyway as success and when HMN closed down then immediately after that around 2010 11 or something. It was 50 at least 50 countries that were working and they had had their assessment and they were working on strategic plans largely based on this HMN architecture. And I think that that's also a very, very important part that for example what I will come back to later is that Kenya was one of the countries that has made their strategic plan and suddenly the old HMN etc disappeared and that was part of the reason why they came to the DHS 2. But at that time also we had a very close collaboration with other global health informatics actors like OpenMRAs, IRAs and others. We had in 2010 also interoperability workshop in Accra and where all these partners were, WHO, OpenMRAs, IRAs and others. And that was then the start of our collaboration with VAHO and Tomeka and basically based on the fact that he said that if Sierra Leone can implement DHS 2 then. Any country in West Africa can do that because if you remember back then at the time we implemented the DHS 2 in Sierra Leone. It was not long after the civil war and all this blood diamond stuff. So it was not a very conducive, generally speaking environment for system development. Anyway, so my reason for mentioning these different global issues and actors is if we go back to say look at the standing of the DHS 2. We can call it discursive strengths, discursive formation influence at this point in time at the start of what would be the big scaling up. We can say that the standing of the DHS 2 was in the global health informatics crowd. It was very high. They were working and having hackathons and interoperability workshops etc together in the country health authorities and the Ministry of Health. It was not that high but it was increasing and interestingly the donor community was very low. It was no donors funded the DHS 2 or his for anything like that at that time. This EU, this framework program, which was not linked to it was research and it was not linked to the donor community at all. So I think that is interesting. We can look at how we sit now. I think maybe the global health informatics crowd. Our standing there is considerably lower now than it was then but in the donor community, very high. So it might be interesting to see how these different measures of discursive strengths or standing is developing through time and maybe there are 400 for what will come later. So my reason for mentioning is it might be very important to work to strengthen our standing or discursive strengths in the global health informatics crowd, which is a lot of fighting there now. Of course, at this time, we're talking here that was the aggregate data where so we didn't fight over the same turf. So I think maybe that is why the fighting is a bit harder now where the tracker and all that. So anyway, that's another discussion. Interesting things happened at the time of the implementation in Kenya, which everybody have heard about. But what happened was that cables around Africa finally came and we were actually, for the Kenya project, we got an invitation from Kenya, from Danida in the end of 2010. Then we went Lars and I and Ola also to Kenya and we worked with the Minister of Health in Kenya. But still, it was not yet the vision of having an online DHIS2. So when we started to set up the DHIS2 in Kenya and we wanted to actually test the internet, the idea was to have standalone implementation across the country. We went to a neighboring small town and tested it in the hospital and we were testing the internet and launched the DHIS2 and it worked fine. But suddenly we saw that it was a power cut and after the power cut it didn't come up again and we just realized that it was not possible to implement online. And we were just on the way out when it was actually a Japanese volunteer that was with us and he said, why don't you use this? And he put up what turned out to be what he called a dongle and that was connection to the mobile internet and we plugged it in in a laptop and fired it up and it worked perfectly. And then first they realized that it was possible to do this online implementation in Kenya and in Africa and what had happened was that they had pulled the cable from Mombasa up to Nairobi just immediately before our test here. Over the next month the people were testing the internet all over Kenya and it turned out to be very fine and then the DHIS2 was implemented in Kenya and that was actually what triggered a lot of work. And it was a lot of work actually the whole with Lars and the whole team moved literally to Kenya and followed up 24-7 over quite some time over the whole 2011 to get the implementation right because Danila was pulling out so they really wanted to finish everything over the first year. And that was what happened and also had the first DHIS2 Academy in Mombasa and that helped scaling to other countries like Uganda, Uganda, Tanzania, etc. So important in this scaling was that the work with West Africa, that's wow and the ESC, that's been very important in enabling the implementation all over West Africa and all over East Africa for example working with ESC. They said, but Burundu hasn't implemented DHIS, we will help you to implement DHIS. And in East Africa, Tomé is Portuguese speaking, he has been irritated for a long time over the only country in West Africa not using the DHIS2, that's a cap word. And finally he managed to get it implemented also in cap word from a couple years back. So this regional approach has been extremely important in scaling of the DHIS2. And