HEALTH MANAGEMENT INFORMATION SYSTEMS I

(HMIS 311)

DEFINITIONS

Data: Collected facts and figures which are in an unprocessed.

Information: Data which is processed and used for decision making.

Community Diagnosis: a quantitative and qualitative description of the health of citizens

and the factors which influence their health. It identifies problems, proposes areas for
improvement and stimulates action (World Health Organisation). It can also be defined as the
identification of the priority problems in the catchment area using a combination of the
situation analysis, the routine data available, and surveys.

The role of a community diagnosis is to identify factors that affect the health of a population
and determine the availability of resources within the community to adequately address these
factors.

Health Information System: is system that integrates data collection, processing, reporting,
and use of the information necessary for improving health service effectiveness and
efficiency through better management at all levels of health services.

District Health Information System: This is an open source software platform for
reporting, analysis and dissemination of data for all health programs.

Quality Management: This is an act of overseeing all activities and tasks needed to maintain
a desired level of excellence. It includes creating and implementing quality planning and
assurance, as well as quality control and quality improvement.

Information Technology: This refers to the computing and telecommunication technologies

that provide automatic means of handling information. IT is therefore taken to represent
equipment both hardware and software.

Information System: These are systems of human and technical components that accept,
stores, process, output, and transmit information. IS may be based on any combination of
human endeavours, paper-based methods and IT based methods. It provides information
support to the decision-making process at each level of an organization

Health Management Information Systems: This is an information system specially

designed to assist in the management and planning of health programmes, as opposed to
delivery of care.

INTRODUCTION TO HEALTH MANAGEMENT INFORMATION SYSTEMS

Routine data is always collected by Health Workers in the course of their duties. The
unfortunate thing is that most of the data is never used to improve health services being
offered. One of the reasons for this course is to enable you to convert data collected at Health
Facility level into useful, population-based information that answers basic questions about the
health of the people served.

Information for Community Diagnosis

Every time a patient visits a Health Facility, a history is taken to get information on what the
problem is, how long it has been present, how it has progressed, etc. after that an
examination is conducted to look at the affected area, feel it, move it and get a better idea of
what is wrong. Sometimes at this point a diagnosis can be made, but often additional tests
may be needed- laboratory tests, X-ray or other - to get a better idea of exactly what is wrong
and precisely what the diagnosis is.

In public health practice, you first take a community history and assess the current situation
by doing a situation analysis of your “patient” - the population you serve.

The first step is to define “who is your patient?” by determining the boundaries of your
catchment area and identifying the population that lives there. Often exact data on the
population is not available, or one community may use several health facilities, but it is
important to make an estimate of the number of people for which each facility is responsible.

This is your “patient”: the entire population you should be serving. That information is put on
a map that shows boundaries, roads, rivers, places where people live, where health facilities,
schools, churches and other community structures are. This allows your facility and the
community you serve to see at a glance where the health services are in relation to other
services and where the people live.
It is also useful for you to get information on your patient’s socio-economic status, education,
occupation, water and sanitation. These bits of information allow you to understand your
patient’s environment and its influence on his health.

Once this “history” is known, you should examine the records of your health facility to find
out the following:

 what the main health problems are in the community,

 who has these problems,
 where these problems occur,
 when in the year they happen, and if possible
 why they occur.
Unfortunately, in most facilities this information is not easily available and if available, is not
in an easy form to use.

The information from the DHIS (collected, analysed and graphed monthly) provides a
dynamic picture of the health status of a given population and the services provided to them.
It is the equivalent of the “medical record” of your “patient”.

Often there will be gaps in the information available and additional details will be needed,
particularly with regard to what is really happening in the community. These “special tests”
will sometimes merit the need for a special survey to obtain information not available from
routine clinic records.

These do not have to be highly sophisticated and scientific surveys. Often the most useful
information is gained from “walk and talk” surveys of health workers walking around their
communities and talking to the people who live there. This is sometimes referred to as a
“transact walk”

The community diagnosis is thus the identification of the priority problems in the catchment
area using a combination of the situation analysis, the routine data available from the DHIS,
and surveys conducted by the District Health Management Team (DHMT). The “treatment”
is development and implementation of an action plan to overcome these problems at a local
level. Unless there is adequate information, this action will be ineffective, as it will not be
based on real and proven priorities.
THE SCOPE OF DISTRICT HEALTH INFORMATION SYSTEM

The DHIS is a web-based information system that uses a combination of forms, procedures
and analytical tools to convert routine anonymous data (i.e. data that has no names attached)
into useful management information that can be used by local program and facility managers.
Data is collect from Health Facilities and submitted to the DHO where it is entered into the
computer. The District Information Office is supposed to provide the facility level staff with
monthly feedback on raw data and indicators. In order to get the maximum use of this
manual, it is essential for you to know generally how the computer system can be used to
improve information quality.

THE HEALTH INFORMATION SYSTEM

The DHIS attempts to answer the six classical epidemiological questions

i. Who gets sick?

ii. What conditions?
iii. When do they get sick?
iv. Where do they come from?
v. Why do they get sick? and
vi. How do we overcome the problems?

I. Who gets sick?

Information about who gets sick is collected on a set of data collection tools, client cards,
registers, tally sheets and data input forms. The patient record (or the clinic/client
card/book), provides the details of each individual (age, sex, residential area, height, weight
etc), their complaints and treatment given. It will identify individuals for follow up at facility
level, and is the legal record of that individual's interaction with the health care system. This
information is normally kept at the Health Facility for the patient and is not captured and sent
to higher levels.

