1. HIBBs is a program of the Global Health Informatics Partnership DESALEGN TEGABU ZEGEYE (MD,MPH) DEPARTMENT OF HEALTH INFORMATICS UNIVERSITY OF GONDAR FEBRUARY 2011 Introduction to Routine Health Information Systems

2. Objectives Explain the roles of routine health information systems (RHIS) in health service management Examine strategies used to improve routine health information systems Acquaint with skills to carry out the process of improving RHIS performance Discuss three categories of determinants that influence RHIS

3. Outline Definitions RHIS concepts Strategies used to improve routine health information systems Analytical Framework for Understanding RHIS Performance –The Prism Concept

4. Definitions Health System - is defined as the system of all actors, institutions, and resources that undertake “health actions” – i.e. actions whose primary purpose is to promote, restore, or maintain health (WHO 2000). Information System - System that provide specific information support to the decision-making process at each level of an organization Health Information System - “A system that provides specific information support to the decision-making process at each level of an organization.” (Hurtubise, 1984)

5. Why Health Information System? Good management is a prerequisite for increasing the efficiency of health services Improved health information system is clearly linked to good management Information is crucial at all management levels of the health services from periphery to the centre. It is required by policymakers, managers, health care providers, community health workers

6. Routine Health Information System (RHIS) Definition: Ongoing data collection of health status, health interventions, and health resources Examples: facility-based service statistics, health administration statistics and community-based information systems

7. RHIS includes… Health service statistics for routine service and special program reporting Administrative data (revenue and costs, drugs, personnel, training, research and documentation) Epidemiological and surveillance data Data on community-based health actions

8. Types of Routine Data Collection Methods Health unit data collection Community data collection  to monitor activities performed in the community by health unit staff or by community health workers  to obtain more representative data on the health status and living environment of the communities served, including data on births and deaths in the community, agricultural and meteorological data, data on education, etc.  to assist in planning for health services that are more accessible to community

9. Data Collection Instruments Curative Medical records Laboratory forms Referral forms Preventive Growth cards MCH cards School health card Family registration records Data collection instruments in RHIS:

10. Data Collection Instruments for Health Unit Management Service delivery records  Registers  Tally sheets  Population charts Resource Management records

11. Issues with Routine Data Collection Instruments Content (comprehensive) Record filing (patient-retained vs. health unit- retained) Layout (self-explanatory) Production form Electronic patient record

12. Guiding Principles of RHIS Data for decision making  Collection of only essential health data used for decision making Data collection for local analysis and use by the health worker  Data collected by all health workers as they perform their day to day duties Data processing and analysis are done starting from the point of collection Integration of all routine information systems Simple to operate and maintain

13. What is Wrong with Current RHIS? Irrelevance of the information gathered Poor quality of data Duplication and waste among parallel health information system Lack of timely reporting and feedback Poor use of information The difference in culture between data people and decision makers: Planning and management staff rely primarily on “gut feeling” to formulate ad hoc decisions rather seek pertinent data

14. Steps Involved in RHIS Restructuring Step 1: Carrying out service and information system assessments Step 2: Developing new sets of essential health indicators Step 3: Defining data sources and developing data collection instruments for each of the indicators selected Step 4: Developing a data transmission and processing system Step 5: Ensuring use of the information generated Step 6: Planning for RHIS resources

15. STEP 1: Assessment of the Existing System Rapid Assessment of the current use and performance of the existing system. Find out how and how well the current system works, to describe the various components of the system and the organizational environment

16. STEP 2: Develop Essential Indicators Select essential indicators for management functions at each level of the health system: Health status (and disease surveillance) indicators Health services (and national program) indicators Resource indicators (human, physical, financial)

17. What Data Elements Should be Collected? Can provide useful information (affecting the management decisions) Cannot be obtained elsewhere Are easy to collect Do not require much work or time Can be collected relatively accurately  ESSENTIAL DATA SET based on indicators reflecting the health status of the community

18. Essential Data Set (From Shaw,2005) MUST KNOW

19. Essential Dataset (continued) WHAT? The minimum amount of data that needs to be collectedWHY? For the effective management of services which allows them to make the greatest impact on the health needs of the community which they serve (improving coverage & quality)HOW? Through routine data collection

20. EDS - Choosing a Type Data - led Focuses on the need to collect data which is required, is of interest, or may be useful Is usually vague on what information output can be obtained from data Action - led Focuses on the need to collect data that reflect identified priority health needs & are required by pre-determined indicators Indicator driven – national & local Usually directly linked to specific objectives and targets  Action-led systems are the most practical way to go