this is just a map showing the different regional HISP in West Africa, South Africa, East Africa, India and in Vietnam and Sri Lanka. So the regional approach has been important. And I just wanted to show this kind of development in Africa, maybe people are not fully aware. I said that when we came to 2010, we had a very strong standing in the HMN and people were making the strategic plan all over Africa etc. But at the same time, we had a mobile explosion with the subscribers in Africa, you see here, increasing 2008, 9, 10. And then we have the bandwidth in Africa, also increasing around 2010, 2011. And of course then we have the implementations of DHIS2 which is kind of directly correlating with the bandwidth. But without the strong standing and the HMN and the fact that all countries were making their plans on the one hand. And on the other hand that we have been struggling with the DHIS2 in the most difficult context in Africa like Sierra Leone and also in India for already many years. All this made it possible to hit the ground running as one might say. And to fully use the opportunity by the new internet revolution. And just a little comment on the principles we developed a couple of years back to put it that way. I think it's very, very recent. And I wanted to mention it now that free and open source software and training and education material is a very, very important part of the DHIS2 community principle. I think it might be important to highlight that now that we get all these other software applications and systems and what you have all calling themselves global goods. I think it's important to highlight that we are actually not only global goods, we are free and open source. So that's one thing and then now I'm probably community etc. But another thing which I will come back to now is that important is the developmental approach to capacity building and research and to engage users, his groups and others in action research. And then I turn to current challenges because we have a new project in his pen that is to work on improving data use, assess what might be improved, what is wrong and what can be better. And we started out before this COVID thing and had an assessment in Mozambique, around Tanzania, Kenya and also in Laos and Indonesia. But particularly East Africa showed that the DHIS data was used but DHIS2 dashboards and visuals were not used. Why? Because it was of many things but denominated data were always problematic to get for the facilities and what we can call last mile features, they are not there. I mean what makes it possible to really use the dashboards. So the new project is to revitalize the participatory design and what we can call the district data use by follow up countries and support countries and also to see how we can engage countries in action research. And to collaborate and support app development where roadmap is too slow and not precise enough and to help countries to build apps, that's the idea with this. Because if you look at the general picture of the development of participatory design in DHIS2 is that you have local use and participatory design in the country and then your feedback via the roadmap etc. Your new requirement is coming in the next release etc. What we have seen is that this is too slow to really help action research and participatory design when you are stumbling in something concrete and that's where this custom app development comes in which we will try to work on and support countries in doing. And we also have a design lab at EFI with students etc. that we will try to involve in that. Just a few examples from our assessment. This is just an example of what is used at the district level in Mozambique in our district we visited. And they were all in all their kind of dashboards and displays they used Excel they took data from the DHIS2 copied downloaded. And put it into Excel and why why not dashboards why why why can't we use that directly in DHIS2 because denominated data and target data is not in the DHIS2 because it's kind of contested. I mean budgets are made based on that and you can't really change it so that is a big problem denominated data is a big problem. Same in Rwanda they have routine monthly data use and evaluation meetings in districts hospitals health facilities every month they are meeting and they are discussing data. How is DHIS2 what can be improved that was our question data from DHIS2 is everywhere but DHIS2 dashboards and analytics are not really being used. Again the problem is denominator and target data for the facilities is a recurrent problem and reason here is not politics but facilities have their own data or target data and they are kind of crossing numerator areas etc. So it's always a bit complicated that's a typical last mile thing to make sure to have this and obviously we should make it easier for locals to operate with alternative denominated data. And we have a group what so group working in Rwanda now and discussing features a lot of the requirements is about adding text and reports and calculating indicators etc. We see that custom apps are possible to develop on many of these issues but many of these things cannot really be made a feature in the DHIS2. This is one example where it's not so easy to make a generic feature in DHIS typical example of a last mile problem where what they want they want to mix colors and texts in a table. So that's the challenge then to maybe make and also to make reports etc. So that's one of the challenges we will work on with the design labs and to support countries to develop custom apps.