Health facilities need to maintain a record of services provided. The DHIS uses:

 Tick registers where there is a need for patient identification with services
provided;
 Tally sheets where important conditions and services not needing follow-up are
recorded with a mark and with no patient identification;
 Program registers for Expanded Program of Immunisation (EPI), antenatal care
(ANC), family planning (FP), tuberculosis (TB), and chronics, where each
patient is recorded on a line and continuity of service to each patient can be
followed and tracked; and
 Reports, which contain the selection of these or “ticks” (services provided),
which are sent to the district each month.
The DHIS deals with aggregated, anonymous data; no individuals are identified in the
reports. Age group and gender information are used where appropriate to ensure that specific
target groups are given appropriate services.

The DHIS emphasizes the community aspects of health, looking wherever possible at the
entire relevant population to determine what proportion or percentage of them have a priority
condition or receive a given service. To do this, one uses rates, ratios and proportions to be
able to compare different sized populations with each other. You will be shown how these
are calculated.

The other important aspect of the DHIS is the emphasis on the people not coming for follow-
up of preventive services (immunisation, ANC), curative care (chronic conditions, TB,
sexually transmitted infections (STIs) follow-up) and rehabilitation. The emphasis on
reaching everyone in need of service “coverage” is an important concept of Primary Health
Care (PHC). Districts need to focus on who is not being reached and take measures to bring
them into the system or reach out to them on a continuing basis.
 II. What conditions?
The DHIS concentrates on diagnoses of local public health importance that are identified
in the situation analysis. The diseases tracked by the DHIS are all priority conditions on
which local staff can take action, such as:

 communicable conditions such as TB, STIs, diarrhoea and lower respiratory infections;
 chronic diseases affecting the elderly (diabetes, hypertension, etc.) and mental health
conditions;
 Minor ailments collected only on tally sheets with no details to record overall
workload.
The DHIS however does not just look at diseases. Emphasis is on:

 preventive activities such as FP, immunisation, and ANC;

 promotion of child nutrition using growth monitoring, birth spacing and vitamin A
supplements;
 Rehabilitation, developmental screening and early identification of important
conditions like hypertension or asthma.
Because of the flexibility of the DHIS to include various data fields, the data to be collected
can be adapted to the changing needs and interests of the staff at each facility. However, to
ensure that the same basic information is available from all facilities, a national committee
has determined the “essential data” that should be collected by everyone delivering PHC
services.

The Information Pyramid (also called the Information Filter) is a schematic way of
looking at the number of data items to be collected at each level of the health system,
allowing each level to gather data of importance and relevance to their daily work while
avoiding excessive data where no action is taken.

In this model the community is the foundation: it is where all information originates and
where most health service action takes place. Most data collected in the community and at
health facilities is of an operational nature and is not needed at district level. Therefore,
“filters” are put in place in the form of reports which send only the “essential data sets” to the
next level. Each of these data sets contains only theessential data of the next level, which get
smaller and smaller as one gets further from patients and the community.
The level closest to the people served must collect all needed data, but it uses information on
its inputs (days used, staff attendances) for its own local management. Districts tend to
monitor the process of service delivery at their facilities, while provinces are generally more
concerned about outputs (coverage of various services). The National level looks more at
outcomes of combined services while the World Health Organization (WHO) monitors
overall impact. These are general descriptions of the type of information most useful at each
level but are not exclusive to these levels.

Data from districts is processed, filtered and streamlined before being sent to the province
and a similar filtering process happens at provincial and national level, before being sent to
the international level. By getting general agreement around this filter process, each level is
aware of the needs of the next level and will collect and report the essential information they
require

Below is an information pyramid:

Health facility/Community level: The Facility level is more comprehensive and uses all the
indicator level viz: Input Indicators, Process Indicators, Output Indicators, Outcome
Indicators and Impact Indicators.

District level: The main indicators used at this level are the Process Indicators, Output
Indicators, Outcome Indicators and Impact Indicators.

Provincial Level: The main indicators used at this level are Output Indicators, Outcome
Indicators and Impact Indicators.

National Level: The main indicators used at this level are Outcome and Impact Indicators
International Level: From the above, it is shown that the Health Facilities use a more
comprehensive selection of indicators because they utilize all the classifications of indicators
in their planning.

The Input Indicators, Process Indicators, Output Indicators, Outcome Indicators and Impact
Indicators are also referred to as classification of indicators.

III. Where do clients come from?

The DHIS is based upon facility information so that all information can be related to the
geographical catchment area of the facility and the people who live there. In addition, the
facility register has more detailed information about whether clients come from within the
catchment area or from outside.

This information, plus local knowledge and personal observation, allows you to put health
data onto hand-drawn maps that illustrate the health of your population. The computer can be
used to prepare larger scale maps of entire districts or provinces using a Geographical
Information System (GIS). Many illnesses, such as cholera or typhoid, start in a local area
and spread from there. Early action based on knowledge of where clients are found can be a
powerful tool to control outbreaks of disease.

IV. When do people get sick?

The monthly DHIS data allows facility staff to graph conditions and use of services over time
and to compare numbers of cases in different months of the year. This prepares you to order
appropriate medicines and equipment for the time of year and to take appropriate preventive
actions.

12

10 10
9
8 8
7 Cases of Diarrhoea
6 per 1000
5 5 5 Cases of Cholera
4 4 4 cases per 1000
3 3
2 2 2 2 2
1
0 0 0 0 0 0 0 0 0
J F M A M J J A S O N D

V. Why do they get sick?

Most people get sick because of underlying social or economic conditions; water, sanitation,
diet, housing, education, and habits like smoking or sexual practise have more direct
influence over health than health services. These underlying causes are almost impossible to
determine from routine health data, but the DHIS provides information to enable research to
be focused on the most important conditions within a given population and to conduct special
inquiry into the causes (environment, poverty, behaviours, etc). A special module on
environmental health to guide environmental health officers (EHOs), will help link ill health
and disease outbreaks to the environmental situation underlying them. In this way, the DHIS
supports the development of health systems research capacity in each district.

