2 October 2006Johan Sæbø HISP Aims of this lecture –See the big picture of HISP, all that surrounds the software –Introduction to DHIS

2 October 2006Johan Sæbø Overview of lecture HISP overview –Goals –Activities Information systems in the context of developing countries –How data is collected and transformed into information –Use of information DHIS and the key design principles

2 October 2006Johan Sæbø What is HISP? Health Information Systems Programme Global network of individuals and organisations –Academic institutions –Non-governmental organisations –Governmental organisations Members are orientated towards the “HISP goal” An example of a South-South-North collaboration

2 October 2006Johan Sæbø The HISP goal To support local management of health care delivery and information flows Design, implement and sustain HIS following a participatory approach In health facilities, districts, and provinces And its further spread within and across developing countries

2 October 2006Johan Sæbø HISP is truly global

2 October 2006Johan Sæbø Achieved through HIS design, development and implementation (including, but not limited to software) Organisational and human resources development Theoretical and practical knowledge about challenges of implementing HIS in developing countries (action research)

2 October 2006Johan Sæbø Short history Started in South Africa after Apartheid Software piloted in one province for two years Political climate allowed a total renovation of the health system Strategy followed a bottom-up development and standardization

2 October 2006Johan Sæbø Short history Mozambique first international node India, Malawi, Cuba, Ethiopia, Tanzania, Vietnam, Botswana, Nigeria, Mongolia etc. Considerable human capacity on HISP developed in India, Ethiopia, Mozambique Different contexts call for different approaches

2 October 2006Johan Sæbø HISP as a FOSS project Software (District Health Information Software, DHIS), FOSS Emphasis on –Participatory development –Creation of software that empowers the users Increasingly open to use of and integration with other FOSS packages Distributed development although major work done in South Africa Customisation of packages done locally Multilanguage enabled software

2 October 2006Johan Sæbø Critique of Software development (last year’s slide) Too focused on SA –In fact too focused on a single individual in SA Possibly we have not harnessed opportunities in India strongly enough In some countries software development component has not been complemented with a strong enough “project implementation” focus

2 October 2006Johan Sæbø Software development today South Africa –Main engine of development of v1.3 and 1.4 Oslo –Two PhD’s and numerous Master’s students developing v.2.0 India –Many programmers, working with 1.4 and 2.0 Vietnam –Some programmers, working with 2.0 Various other smaller projects –Extra modules often made locally

2 October 2006Johan Sæbø The context of a developing country Often severe problems related to: –Infrastructures –Human resources –Inequality (urban/rural) –Hardware and spare parts –Politics –Migration, natural disasters, war etcs –Centralistic, bloated, and fragmented legacy systems

2 October 2006Johan Sæbø

2 October 2006Johan Sæbø Health Information use in developing countries Curative vs. Preventive approach reflected in information system Little use of information at local levels Little use of indicators, focus on raw data Centralistic approach, data collected for the top level, little or no feedback Fragmented, little communication between health managers

2 October 2006Johan Sæbø Legacy systems Hard to change, reflects power relationships Donor agencies works around them by making their own systems, just increasing the original problem of fragmentation. Developer has left many years ago, took the code with him Legacy systems can be a force of resistance against new systems

2 October 2006Johan Sæbø HISP strategy Often beginning with a strong association with grass roots organisations and services Focus on piloting and modifying system in a few districts Empower local health managers with information and train them how to use it Creation of alliances with ministry for recognition of grass-roots progress and further roll-out

2 October 2006Johan Sæbø Health Statistics District-DHT Facility 1Facility 2Facility n IDSR–Notifiable Diseases PMTCT EPI STD Home Based Care Nutrition MCH Family Planning HIV/AIDS TBSchool Health Mental Health And more … Facility 3 IPMS ARV Current Scenario, Botswana

