Process-Related Challenges Resistance to Change Some people were resistant to adopting the new system. Limited Local Expertise Many team members didn't have enough expertise in health informatics or DHIS2, slowing progress. Coordination Between Multiple Stakeholders Different stakeholders, like the Ministry of Health, NGOs, and academic institutions, sometimes had conflicting goals and timelines. Technical Challenges Nepali BS Calendar Integration The Nepali BS calendar’s complex structure caused issues with data entry and reporting in DHIS2. The mismatch with the Gregorian calendar affected data accuracy. System Scalability for Increased Usage The growing amount of data and new features put stress on DHIS2’s current system. Policy Changes and Regulatory Shifts New laws on health data privacy and digital sharing added complexity. Contextual Factors Government Support Recent health sector reforms and a push for digitalization made it easier to adopt DHIS2. Integration with External Data Sources External data sources often had inconsistent formats and required manual cleaning.

Provide early training, workshops, and opportunities for learning from international experts. Define roles clearly from the start and hold regular meetings to keep everyone aligned. Appoint a liaison to coordinate efforts. Create solutions for dual-calendar support in DHIS2. Optimize the database, improve caching, and test the system's ability to handle more data. Set up automated processes to standardize incoming data, reducing the need for manual intervention. Align the project with national health policies and digitalization goals to secure ongoing support and funding. Positive Influences on Implementation The involvement of universities, NGOs, and health departments helped shape the system. Their feedback improved the system's relevance. Best Practice: Keep collaborating with stakeholders throughout the project for better adoption. Adoption of Open-Source Solutions Using open-source tools like DHIS2 offered flexibility, customization, and cost savings. Best Practice: Promote open-source solutions for sustainability in government and healthcare projects. Implications for Scalability and Sustainability Scalability The system can grow to other regions or countries by ensuring core components are standardized and new features, like the Nepali calendar, are modular. Recommendation: Keep scalability in mind so future updates don’t disrupt the system. Sustainability Local involvement and training can reduce dependence on external consultants, ensuring the system lasts long-term. Recommendation: Focus on building local expertise, provide ongoing support, and encourage innovation to meet local needs. Stay updated on regulations and adapt the system to meet new legal requirements.