VI. How do we overcome the problems?

Analysis of the DHIS identifies the common problems, the age groups that are affected and
the places they occur. This gives facility health managers the knowledge to plan, implement
and evaluate activities to overcome such problems. It shows where facilities are doing a good
job preventing illness and also illustrates which facilities are not performing and will need
additional support.

This comparison of individual facilities at district level allows weaker facilities to learn from
stronger facilities and has been shown to be a vital way of improving health services.
Similarly, facility managers can look at individual programs to identify those that are meeting
targets and help them to support others that are not performing well.

MANAGEMENT INFORMATION SYSTEM

When considering Management Information system, the DHIS answers five vital questions
which are:

i. What services exist?

ii. For whom are the services provided?
iii. Where are the services?
iv. When are services provided?
v. How much do they cost?

i. What services exist?

The DHIS offers a full spectrum of services which are to be offered. The services offered
needs to be balanced are meet the needs of the community. These services are:
  Curative services such as management of communicable disease, chronic conditions,
mental diseases and minor ailments.
 Preventive health services such as antenatal care, immunisation, FP
 Promotiveservices such as growth monitoring, health education, STI contact tracing
 Rehabilitative services such as food supplies for severe malnutrition or disability
care.
ii. For whom are these services provided?
It is ideal that all the intended people who need a service receive it when required. Many
DHIS indicators look at service utilization and the coverage of the community served and
thereby identify the locations from where the people have not come to get services. These are
the real challenges of public health and the PHC approach - to reach out to those people and
serve them too. Those people who have not been reached can be accessed using outreach or
mobile services.

iii. Where are the services?

The catchment area map, which is an integral part of the DHIS, should show all services
provided by each facility, including outreach points, satellite clinics, mobiles, non-
governmental organisations (NGOs), community-based organisations (CBOs), community
health workers (CHWs), traditional birth attendants and traditional healers.
A catchment area map will show the distances between each facility, roads and
communication systems, as well as populations not adequately served.
It is imperative that with the advent of technology,a Geographical Information System
(GIS)is used which can enable health workers to use the DHIS to plot maps depicting
electronically the service coverage (e.g. immunisation,ANC, FP) in different (sub) districts,
where specific diseases (e.g. malaria, measles, cholera) are occurring, and where services are
provided in relation to populations.

iv. When are services provided?

Most clinics are busy in the morning and quiet in the afternoons. With minimal effort, the tick
register or tally sheet can be adapted to convincingly show facility managers and health
workers when patients are coming. This allows facility managers to adjust staff schedules and
to develop booking systems that encourage chronic patients or others who may benefit from a
less pressured time (i.e. ANC Clinics, Under five Clinics etc) to come at times that are less
busy such as afternoons or special days. This is entirely consistent with the PHC policy and
improved quality of care while reducing waiting times. It is up to each clinic to adjust its
schedule accordingly to distribute workload and services throughout the day.

v. How much do they cost?

The DHIS has not dealt with financial data, as not much financial management has taken
place at facility level. Current in Zambia, Primary Health Care is offered free of charge.
However, clients in many parts of the country still incur some cost like buying of client book
or procuring of drugs in case they are out of stock.

PLANNING

What is planning?

A plan is a course of action one intends to follow in order to solve a problem. It is a systemic
approach to attaining explicit objectives for the future through efficient and appropriate use
of resources available now and in the future. A plan ensures that objectives are set to deal
with problems and to make best use of available resources. Plans, the result of such planning
decisions are therefore statements of intent concerning how resources will be used to achieve
set objectives

Planning questions that can be asked include:

i. Where are we now?

 This is referred to as the situation analysis where health facilities checks on their current
status in term of the disease trends and health service. Indicators need to be analysed so
that they can see where they are against the set targets and objectives.
When this is done, they can then put the priority health problems that the facility is facing,
the resources (human, financial, transport etc).
ii. Where are we going?

What are the goals we wish to accomplish? What objectives will we set ourselves for the
next period of time (usually a financial year)? What indicators will we use to measure
progress towards these goals and objectives?.
iii. How will we get there?

What is our strategy for action? Who will do what activities over what time period and with
what resources in order to achieve the targets we set?
This is a road map which shows how the target will be met. This is what is referred to as the
Action Plan. It is done by outlining the activities that will be done and interventions to
implement in order to reach the targets. Care need to be taken in choosing the interventions
so that the input and the output are the best. The most costly intervention is not always the
best.
iv. How will know when we arrive?

This is where the concept of Monitoring and Evaluation comes handy. What data needs to
be gathered in order to monitor and evaluate progress?
Rationale for Operational Planning

Purpose

1. Strengthen monitoring of health service delivery

 Coverage and quality of key health status indictors
 Service efficiency and efficacy & equity
2. Improve strategies to use information for management

Outputs

1. Formalized health management infrastructure

2. Formalized data flow & feedback mechanism
3. Formalized reporting mechanism
 Report format
  Reporting time lines

Determine District Health Priorities

 Identify national health priorities – 5 year strategic plan

 Correlate with district priorities – 1 year operational plan

MATERNAL HEALTH CHILD HEALTH WOMEN’S HEALTH

Antenatal care Immunization coverage Family planning
Delivery Malnutrition Cervical screening
HIV-PMTCT Diarrhoea STI’s
Respiratory Infection
HIV

• All planning starts with determining health priorities. One needs to review national,
provincial and district priorities as one starts planning
• Explore how managers and decision makers must establish a balance between health needs,
service demands and available resources at the operational level. These should be linked to
components of operational plans (essential ingredients) which are goals, objectives,
indicators, targets and strategies.
• Effective management (program planning) starts with identifying district priorities and then
allocating resources accordingly. This is normally a challenge because resources are never
enough to chatter for all the needs that may arise. One needs access to relevant, current
information in order to make informed decisions.