2 October 2006Johan Sæbø Health Statistics Facility 1Facility 2Facility n IDSR–Notifiable Diseases PMTCT EPI STD Home Based Care Nutrition MASA MCH Family Planning IPT TB School Health Mental Health Others Facility 3 National HIS District 1 DHISDistrict n DHIS IPMS District 2 DHIS Future scenario, Botswana

2 October 2006Johan Sæbø Part II DHIS and design principles

2 October 2006Johan Sæbø Basic Criteria for Health Information Software: 1. Data capture: Prevents the capture of duplicate datasets. Has mechanisms for data validation. Can be adapted by users to reflect the changing reality in the health sector –Organisational units –Data elements (and indicators). Is able to calculate indicators that use population as a denominator.

2 October 2006Johan Sæbø 2. Reporting functions: Reporting must be readily available to provide managers with real time data. Can provide automatic reports to various organisational levels. Must allow the creation of customised reports Links to GIS functionality

2 October 2006Johan Sæbø

2 October 2006Johan Sæbø

2 October 2006Johan Sæbø Immunisation Coverage 2001 Immunisation Coverage 2002

2 October 2006Johan Sæbø 3. Export/Import function: Can automatically export data from lower levels for import at higher levels. Can specify data export of different groups of data (for onward transmission to various stakeholders – e.g. donors, programme managers, etc). Can export data for use with other applications and databases

2 October 2006Johan Sæbø 4. Maintenance: Can be locally (in country) supported, adapted, and developed. FOSS + Platform independent

2 October 2006Johan Sæbø HISP activities are all about moving people from providing services, to also using information to manage services

2 October 2006Johan Sæbø

2 October 2006Johan Sæbø

2 October 2006Johan Sæbø

2 October 2006Johan Sæbø

2 October 2006Johan Sæbø Record of patients seenSummary of key information Data entry into database Data analysis and use

2 October 2006Johan Sæbø DHIS Originally developed in Visual Basic for MS Access and Excel DHIS 1.4 last version to be tied to MS DHIS 2.0 platform independent FLOSS, web-enabled. Same functions as still used in most countries, some use of 2.0 in India and Ethiopia

2 October 2006Johan Sæbø DHIS, the basic structure Same principle for all versions of DHIS –Need to reflect the health hierarchy –Need to map data to each reporting unit –Need to be easy to use –Need to be flexible

2 October 2006Johan Sæbø “Reporting OrgUnit” The Organisational Hierarchy DHIS 1.4 supports an “infinite” number of OrgUnit levels in the hierarchy, but standard setups would be between 3 and 7. The lowest level is in this case called the “reporting OrgUnit”.

2 October 2006Johan Sæbø “Parent OrgUnit” “Reporting OrgUnit” “Parent OrgUnit” Country Health district Facility The Organisational Hierarchy Reporting OrgUnits belong to parent OrgUnits, which are either physical health facilities (clinics, hospitals) or administrative OrgUnits arranged in a hierarchical structure. Parent OrgUnits can also be reporting OrgUnits, but the norm is to collect as much data as possible at the lowest level.

2 October 2006Johan Sæbø An example of an organisational hierarchy in the DHIS14 1. Central Ministry 2. Health districts 3. Health facilities

2 October 2006Johan Sæbø

2 October 2006Johan Sæbø “Parent OrgUnits” “Reporting OrgUnit”“Semi-permanent data” Routine data set (monthly, weekly, quarterly, annually, daily, etc) Data element 1 Data element 2 Data element n Adding data to the org units Data that is collected is “attached” or “linked” to reporting units.

