1. Overview of the HISP Network
Nigeria
Zambia
Dominican Republic
India
Cuba
Angola
South Africa
Mongolia
Norway
Ghana
Ethiopia
Malawi
Tanzania
Mozambique

2. District Health Information Systems
Topic 2: The health district and the district health system
Humberto Muquingue
MED-INF 5200
April 2007

3. Describe the tasks performed in a health district setting
Learning outcomes
Provide a standardized definition of health district and district health system
Explain the advantages presented by the concept of health district, with emphasis on information and the roles of the District Health Management Team (DHMT)
Describe the tasks performed in a health district setting
Explore the adequate characteristics of a health district
Justify the current focus on district health systems

4. What is a health district ?
...It is the point of the national health system where people can get comprehensive health care
...It is a clearly defined geographical/administrative area
...It is the implementation spot for primary health care (Alma Ata, 1978)
...It is the optimal operation unit for the identification of the excluded from health care and for the implementation of health improving strategies (Harare, 1987)

5. Community Level HEALTH SYSTEM NON-ROUTINE DATA COLLECTION METHODS
TERTIARY
Patient/Client contact
Referred patients
First level care unit
District Hospital
Regional Hospital
Regional Health Management Team
National Hospital
University Hospital
Ministry of Health
Universities
Other Health Institutions
INDIVIDUAL
CARE MANANAGEMENT
HEALTH UNIT MANAGEMEET
SYSTEM MANAGEMENT
DISTRICT LEVEL
REGIONAL LEVEL
NATIONAL LEVEL
HEALTH CARE SERVICES
HEALTH SERVICES SYSTEM
HEALTH SYSTEM
NON-ROUTINE DATA COLLECTION METHODS
CATCHMENT AREA POPULATION
District Health Management Team
HEALTH CARE LEVEL
PRIMARY
SECONDARY
This is a simplified health system map:
Health care services: focused on individual health care
Health services systems: englobes both individual and public health interventions
Health system: includes other sectors such as education, transport, agriculture.
The health system has mostly three organizational levels, from the periphery to the center. Each of these levels has specific functions, requiring a series of specific decisions to be made, to ultimately improve the health status of the population. From a management perspective, functions can be grouped in three types of "management functions”, related to (1) individual care management; (2) health unit management; and (3) health system management, which include public health functions, such as protection of the environment; or, prevention and control of disease.
Routine health unit-based health information system provides information on both individual health care services and public health functions, it seems obvious that it should be the main information source for integration of both type of interventions.
OTHER SECTORS:
-Environment
-Civil Administration
-Transport
-Education
Routine Health Information System

7. What are the characteristics of a health district ?
Clearly delineated geographical area
Population between 30,000 and 500,000 (most cases)
Identifiable form of local government
Managed by few officers
Balance between population size and availablity of technical specialised staff

8. What advantages presents the health district ? 1/2
...It is close enough to the community to understand and act on its problems and constraints
...It has easier communication with the community to ensure its participation in planning and organization
...It is the most appropriate level for coordinating top-down and bottom-up planning

9. What advantages presents the health district ? 2/2
...It is the most suitable place to provide support to health workers in the health posts and health centres
...It presents large potential for effective collaboration with other sectors towards the health of the community
...It has the ability to handle decentralisation of resources and of decision-making

10. What are the tasks of the health district ? 1/2
...Implementation of all community based health programmes
...Supervision and control of all community health workers in the district
...Organization and operation of district hospital services
...Management of all other public health facilities
...Coordination and supervision of all public, non-government and private health systems

11. What are the tasks of the health district ? 2/2
...Promotion of active links with local government entities
...Promotion of community participation in the local health service planning
...Preparation of annual health plan
...Raising additional local funds
...In-service training of health workers
...Collection, compilation and dissemination of routine health information

12. What is the experience of districts in your country ?
Exercise 1: YOU are asked to (individually):
- Fill up a table characterising your “district” in the country you originally came from. Please indicate, local name for “district”, geographic size, population, population density, approx ratios health professionals/inhabitant.
- Shortly describe your experience of living in a health district (their functions, responsibilities, involvement, etc) in your respective countries.