GOALS
A goal is the final target that we want to reach. This is normally set at national level by
political and health decision makers. Goals are:
 broad policies and long term objectives
 broad aims stated in general terms
 represent future direction

Those that are set at provincial and district levels by health managers’ form what is referred
to as the:
 5 year strategic plan
 1 year operational plan

OBJECTIVES
 The objective states exactly WHAT has to be achieved

Objectives should be SMART

Specific -measurable based on changes in situation concerned

Measurable -able to be easily quantified

Appropriate -fits in to local needs, capacities & culture

Realistic -can be reached with available resources

Time bound -to be achieved by a certain time

Examples of SMART Objective

Priority Area Objectives

To reduce malaria incidence rate from 28/1000 to 24/1000 by the end of

2017.
Malaria
To maintain malaria case fatality rate at 0/1000 by the end of 2016.
To increase the supply of ITNs from 1,540 to 7,399 by the end of 2017

ESSENTIAL INGREDIENTS OF AN ‘OPERATION PLAN’

Program: Maternal and Child Health

Goal: Improve Health Status of Children
Objective Indicator Target Key strategies Monitoring

To Improve full Immunization Increase FIC from Outreach and Quarterly

Immunization coverage rate 75% to 80% by end Static review
coverage from of 2016 Immunization
75% to 80% by services
end of 2016
To reduce Diarrhoea Reduce diarrhoea Health education Quarterly
morbidity incidence rate incidence rate to review
diarrhoea disease from 10/1000 to
from 10/1000 to 7/1000
7/1000 by 31st
December, 2016

• Goal -broad aim to address the health priority terms.

• Objective – more specific description of the health needs. Should be SMART
• Indicator -is very specific
• Targets must be realistic, have a time frame and must have a from (current status)
and a to (where we want to be).
• Key strategies andMonitoringtime frames is tools to keep us on tract to reach the
target.
 HMIS 322: HEALTH MANAGEMENT INFORMATION
SYSTEM II
THE INFORMATION CYCLE

According to Heywood and Rohde (2003:21) “the Information Cycle is a diagrammatic way
of looking at information and enables you to see the links between the different phases of
collecting, processing, analysing, presenting, interpreting and using information”.

Below is diagrammatic view of the information cycle:

DATA COLLECTION

This is the first stage and very important stage in the information cycle. It is cardinal that data
which is collected is of good quality and useful for decision making. If data collected is not
going to be used then it is better not to collect it at all.

To ensure comparability between different facilities, districts and provinces, data elements
and indicators need to be standardised.

Six ‘Ws’ of Data

 i. What is collected?
ii. Who is involved in Data collection?
iii. Where is Data collected and processed?
iv. When is Data collected and processed in each category?
v. Which requirements and constraints must be considered?
vi. Why is data collected and processed, clients of data from Health record and statistical
datasets?

Sources of Data

They are many sources of data for a health information system such as:

 Special surveys (e.g. Zambia Demographic Health Survey, the Census);

 Universities and NGO research;
 Line ministries (Home Affairs, Education and Agriculture) and
 Health Facilities.

In a Health Facility, data is collected from a variety of sources using different Data Collecting
tools. These Data Collection points are the points of contact between the Health Care
Provider and the Client. Note that the term Client is used here to indicate that people who are
attended to are not only patients. Other people may come for services such as family
planning, collection of drug refills, counselling and testing, general medical check-ups etc.

Data collection Points

Some of the Data collection points in a Health Facility are:

i. Outpatient Department (OPD): Collects data on patients who visit the clinic but do
not need to be admitted or kept for more than 24 hours.
ii. Inpatient Department (IPD): Collect data on patients who are admitted to the facility.
iii. Maternal and Child Health Services: Collects data on women who are pregnant or are
planning to get pregnant; it includes data on antenatal and postnatal. It also collects
information on Child Health Service such as growth monitoring and promotion
(GMP), and immunizations.
iv. Labour Ward: Collects data on deliveries, whether it was normal or not
v. Laboratories: Data collected here is on all the tests that are conducted in the
laboratories include the results.
 vi. Voluntary Counselling and Testing Services: Collects data on clients who come for
counselling and testing on voluntary bases.
vii. Tuberculosis Clinic: This section collects data on TB Patients who come is either
initial testing or coming for drug collection. The patients are also assessed to
determine how they are improving
viii. Antiretroviral Therapy Clinic: Collects data on all those clients who come to collect
ARVs to the facility. These are also assessed to determine how they are improving in
terms of their health.
ix. Environmental Department: Collects data relating to water quality monitoring,
sanitation and control of communicable diseases.

Data collection tools are used by Health Care Workers who work in these various sections to
collect data. They are a variety of data collection tools used which defer depending on the
department in question. An important point to remember is that Data Collection Tools should
be utilized at the point of service delivery or the point where data is generated. They should
be updated as soon as the client lives the service area.

Data Collection Tools

The main types of data collection tools used are:

a) Client Record Card: This is where the information of the client is entered and kept
on initial and subsequent contact with the Health Facility. The client record card or
book is the most detailed data collection tool and the data is more qualitative in
nature.
Information captured on the Client Record Card depends on the service that he or she
requires. If one visits the out-patient department, the information collected will
include:

 Name of Patient and number

 Date of Birth
 Sex
 Physical Address
 History of illness- Complaints (including duration of complaints)
 Further examination
 Laboratory test requested
  Final Diagnosis or refer if indicated.
 Treatment given

In most Zambian facilities, Clients cards are mainly kept at the Health Facilities and
Clients are given a number which is used for ease retrieval of information. For some
services however, Clients are allowed to keep their Cards. Challenges are mainly
faced because most facilities miss-file the cards. This can be attributed to lack of
qualified personnel in facilities to handle the records.

