1. Health Information Systems Challenges

2. 2 But first.. Some Concepts from Yesterday’s Readings/ Lectures You should be able to explain to a friend what these concepts mean in relation to Health Management Information Systems: 1. Primary Health Care (preventive/curative care) 2. Routine Health Information 3. Individual/patient care / Continuity of Care 4. (Electronic) Medical Record 5. Epidemic disease / disease surveillance 6. Fragmentation 7. Integrated Health Information Architecture 8. Data Warehouse / Data Repository 9. Indicator (covered later in course)

3. Our goal with the Health Information System “is to produce relevant information that health system stakeholders can use for making transparent and evidence-based decisions for health system interventions” (HMN) But the challenges here are many: –You need access to data –You need quality data (covered later in the course) –You need to know what to do with it

4. Picture: HMN Accessible data?

5. Picture: HMN

7. The lack of access to health information Why?

8. Multileveled fragmentation Uncoordinated Health programs Different Health information domains Public/private Many electronic formats (and paper still very common)

9. Some Global Trends and Goals Towards more granular patient based data Globally, two-thirds (38 million) of 57 million annual deaths are not registered. And every year, almost 40% (48 million) of 128 million global births go unregistered. Towards integrated and shared data Many ministires of health are fragmented and have vertical programs with their own reporting and data analysis systems (+ donors) From Paper to Digital (integration or more mess?) From ‘data collection’ to evidence based decision making Mobiles and ICT often proposed as solutions technical solutions to social problems??

10. Example Routine PHC data (clinic/outreach) Special programme activities Reproductive health Child health & nutrition HIV/AIDS, STI and TB Chronic diseases Routine Service Activities Minor ailments Non-priority activities Epidemiological surveillance Notifiable diseases Environmental health Administrative Systems Infrastructure, equipment Human resources Drugs, transport, labs, finances, budget, staff PopulationCensus: age, sex, place Births & deaths registration

13. Registers/records Record data that need follow-up over long periods such as ANC, immunisation, FP, TB

14. some registers in Practice…

15. Paper Reports monthly, Quarterly but there are many different reports….

16. Fragmentation of health programs One information stream for Malaria program One information stream for TB program One information stream for… etc etc etc Surveys Data not available for comparison. Double counting, low data quality Country X (e.g., Malawi): three national figures of HIV+ rate or infant mortality rate. All different…

17. Many official actors: risk of fragmentation Ministry of Health is not alone… –Central Statistics office (census) –Ministry of Local Government (run the clinics) –Ministry of Education (school health programs) –Ministry of Defence (military clinics) –Special units on for example HIV What does this look like In Norway?

18. Why program fragmentation? Health services inherently fragmented due to high level of specialization Donors (both from necessity and ignorance) WHO is highly fragmented itself Interests and ownership Leads to lack of transparency, some people thrive on that (corruption)

19. WHO’s history of success with focused programmes Smallpox eradicated in 1977 Eliminating polio in the Americas in 1985 Eliminating measles in Southern Africa Reducing guinea worm disease by 99% in 20 African countries between 1986 and 2005 Relative successful compared to other UN agencies (such as World Bank). Each disease eradication program operated autonomously, with its own administration and budget and very little integration into the larger health system 19

20. But health systems continued to be inefficient Short-term successes were not addressing poor populations overall disease burden Health systems were urban based, high-technology, curative oriented. Little contact with the population for preventive care Health is socioeconomic: –Health services, economy, security, education, nutrition… More comprehensive approaches emerged in a number of countries 20

21. Primary Health Care Promotive, preventive, and curative Involves related sectors (education, food, agriculture etc), and wider aims (equity, affordability etc) Promotes community and individual involvement and committment Came as a reaction to older, high-tech, curative approaches. Based on bottom-up experiences from ”developing world” How to implement it? Comprehensive vs selective? Overarching question ever since 21

22. Comprehensive vs. selective today? Both exists WHO is still very fragmented in specific programs, which are replicated at country level Cross-cutting units have been created; Health Metrics Network In other areas, new agencies have been created to target specific areas: Global Fund, UNAIDS, GAVI Alliance 22

23. HMN Framework: An example of comprehensive appraoch to HIS 23

24. A selective approach to HIS 24

25. Comprehensive vs. selective: ICTs Comprehensive: integration, comprehensive information needs, varied outputs Selective: Silos, fragmentation, inefficient development and utilization of infrastructure. Closed-boundary ICT systems. Potential for cross-comparison of indicators is lower. Both: provision of health services decentralized. IS needs to allow local levels to collect, process, and use information Scope for various technologies to contribute: Mobile phones, mobile modems to access online services 25

26. The MDGs in the PHC tradition (millenium development goals) Adopted by UN in 2000, to reach by 2015 goals related to: 1.Poverty and hunger 2.Universal primary education 3.Gender equality 4.Child mortality 5.Maternal health 6.HIV/AIDS, Malaria, and other diseases 7.Environmental sustainability 8.Developing global partnership for development 26

27. The MDGs in the PHC tradition Despite the comprehensiveness of the MDGs, selective approaches within health continues Addresses some critique of selective PHC –Take into account the broader context of development –Does ackowledge the role of social and gender equity Still challenges related to: –Donor-driven technocratic approach to priorities, rather than grassroot approach of Alma Ata –Vertical objectives, fighting one disease at a time –Little coordination among vertical programs New actors find legitimacy in the MDGs for focusing on specific areas, contributing to and sustaining fragmentation 27

28. In Conclusion There is a strong trend towards individual and encounter-based data (drilling down) –Security, patient confidentiality, robustness Increased focus on Civil Registration and Vital Statistics will lead to new requirements for selective sharing of data –Birth data: not all stakeholders should get all data –Who has access, who owns the data 28

29. In Conclusion II ICTs only as effective as the system they support International health community becoming increasingly aware of the limitations of ICTs: What ICTs can do? Help in integration, collection, storage, processing, presenting information. Decentralization. Community empowerment, but not without its challenges 29