Health professionals' experience on District Health Information System (DHIS2) and its utilization at local levels in Gandaki province, Nepal: A qualitative study
Prakash Raj Bhatt, Rabindra Bhandari, Shiksha Adhikari, Nand Ram Gahatraj
PLOS Global Public Health · 2024 · DOI: 10.1371/journal.pgph.0002890
Countries: Nepal
What Was Studied
This exploratory qualitative study examined health professionals' experiences using the District Health Information System 2 (DHIS2) and their utilization of DHIS2 data for local-level decision-making in Gandaki province, Nepal. Using purposive sampling, the researchers conducted 20 in-depth interviews (20–40 minutes each) between 28 June and 31 July 2023 with DHIS2 focal persons across 10 local levels and 9 health posts in five districts (Kaski, Gorkha, Syangja, Nawalparasi, Mustang), spanning mountain, hill, and Terai ecological zones, plus one participant from the provincial health directorate. Interviews were conducted in Nepali, audio-recorded, transcribed and translated into English, and analyzed thematically (Braun and Clarke's six-step approach) using NVivo 12, following the COREQ qualitative reporting checklist, with interviews continuing until data saturation was reached.
What They Found
The study conducted 20 in-depth interviews with health professionals in Gandaki province, generating 79 descriptive codes organized into six major themes. Participants included 12 respondents from hill districts, 4 from Terai, and 3 from mountain districts, plus 1 provincial-level focal person; most had 3 or more years of experience using DHIS2. Health professionals consistently described DHIS2 as improving timeliness, data storage, error-checking, and analysis/visualization compared to the prior manual system, and reported strong self-motivation to use it even though no additional incentive existed. However, significant barriers persisted: frequent server downtime and data-lock/data-loss issues forced some workers to re-enter data from home at night when internet connectivity improved; poor internet and unreliable electricity disproportionately affected mountain-district facilities; typically only one trained DHIS2 focal person existed per facility, creating a single point of failure when that person was absent or overloaded; and most participants said they had received no refresher training since their initial basic orientation, with no hard-copy training manuals available on-site (only e-copies or pen-drive video tutorials). Despite facility-level data being routinely available, participants reported that low data literacy and limited interest among locally elected representatives, plus weak leadership in the health sector, meant DHIS2 data was underused for evidence-based planning at the local level.
What This Means for Nepal
DHIS2 data quality is explicitly named among Nepal's 2026 digital-health reform priorities, and this Gandaki-province evidence is directly relevant given DHIS2's near-universal rollout to all 753 local governments since 2019. The findings expose the federalism/Schedule 8 tension documented nationally by Wasti et al. (2023): local governments constitutionally own "basic health and sanitation" delivery, yet DHIS2's servers, technical support, and training remain federally or provincially managed, leaving the single trained focal person typical at each facility without adequate backup, refresher training, or reference materials. Three concrete actions follow: (1) DoHS/MoHP should institute a mandatory annual refresher-training cycle for DHIS2 focal persons — not a one-time orientation — prioritizing understaffed mountain-district facilities where connectivity and staffing gaps compound; (2) provincial health directorates should scale up the kind of "data literacy for elected representatives" sessions Gandaki's provincial directorate has already piloted, since low political engagement with health data is a recurring barrier to evidence-based local planning; (3) DoHS should add reporting fields for locally-funded health programmes to DHIS2, so that local-government health spending — now largely invisible in the national HMIS — is captured, strengthening the evidence base needed for Nepal's national digital-health strategy.
Contextualisation
Digital health — specifically DHIS2 data quality — is named among Nepal's explicit 2026 digital-health reform priorities, and DHIS2 reporting now nominally covers all 753 local governments following the 2019 federal-structure rollout. Yet Nepal's federal design assigns local governments constitutional ownership of "basic health and sanitation" (Schedule 8) while health remains concurrently shared across all three tiers (Schedule 9) — a structural coordination gap documented by Wasti et al. (2023) — and this Gandaki-province study shows it concretely: DHIS2's servers, technical support, and training remain federally or provincially managed even though facility- and local-level staff carry the reporting burden.