Examples of client records used are OPD Book, Under 5 Card, Antenatal Card, TB
Treatment Card etc.

Discuss the merits and demerits of keeping the record at the Health Facility and the
patient held system?

Which of the above mentioned cards is kept by the Health facility and which is kept
by the client?

b) Registers: The register aggregates what is reflected on the Clients Record Card. They
are records of data that need continuity such as conditions that need follow-up over
long periods such as ANC, immunisation, family planning, tuberculosis or chronic
illnesses.
Quality of care is vitally involved with continuity, far more than just the number of
services provided. Most priority program areas require continuity and should have
registers that enable a Health worker to see at a glance which patients have attended
clinics as expected and which need follow-up or tracing in the community. Regular
review of registers enable identification of patients who must be actively pursued to
assure completion of immunisation, timely continuation of contraception, full
treatment of TB, or regular monitoring and control of blood pressure.

Examples of registers include OPD, ANC, delivery, and full immunisation of the
infant.
 In the OPD, the register would only contain the Date when the Client visited the
facility, Name of the Patient, the sex, the age, the address, the final diagnosis and the
treatment given. Figure 1 below shows a sample of an OPD Register.

c) Tally sheets: This is a sheet used for checking, scoring or counting as clients are
seen. They are an easy way of counting identical data on condition that no follow-up
is required. They are used for headcounts, minor ailments, children weighed etc. This
data is important to collect to understand the frequency of a condition or the number
of services provided, but is not useful for follow-up or public health activities.

Data collected using a tally sheet is quantitative. Figure 2 below shows a sample of an
OPD tally.

d) Tick Sheet: This is also referred to as a ‘Check sheet’. It basically a document

demarcated into regions or columns and rolls and the user is only required to tick the
appropriate cell. Like the Tally Sheet, the data collected in this manner is more
quantitative. Figure 3 below shows a Child Health Activity Sheet and it is an example
of a ‘Tick Sheet’
 Figure 1: OUT PATIENT DEPARTMENT REGISTER

ID Date Name Age Sex Diagnosis Treatment Comment

Figure 2: OPD TALLY SHEET

Under 1

DIAGNOSES Year 1 to Under 5 Years 5 Years and Over Code

Total Total Total

NOTIFIABLE DISEASES
Acute flaccid paralysis (suspected 00000 00000 00000 00000 00000 00000
NTF05
poliomyelitis) 00000 00000 00000 00000 00000 00000
Cholera 00000 00000 00000 00000 00000 00000 NTF10
Dysentery 00000 00000 00000 00000 00000 00000 NTF15
Measles 00000 00000 00000 00000 00000 00000 NTF20
Meningitis 00000 00000 00000 00000 00000 00000 NTF25
4
3
2
1
No
Rabies
Plague

Date
Neonatal tetanus

Card
Number
Under 5
Attendance child
Figure 3: TICK SHEET

health <12 months

male
Attendance child
00000
00000
00000

Attendance

health <12 months

female
Attendance child
CHILD HEALTH

health 12–59 months

00000
00000
00000

male
Attendance child
health 12–59 months
female
Attendance child
health from outside
00000
00000

catchment area

BCG dose <1 year

00000
00000

Immunisation

OPV 0 dose

OPV 1st dose

00000
00000

OPV 2nd dose

00000
00000

OPV 3rd dose

NTF40
NTF35
NTF30
 DATA PROCESSING

Data Processing is an important stage in the information cycle. It is important that the data that is
used is of good quality.

Data Process involves:

 Collation
 Data Quality Checks
 Data verification
 Data validation

The main tools that are used during Data Processing are Collation Tools and Validation tools. In
HMIS, Validation is normally done by the DHIS software.

Data Collation is a process where data is put in the right order. They are four types of collation tools
and the first two are the main owns and are found in almost all Health Facilities.

The following are the collations tools:

i. HIA 1: This is a tool which is used to collect data on diseases. These are both
communicable and non-communicable diseases.
ii. HIA 2: This is a tool that is used to collect data on services that are offered to clients.
This service can be promotive, preventive or rehabilitative services.
iii. HIA 3: This is a tool that is used to collect Hospital Data.
iv. HIA 4: This is a tool that is used to collect community data. This tool is used by the
Community Health Assistants during their field Household visits.

DATA QUALITY

It is important that data collected reflects what is prevailing on the ground. This is because it is not
possible to make correct decision when the data is not of good quality. The main reason for learning
HMIS is to ensure that information is used for decision making.

In many Health Facilities, Health workers are experiencing work overload hence they simply collect
data without knowing why. In most cases, they send data to the next level without expecting
feedback unless it is to point out errors. The aim of DHIS is to improve coverage and quality of local
health services.

It is cardinal that all cadres share the burden of collecting quality data in the facility. The In-charge
remains accountable for the process of data collection and collation, however, he/she may delegate
the responsibility to support staff that can be trained to share this burden. This should be done
intelligently so as not to compromise on the quality.

What is Good Quality Data?

This is data that meets the 3 Cs of which are as follows

 Correct: Data which shows the true reflection of what is prevailing on the ground.

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  Complete: Data should be received from all the reporting sites.
 Consistent: Data should be within normal ranges.

Why is Good Quality Data Important?