2 October 2006Johan Sæbø

2 October 2006Johan Sæbø “Parent OrgUnit” “Reporting OrgUnit”“Semi-permanent data” Routine data set Data element 1 Data element 2 Data element n Data can also be added to higher level OrgUnits (i.e. data can be captured at multiple levels) Adding data to the org units

2 October 2006Johan Sæbø Org unit 5 Org unit 4 Org unit 3 Org unit 2 Org unit 6 Org unit 1 Group 1 Group 3c Group 3b Group 2 Group set 1 Group set 2 Group 3a Exclusive Compulsory An example: Org unit types Location Ownership Understanding org units, org unit groups, and org unit group sets

2 October 2006Johan Sæbø Org unit 5 Org unit 4 Org unit 3 Org unit 2 Org unit 6 Org unit 1 Group 1 Group 3c Group 3b Group 2 Group set 1 Group set 2 Group 3a Exclusive Compulsory Examples: Accreditation Inclusion in Training programmes Inclusion in research projects Understanding org units, org unit groups, and org unit group sets

2 October 2006Johan Sæbø Importance of this function Health services are often in a state of flux Hard-coding various types of classification (e.g. groupings might thus block specific use Enabling the user to determine these options increases functionality in an environment that is constantly changing (and with large variations between DHIS-using countries) Main purpose of these groupings is to allow analysis to be performed on certain groups Limits on groupings in version 1.3 have been a significant impediment, with a lot of tinkering and ad-hoc modifications necessary to make it work

2 October 2006Johan Sæbø Routine data set Data element 1 Data element 2 Data element n Data element groups Indicators Understanding data elements, and data element groups (which are also used as indicator groups)

2 October 2006Johan Sæbø Routine/semi-permanent/survey data sets: Data element 1 Data element 2 Data element n Data element groups Indicators Raw data Processed information Understanding the data elements, and data element groups

2 October 2006Johan Sæbø Data element Data Element & Indicator Groups are defined in the lookup tables. The grouped data elements / indicators have some characteristic in common (a data entry form, a programme/service, whether they are gender sensitive or not) Understanding data elements, and data element groups People are interested in a grouping in one way or another – this is what we analyse Data element

2 October 2006Johan Sæbø Data element 1 Data element 6 Data element 5 Data element 4 Data element 3 Data element 2 Data set 1 Data set 2 The DHIS “back-end” data file uses One table to store all data elements. Each data element can be assigned to one or more data sets. Each data set can be used to capture or import data for a number of OrgUnits – but it may not be necessary for all org units to complete all data sets. Typically, a data set reflect either one paper form, a collection of data that “belong together” (e.g. Census data), or a collection of data elements traditionally updated in a similar manner (e.g. semi- permanent data) Understanding data elements, and data sets

2 October 2006Johan Sæbø Data element 1 Data element 6 Data element 5 Data element 4 Data element 3 Data element 2 Data set 1 Data set 2 Data entry form 1 Data entry form 3 A data entry form can be created to address the specific needs of: A dataset, or An org unit. Understanding data elements, and data sets

2 October 2006Johan Sæbø

2 October 2006Johan Sæbø Data element 1 Data element 6 Data element 5 Data element 4 Data element 3 Data element 2 Data set 1 Data set 2 Data entry form 1 Org unit 5 Org unit 4 Org unit 3 Org unit 2 Org unit 6 Org unit 1 Data entry form 3 Understanding data elements, and data sets

2 October 2006Johan Sæbø Useful Articles Braa, J., O. Hanseth, et al. (2005). "Standardisation of Health Information Systems in Developing Countries - flexible standards the "third way"." Braa, J. and C. Hedberg (2000). Developing District-based Health Care Information Systems: The South African Experience. IRIS 23. Braa, J. and C. Hedberg (2002). "The Struggle for District Based Health Information Systems in South Africa." 18: Braa, J., E. Monteiro, et al. (2004). "Networks of Action: Sustainable Health Information Systems Across Developing Countries." MIS Quarterly 28(3): Wilson, R., C. Hedberg, et al. (2003). South Africa's District Health Information System: Case Study, EQUITY Project: 17. HISP Websites (follow links from confluence) Manual on DHIS 1.4 (early, limited draft only!!) Manual on DHIS 1.3 (comprehensive but occasionally complicated) GIS User Manual