Notice F0: Reference implementation of the World Health Organization Antenatal Care Digital Adaption Kit

Tamanu for Antenatal Care

Two-sentence Overview: 

This project will expand the functionality of Tamanu, our patient-level electronic medical record, to address the healthcare needs of expectant mothers in line with the World Health Organization’s Digital Adaption Kit focused on Antenatal Care. BES designed Tamanu and has led its successful implementation in Fiji, Samoa, and Nauru, alongside other digital health solutions we have delivered across more than 12 countries in Asia, Africa, and the Pacific region.

Executive Summary: 

Tamanu is a fit-for-purpose patient-level electronic medical record (EMR) designed to address the distinct healthcare challenges of the Pacific. Tamanu is offline-first across both desktop and mobile, accounting for slow or intermittent internet connections by working offline and syncing when internet becomes available; it is also free and open-source, ensuring that countries are not burdened by high ongoing costs or tied to any single implementation vendor. Tamanu is ONC certified and is an existing approved Digital Square Global Good.

This investment will go towards the development of Tamanu to support healthcare workers in the care of expectant mothers, in line with the World Health Organization’s Digital Adaption Kit focused on Antenatal Care. Our team will create a workflow in Tamanu specifically to support digital tracking and decision support for health workers during antenatal care. The WHO DAK will help to determine the content requirements in a way that is consistent with international health standards. Our goal is to ensure that patients in the Pacific receive consistent and international-standard healthcare from birth to death and the inclusion of antenatal care services in Tamanu will help us to reach this goal. This project will expand the functionality of Tamanu in Nauru, Fiji, Samoa, and Palau where full-scale implementations of Tamanu are currently taking place and available in all future implementations of the software elsewhere in the world. These countries provide immediate opportunities for deployment.

BES designed Tamanu and has led its successful implementation in Fiji, Samoa, and Nauru. We have implemented other digital health solutions in more than 12 countries across Asia, Africa, and the Pacific region, seeking always to promote an entirely integrated and open-source ecosystem. We are consistently working to expand the services available within Tamanu to ensure it functions as a comprehensive birth-to-death EMR, and the development of an antenatal care is a vital next step. This project will be supported by our team of experts in public health, health information systems, and software development.

Consortium team: 

Prime organization

Beyond Essential Systems is a medium-sized Australian company that creates and implements innovative software solutions for low-resource settings in the Asia-Pacific. They have managed large projects on behalf of partners including the Australian Government Department of Foreign Affairs and Trade (DFAT), New Zealand Ministry of Foreign Affairs and Trade (MFAT), Bill and Melinda Gates Foundation, World Food Program, Save The Children International, UNFPA, UNICEF and WHO. Our full-time staff of 40 includes specialists in public health, procurement, clinical services, project accounting, geospatial epidemiology and a full-time software development team of 22. Our team works across offices in Melbourne and Auckland, with project offices in Samoa, Tonga and Fiji.

Project Description: 


In 2022, Tamanu will be implemented at scale across all levels of health care in Nauru, Fiji, Palau and Samoa. Within the scope of each of these projects is the implementation of Tamanu for use by maternal and child health workers.

Quality care is essential for improving maternal and newborn health. Indo-Pacific low- and middle-income countries in particular experience a significant burden of preventable maternal and newborn morbidity and mortality and face considerable challenges in optimising the quality of care for mothers and newborns.

While our Tamanu project managers will work with each country project team to align system design with their existing ANC protocols, the Digital Square grant provides a timely opportunity to ensure that the Tamanu ANC workflow is following an established standard of care and can offer a reference point for informing ANC content. Adopting an established standard of care will also ensure that ANC clinical teams can effectively benefit from the implementation of Tamanu.

Existing Tamanu functionality including a flexible programs module, configurable clinical decision support, patient tracking features, care plans and reporting suite will be adapted to align with the Digital Adaptation Kit for Antenatal Care to create the Tamanu Antenatal Care Module. This ties in with our philosophy of supporting multiple use cases inside a single EMR, instead of implementing specific, siloed applications for each vertical program or process.

Through the adaptation of existing Tamanu functionality, health workers will be able to use Tamanu to maintain a comprehensive and persistent patient-level record including health events and encounters that can be digitally tracked. The incorporation of clinical-decision support, and patient line list and summary reports, will help to reinforce good practice and accountability.

The development of a Tamanu Antenatal Care Module means that countries will be expending resources more efficiently, it will save on training and deployment costs and its alignment with WHO guidelines will ensure the module is scalable to future implementations.