Good Quality Data:

 Facilitates good decision-making,

 Facilitates appropriate planning,
 Facilitates ongoing monitoring and evaluation,
 Facilitates improved coverage and quality of care and
 Facilitates knowledge of an accurate picture of a health programmes and services.

It is important that data is used at local level, in order for it to be used locally, data should be:

 Available on time: This means that fixed dates for reporting should be put.
 Available at all levels: It should be clearly known who reports to whom and what
feedback mechanisms are available.
 Reliable and Accurate: Data should be checked to ensure that it meets the 3 Cs
(Correct, Complete and Consistent)
 Comprehensive: This means that Data should be collected from all possible sources.
 Usable: Data should be used for decision making. If no action will be taken from that
particular data then throw it away.
 Comparable: When collected, one should be able to compare one health facility with
the other. For this to be possible, it is necessary that same numerators and
denominators are used in formulating indicators.

COMMON PROBLEMS WITH DATA

 Large gaps
 Unusual month to month variations
 Inconsistencies- unlikely values
 Duplication
 Data entered in wrong boxes
 Mathematical errors
 Data present where they should not be
 Typing errors

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 DATA ANALYSIS

This is defined as the process of inspecting, cleansing, transforming and modelling data with the goal
of discovering useful information, suggesting conclusions, and supporting decision-making. It is a
process that turns good quality data into information that can be used for decision-making.

The main tools used during Data Analysis are Indicators. (NB: Refer to topic on indicators in HMIS
311)

What is data analysis?

A process that turns good quality data into information

Why do we analyse data:

It is important to analyses data because it facilitates:

 Comparison
 Assessment of progress towards targets
 Supports decision-making

How do we analyse data?

Data is analysed through the use of:

1. Basic epidemiological concepts: These concepts are basically epidemiological

questions that need to be answered. They are two sets of questions one referring to the
patients and the other referring to the services provided. The question that relate to the
patients are as follows:
i. Who gets sick?
ii. With what condition?

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 iii. Where are they coming from?
iv. When do they get sick?
v. Why do they get sick?
The following questions relate to the services provided:
i. What health services exist?
ii. For whom are the services provided?
iii. Where are the services provided?
iv. When are the services provided?
v. Why are the services provided?
vi. How much do the services cost?

2. Indicators
Epidemiology refers to the study of the distribution, frequency and determinants of
health. The use of health information is necessary to promote health and reduce
diseases. This is done by the use of indicators to answer basic epidemiological
questions.
When describing health problems, it is important to describe health problem by
Person, Place and Time (PPT)

Measures of Frequency

Frequencies of conditions or illness in epidemiology are either measured as Incidence (new cases
over a period of time) and prevalence (existing cases at one point in time).

When frequency is measure as a rate, it can either be measured as a proportion (numerator part of
the denominator) or a ratio (numerator not part of the denominator).

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DATA PRESENTATION

Data presentation is defined as the process of summarizing, organizing and communicating

information using a variety of tools. Data needs to be analysed and displayed to be functional
for decision making. The first step of data presentation is formulating of workable indicators.
For them to be useful, indicators need to be displayed in a manner that is easy to understand.

The main tools which will be discussed will be tables and graphs that can be readily seen and
understood. The main purpose of data presentation is to make data and information “Visible”
and meaningful to all who need it.

Tables

This is where data is arranged in columns and rows; they are normally in the form of figures
put in cells.

Beware Information Overload:

 Just because you can, it does not mean you must!

 Easy to produce – difficult to use

Uses:

 Trends over time

 Comparisons

 Pick up outliers

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Understand the following:

 What is the underlying data?

 What are the averages hiding?

Explore the advantages & disadvantages of using tables

Tables show figures as cells in a spreadsheet format and enable you to compare your facility
over time or against other facilities. They are easy to make, especially using computers, but
difficult to use, especially if they are big. Columns of figures can be intimidating and are
often a struggle to understand.

Example: Table with Outliers underlined

Immunisation Coverage under 1 year (annualised) Province Alpha

District Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06

District 1 69.6 54.2 62.3 57.9 94.9 79.0

District 2 71.2 67.5 73.9 65.9 77.3 93.3

District 3 64.6 67.6 109.6 70.4 88.4 76.4

District 4 85.6 69.6 23.1 77.7 90.3 86.8

District 5 77.5 71.0 78.1 65.5 86.5 69.8

District 6 100.1 85.6 113.3 81.7 212.6 100.6

District 7 78.8 73.8 57.6 99.1 96.6 67.7

District 8 75.7 76.1 88.9 78.3 84.7 82.2

District 9 97.0 94.5 68.0 82.0 93.8 71.4

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Page 29 of 69
GRAPHS

Types of graphs

They are various types and sub-types of graphs that have been developed. In the HMIS, we
are going to consider four main types and these are

 Line graphs
 Bar graphs
 Cumulative coverage graphs
 Pie charts

Graphs are a very important way of making sure that information is fully understood, as it is
easier to get a point across visually than with a mass of figures. Graphs should tell a story by
themselves and are essential at facility level (and all other levels) to:
 Summarise data
 Detect trends over time
 Search for patterns among large amounts of data
 Analyse the relationships between variables
Golden Rules for Graphs
 Hand-drawn graphs are the best they show that the team understands and cares about
the data.
 Never put too much information one the graph. Keep it clear and simple: usually one
indicator on one graph.
 Never mix different activities: stick to one group of people or diseases or services.
 Label your graph: always have a clear heading, easily read labels on the axes, and a
legend which explains each of the lines or bars.
 Select scales that fill the entire graph on both axes.
 Where possible, show a target line or reference point to show where you are aiming.

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 1. Bar graphs

Bar graphs are used to compare different facilities or unrelated activities. Use separate bars to
correspond to the size of the groups being shown.