21. Community Information Systems District Information Systems Zonal Information Systems National Inf. Systems International IS Indicators, Procedures, datasets & use of info for ACTION: Community District Province National International Standardised Usefulness Address the needs of all stakeholders User-friendly Dynamic EDS at Each Level: The Information Filter (From Shaw 2005)

22. Step 3: Data Sources and Data Collection Tools Defining data sources and developing data collection instruments for each of the indicators selected. Data collection Data collection  start small - as data quality improves & systems are streamlined - add slowly  collect data – linked to objectives - that can be used to calculate indicators

23. Data Sources and Data Collection Tools (continued)  Collect only data that is easily available - determine easiest site for recording of data - do not duplicate points of data collection  Use clear & standardised definitions  Train & provide ongoing support to data collectors – improve data quality Data collection tools  Use a minimum number of tools - user friendly, familiar & acceptable

24. Step 4: Developing a Data Transmission and Processing System Information flows (including referral systems):  Horizontal data transmission  Vertical data transmission Use appropriate communication technology:  Paper-based  Electronic: Telephones, diskettes

25. Data Processing and Analysis  Paper-based systems:  Error-prone  Computerized systems:  Off-the-shelve versus customized  Decision support systems  Use of appropriate technology  Capacity-building

26. Step 5: Ensuring Use of the Information Generated How can we improve information use? 1.Ownership and relevance of the information must be felt among all potential users of the information, through active participation in the system design 2.Data need to be of appropriate quality, aggregated at the right level, and produced in a timely manner

27. Ensuring Use of the Information Generated (continued) 3.Performance-based management systems tend to increase use of information for decision making. 4.Cultural differences between data people and action people can be decreased through consensus building, teamwork, and training. 5.Data presentation and communication (feedback) should be customized for users at all levels.

28. Step 6: Planning for RHIS Resources Adequate staffing Adequate logistic system for printed supplies Computer hardware/software and maintenance Communications equipment HIS line-item in MOH recurrent budget

29. Analytical Framework for Understanding Performance of Routine Health Information Systems in Developing Countries

30. The Prism Framework The Prism, or three-point framework, is predicated on the assumption that improving capacity in RHIS (and subsequently performance) requires interventions that address  the environmental  behavioral determinants of performance, and  the technical determinants It broadens analysis of routine health information systems to include the behavior of the collectors and users of data and the context in which these professionals work

31. PRISM framework (From Aqui,2009)

32. RHIS Performance Diagnostic Tool 1.Data Quality Assessment at District or Higher Level 2.Use of Information Assessment at District or Higher Level 3.Data Quality Assessment at Facility Level 4.Use of Information Assessment at Facility Level

33. Prism tools (Aqil,2007)

34. Sources Aqil A, Hozumi D, Lippeveld T. 2005. PRISM tools. MEASURE Evaluation, JSI. Available online at: http://www.measure.com.http://www.measure.com Aqil A, Lippeveld T. 2007. Training manual on continuous improvement of HMIS performance: quality and information use; focus on HIV/AIDS services. MEASURE Evaluation, Guangxi and Yunnan CDC. Aqil, A, Lippeveld, T & Hozumi, D 2009, PRISM framework: a paradigm shift for designing, strengthening and evaluating routine health information systems. Health Policy and Planning, vol. 24, no. 3, pp. 217-228. Aqil, A., Lippeveld, T 2010, Improving RHIS Performance For Better Health System Management, Routine Health Information System Course Trainer Guide. Lippeveld T, Sauerborn R and Bodart C (eds.). Design and Implementation of Health Information Systems. Geneva: World Health Organization, 2000 Helfenbein, S. et al. (1987) Technologies for Management Information Systems in Primary Health Care. Geneva: World Federation of Public Health Associations

35. Sources (continued) MEASURE Evaluation http://www.cpc.unc.edu/measure RHINONet:http://rhinonet.orghttp://www.cpc.unc.edu/measure Shaw, V 2005, Health information system reform in South Africa: developing an essential data set. Bulletin of the World Health Organization, vol. 83, no. 8, pp. 632-636. Health Metrics Network: http://www.who.int/healthmetricshttp://www.who.int/healthmetrics WHO,2000. World Health Report 2000: Health Systems: Improving Health Systems Performance; World Health Organization: Geneva.

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