13. The PHC Approach
…is a conceptual model for health care planning and health systems development

14. Primary Health Care (PHC) should (Alma-Ata, 1978)....
respect the needs and lifestyles of the target population,
be an integral part of the national health system,
include other health related sectors,
involve the communities in planning, decision making and realization,
rely on local resources and be cost-effective,
integrate and coordinate preventive, curative, rehabilitative and promotive measures,
take place near the targeted level.

15. Why size matters ?

16. If the health districts are too small...1/2
....greater number of health districts, then...
more management structures and systems
cohesion and co-ordination more difficult at a national or provincial level
it will cost more and fail to capture economies of scale

17. If the health districts are too small...2/2
district hospitals will be managed as separate entities from the rest of primary level health care
could create a further dislocation between primary level services and district hospital services (many health districts without a district hospital)

18. If the health districts are too large...
district-level management can become unwieldy and bureaucratic
the DHS loses its “service delivery" functions
The DHS becomes too remote from the community.

19. Comprehensive services Population size
The required balance
Comprehensive services
Population size
Geographic size
Community involvement
Technical autonomy

20. What is a DHS ? (WHO, 1987) 1/3
...more or less self-contained segment of the national health system
...it comprises first and foremost a well-defined population
...within a clearly delineated administrative and geographical area
...it includes all the relevant health care activities in the area, whether governmental or otherwise.

21. What is a DHS? (WHO, 1987) 2/3
...it will be most effective if coordinated by an appropriately trained health officer ...to ensure as comprehensive a range as possible of promotive, preventive, curative and rehabilitative health activities

22. What is a DHS ? (WHO, 1987) 3/3
...ideally contains a network of primary health units and a district hospital for referral of cases
...it is the point and level at which different health service activities are integrated into a comprehensive and holistic approach to health care
...it is able to accept the transfer of responsibility, resources, authority and seniority from central levels of management to the periphery

23. Why the focus on DHS ? 1/3
... too much emphasis on curative services
... little attention to preventive and promotive areas
... weak assessment of the health status of the population
... data gathering is low priority, unreliable and routinely performed, it strongly affects the information circulation in the health system
... frail coordination with other sectors: water, sanitation, agriculture, housing, roads and transportation
... lack of skills
... growing pressure for health reform and decentralisation

24. ...inadequate information for the managerial processes !
Why the focus on DHS ? 2/3
...the many responsibilities of the district health team
...the need to carefully allocate the scarce resources
...the necessity of sound health management
 obvious need for adequate information BUT
 the main constraint for implementing the primary health care approach in practically all countries:
...inadequate information for the managerial processes !

25. The district information system has yet to make available...
Why the focus on DHS ? 3/3
The district information system has yet to make available...
... the right information and the right knowledge
... to the right persons and institutions
... in the right form
... at the right time
... in the right place

26. The implications of a DHS 1/3
The DHS can only be a functioning entity if the following assumptions are met.

27. The implications of a DHS 2/3
 DHS is a means to an end, rather than an end in itself
... the "means" to achieve the "end" of an equitable, efficient and effective health system based on the principles of the Primary Health Care (PHC) approach
 DHS is more than just a structure or form of organisation
...it is also the manifestation of a set of activities:
community involvement, integrated and holistic health care delivery, inter-sectoral collaboration and a strong "bottom-up" approach to planning, policy development and management

28. The implications of a DHS 3/3
 the PHC approach and the DHS model apply to the whole of the health system and at all levels of health care delivery
... the health district and its management structure should be the core building block of the entire heath system,
... DHS should be the underlying framework for the organisation of health care as a whole
 the essence of the DHS is the organisation of health care according to geographic sub-divisions of a country which are managed through a decentralised management structure

29. the theory of the DHS is straightforward
Theory vs practice
the theory of the DHS is straightforward
...but its implementation is much more complex
...there are different interpretations of what is adequate:
size
Health district - local government
roles and relationship
National - provincial - district levels
District hospital

30. Health District versus District Health System
= geographical/administrative area
District Health System
= a segment of the national health system with a complex set of actors interacting in a health district

31. Additional Literature
David McCoy, Beth Engelbrecht, Establishing the district health system, in Health Systems Trust (eds) South African Health Review 1999
Uwe Washer (1991) Construction of an Adapted Health Information System,
WHO (1987). "Eighth General Programme of Work Covering the Period ". "Health for All" Series 10. Geneva: World Health Organization
WHO (1988) The challenge of implementation: district health systems for primary health care, WHO/SHS/88.1/rev.1