A sub-type of a Bar graph is a ‘stacked bar graph’; this one is useful when you want to
include an element of comparison in your graph.

Features of Bar Graphs

 Displays data over time

 Can compare two or more facilities/ districts/ years
 Useful when you want to include an element of comparison in your graph.

Advantages

 Easy to draw each month

 Easy comparison and trends

Disadvantages

 Cumulative total

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 Many items confusing

• Bar graphs plot data values much like a line graph except that a bar is drawn from the
X axis to the plotted Y value.

• Each data series should be represented by a different color or pattern.

• Stacked Bar graphs work exactly like the non-stacked versions except that the Y
values from previous data sets are accumulated as each new data set is plotted. Thus,
bars appear to be stacked upon each other rather than being placed side-by-side.

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• As far as possible National and District targets should be displayed as target lines in
graphs.

• As far as possible National and District targets should be displayed as target lines in
graphs.

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 • Bar Graphs can be horizontal or vertical.

• It is useful to rank different facilities or district’s performance.

2. .Line graphs

These are the easiest graphs to draw, with data plotted as points joined to form a continuous
line.

The X-axis (across/horizontal) is usually time and the Y-axis (vertical) is the variable.

Features of Line graphs

 show patterns or trends of related activities over time

 Useful if more than one data item is to be displayed; if more than one data element is
displayed, it is importance to use different colours for the different data elements.
 Can be used for comparison of two or more items.

Advantages

 Easy to construct and understand

 Good way to make comparisons over time

Disadvantages

 Can be confusing if too many lines are drawn

 Total figures are not shown

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• Very powerful graphs for managers to monitor progress to set goals and targets.

• Note the difference between the monthly coverage value and the cumulative value.

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• Pie charts show the percentage that each data value contributes to the sum of all the
data values.

• In order to create a pyramid either the male or female values must be negative (left of
the Y axis) – the Y axis usually crosses the X axis at 0.

• Add the population totals for each year in even groups – usually 5 years age groups.

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FEEDBACK ON DATA

Feedback is very important in the information cycle. It can be defined as ‘the communication
of analysed information presented in an interesting way and interpreted in the light of local
reality’. Information informs the potential users of their action the vehicle used to inform
them is feedback. From the definition, it is noted that feedback is only provided once the
information has been interpreted and understood. (Heywood and Rohde, 2003)

The best way to improve the quality of information is to ensure that the individuals
submitting the data get feedback from those using the information on indicators. Feedback
reports will be provided at an early stage on.

 quality of the data; and

 Performance of the unit.

This encourages use of information at the lowest possible level and inculcates a drive to
improve the quality of submitted data so that the outcomes can be monitored.

WHY PROVIDE FEEDBACK

Feedback is important to provide the generators of data who are the Health Care Workers on
the following.

1. Data Quality. This will show the completeness and accuracy of the data that is being
generated at the Health Facility.
2. Feedback will also highlight the errors that may have been noted during the data
collection and processing. Other notable things that can be captured and
communicated when providing feedback are the data gaps and validation rules.
3. Lastly but not the list feedback provides information on the trends health services.

Apart from having direct benefits on the Health Care Workers,

4. feedback facilitates discussion making on data quality,

5. provides possible interpretation of data and
6. Potential users that the current information has.

QUALITIES OF GOOD FEEDBACK MECHANISM

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It is important to feedback provided is of good quality and appropriate for the people it is
presented to. To achieve this, feedback should be ‘CRISP’.

CRISP

C- Constructive Feedback should be constructive in that it should be able to build the

capacity of Health Care Workers. The focus should not be finding
faults of the Data Collectors and Processors but to help in improving
the service delivery to the clients.

R- Relevant Feedback should only be provided for information or indicators which

are relevant to the Health Facility or Health Care Workers.

I- Immediate It is cardinal that feedback is provided as soon as possible after the

data is analysed. If it takes too long, the feedback can be out of time
hence irrelevant to the Health Care Workers. Immediate feedback
ensures that corrective measures are promptly taken

S- Selective There is a lot of data that is generated in Health Facilities, it is not

possible to provide feedback on all the information that is collected
and sent to higher level. If this was to be done, it can easily be
information overload on the people who are receiving this feedback.
This can make them miss out on the most important aspects of the
feedback. It is for this reason that feedback is supposed to be selective.

P- Presentable In making feedback presentable, it will be easy for the recipient of the
feedback to understand what is being communicated to them

Effect feedback should show its relevance on the output, outcome and impact on the Health
Facility indicators (NB: refer to the information filter/pyramid)

 Output: This monitors the results achieved. Regular presentation of reports and
graphs enables Health Care Workers and management to be informed of the health
trends and can thus inform communities.
 Outcome: This monitors changes in health status of the population. It helps Health
Care Workers’ and Management to identify areas of service delivery that require

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 attention and request relevant information that is needed for strategic, technical and
operational planning.
 Impact: This measures the extent to which the goal has been achieved and is usual a
long time goal. It enables Health Care Workers’ and Management to better able plan
for the delivery of appropriate services that will improve coverage and quality
(equitable and adequate distribution of resources.

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DATA FLOW POLICY AND MECHANISM OF FEEDBACK

An example of a Data Flow is shown below:

M&E Committee
National M&E (HMIS)

Province Data League tables

Export and appraisal
NHO M&E
By 5th of 3rd month By 15th of 3rd month

Province M&E (HMIS)

Prov Director,
Prov Programme
League tables
DMS District Data Export
and appraisal
By 30th of 2nd month By 20th of 3rd month

District M&E (HMIS)

Director, DHIO,
Programme focal persons
Summary sheets & Self League tables
Data &
assessment and appraisal
performance
By 7th of 2nd month by 30 of 2nd month
th By 30th of 3rd month

Health Facility
Sister in Charge

HIA (Monthly
Summary Report)
DailyTally
Sheet

Date due:
Every D/W/M

Patient As Patient Facility

Record Consulted
Registers

The data flow above is a two-way data vertical flow emphasising the importance of providing
feedback to the lower levels.