The following objectives will be met:

  • Design and development of ANC workflows in alignment with the DAK business processes, including configuration of the core ANC data elements
  • Configuration of clinical decision support in alignment with DAK  
  • Creation of data dictionary about each ANC data element containing their definitions, relationships, origin, usage and data type
  • Generation of reporting suite in alignment with key indicator and performance metrics



The following work will be delivered:

  • Demonstration of the Tamanu ANC workflow referencing the DAK
  • Demonstration of ANC reports
  • Published data dictionary demonstrating use of the core antenatal care data elements
  • Training materials made freely available online (including manuals, training videos and webinar)



February-April 2022: Design and development of ANC workflows, Creation of data dictionary

May 2022: Generation of ANC reports

June 2022: Development of training materials


Risk mitigation

Long-term Sustainability

Software solutions change rapidly, and new technologies are constantly emerging to support better healthcare outcomes. As a result, there is an inherent risk that the proposed software, Tamanu, becomes obsolete or no longer supported.

This funding support would augment existing funding streams from World Bank, Palladium International, Aspen Medical and DFAT, so we would be using to provide this supplemental activity rather than as core funding.

The work will be completed as part of 4 contracted and planned implementations in 2022 so we should be able to demonstrate rapid scalability and adapt our model with an agile methodology and knowledge feedback loops from the field.

Security/Data Breaches

Data breaches are a major risk to any digital health project and are taken very seriously. All data in Tamanu is encrypted at rest and in transit. Access to data within Tamanu is password-controlled. The ability to view and download data is restricted to specific user groups.

Clinical Adoption/Change Management

Clinical adoption is a primary risk in the implementation of any EMR, with clinician resistance and technical literacy frequently observed as key barriers. To mitigate this risk, we have developed detailed training and user manuals, as well as change management processes to ensure that adoption is maximised.

Application Status: 
Not Approved


Thank you for the concept note. For the full technical application, in addition to general recommendations per the email, please also include more technical aspects on how this will align with the DAK business processes, as well as direct call outs to the inclusion of the FHIR IG aspects of the DAK in the application.

Many thanks - one final note, we feel we could have prepared something more comprehensive and that there are certainly gaps in our technical documentation but the last few weeks have been very challenging in Australia with COVID cases spiking extremely quickly. Our team are responding to outbreaks in Fiji and Palau and additionally, the last two weeks especially have seen many staff out sick or required to quarantine - this is not an excuse or a request for an extension, just a small explainer. We would welcome the opportunity to clarify any issues further however if they are unclear.

Thank you for a great application. Please elaborate on:

  1. What is the community governance mechanism for the solution.
  2. How will the applications be expected to align and strengthen the shelf-readiness.
  3. How will the application be expected to incorporate key data standards and align to workflows.
  4. How will you ensure that the applications can fulfil the data exchange needs of the DAKs.
  5. How will you ensure alignment with OpenHIE approach and interact with other solutions.

Thank you for the follow-up questions: Please see responses below:

1. We are currently in the process of setting up fortnightly community meetings where we showcase new functionalities and features to the wider Tamanu community and key stakeholders. Incorporated into these meetings are discussions regarding clinical and data standards, and meeting participants will be allowed the opportunity to ask questions and provide feedback following each showcase.

We have also been working with PATH on understanding the OpenHIE architecture and opportunities for adoption, conformity and overlap. We aim to continue these exchanges, scaling up to present at community forums and communicating in Webinars at a more regional (Pacific) level.

We also plan to build out our open-source community with better hosted wikis and community forums within our GitHub repos.


2. Tamanu is planned for full scale implementation in Nauru, Samoa and Palau this year. Development of an Antenatal Care module will significantly improve the shelf-readiness as it will form part of the overarching Tamanu Maternal and Child Health Module which will be developed and implemented in each of these countries.


3. The configurable design of Tamanu provides flexibility in ensuring that the system is able to incorporate key data standards and maintain conformity as these key data standards are updated. For example, updated ICD codes can be easily imported into the system using our flexible reference data model.

Tamanu will also maintain a data dictionary to ensure that necessary codes and data elements are incorporated into the system. This will enable us to carry out frequent reviews to identify standards requiring update.

We will also maintain standard workflow designs in alignment with these data standards.


4. We are confident that Tamanu will fulfil the key data exchange requirements of the DAKs.

Firstly, Tamanu conforms with HL7 FHIR standards for data exchange with other eHealth solutions. This aligns with the OpenHIE approach which is a strong advocate for the adoption of this standard.

Secondly, the sync-enabled architecture of Tamanu means that data can be recorded seamlessly with or without an internet connection via both the mobile and desktop application. When an internet connection becomes available data will sync with a central database to then be available for other health facilities to sync and view.


5. Tamanu conforms with HL7 FHIR standards for data exchange with other eHealth solutions. This aligns with the OpenHIE approach which is a strong advocate for the adoption of this standard.