Why is information disseminated?

It is important for information to be disseminated as illustrated above in that it:

 Facilitates monitoring of progress made towards achieving stated objectives against

set targets,
 Aids in sharing knowledge by providing feedback on performance and,
 Promotes understanding by making sense out of the information.

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How should Data be disseminated?

Data should be disseminated through the use of standard reporting formats and adhering to
the report time frames. The reporting format can be in form of tables, graphs and reports.

FEEDBACK AND STAFF MOTIVATION

For a Health Management Information System to work effectively, HCW must have goals
and target which they should aim to reach. These are set in the light of the indicators that are
formulated.

Staffs feel motivated if they are provided feedback on the work that they do. Feedback
provides information on the progress on the work that they are doing, their achievements and
areas of improvement. This is critical to ensure that they improve their performance by
enhancing ability, encouraging and acknowledging results.

Feedback may be provided the higher level in a formal or informal manner. Informal
feedback can be verbal and provided whenever the supervisor feels necessary. Formal
feedback is mandated to be provided by a specified data in the data flow. For example, the
District is mandated to provide feedback to the Health Facility by the 30th of the 2nd Month of
reporting.

An effective feedback mechanism helps to reduce employee mistakes, enhance performance

and increase efficiency in Health Service Delivery

IMPORTANCE OF GIVING EFFECTIVE FEEDBACK

Giving effective Feedback can benefit both the HCW and the Organisation as a whole in that
it can contribute to:

 Persistent effort
 Learning and personal growth
 Creativity and skill development
 Improved job performance
 Improved morale
 Increased job satisfaction

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 Building and maintaining healthy professional relationships
 Generating meaningful discussions
 Establishing a shared understanding about goals and the standards of performance and
achievement
 Reducing uncertainty about what should be achieved and how it should be achieved
 Communicating wider organizational requirements

WHAT SHOULD BE IN A FEEDBACK REPORT

Class work: Discuss what you would expect to find in a feedback report.

They are certain characteristics that a feedback report should always have and these are as
follows:

 Timeliness in reporting for the Health Facility.

 Completeness of reports that the Health Facility submits to the district.
 Comparison to other facilities with respect to various indicators (participants might
provide details of indicators).
 Where my facility stands in comparison to district targets/standards.
 Information tells me whether my performance has improved over time.
 Information tells me that I need to improve my performance.

Class Exercise

A district received the following information for the year 2015 from its facilities. From the
information provided, provide feedback to the Health Facilities by:

i. Comparing the performance of the health centre in relation to other facilities.

ii. Comparing the performance over time in quarters.
iii. Provide comments on what you notice from your analysis

DISTRICT
PROFILE %
0-11 4%
12-59 months 16%

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 Comparing Among other Health Facilities
Health Facility A B C D
Population 1000 1500 2500 800
ANC 65 80 110 50
Fully Immunised 35 55 70 30
Malaria in Under Fives 120 140 100 100
Pregnant Women Delivering at Facility 60 70 85 40

Fully Immunised % 88% 92% 70% 94%

Malaria incident rates per 1000 24 18.66667 8 25
Deliveries 92% 88% 77% 80%
Comparing Performance Over Time
Health
Facility Q1 Q2 Q3 Q4 Total
A Fully Immunised 10 15 10 30 65

Malaria in U5 35 30 25 30 120
0
B Fully Immunised 10 15 15 15 55

Malaria in U5 40 35 30 35 140
0
C Fully Immunised 10 15 20 25 70

Malaria in U5 25 20 35 20 100
0
D Fully Immunised 10 8 7 5 30

Malaria in U5 30 25 20 25 100

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INTERPRETATION OF INFORMATION

a) Data handling processes for interpretation of data.

b) Factors influencing the interpretation
c) Preparation for interpretation: Essential ingredients
d) Interpretation as a tool in decision-making
e) The risks of manipulation

As discussed earlier, the information cycle helps use understand how data flows from
collection up to when it is developed into information for use. In the information cycle once
data is collected, it is processed, analysed and presented. At presentation stage, the figures are
no longer data but information since the analysis would have been done. After presentation
stage, the information has to be interpreted.

What is Interpretation?

Interpretation of information refers to the process of making sense of the numerical data that
has been collected, analysed and presented. For information to be accurately interpreted, one
has to take a closer look and the analysis and practice critical thinking skills.

Critical thinking refers “the intellectually disciplined process of actively and skilfully
conceptualizing, applying, analysing, synthesizing, and/or evaluating information gathered
from, or generated by, observation, experience, reflection, reasoning, or communication, as a
guide to belief and action.”

Remember that Interpretation of HMIS Information comes after the analysis has been done.
Hence Interpretation will basically come from the analysis.

Interpretation involves:

 Examining the analysis closely;

 Presenting a coherent or logical argument;
 Drawing a conclusion and
 Summarizing

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Sometimes, it may be discovered that one has not collected sufficient data to come up with an
ideal interpretation of the information. However, the current HMIS system data collection
(through the DHIS) collects most of the relevant data that one may require to come up with a
logical conclusion. It is however important to note that data collected is mainly quantitative
hence it comes with its own advantages and disadvantages.

Figuring out what the data means is just as important as collecting it. Even if the data is
soundly collected, the data can easily be misinterpreted. When interpreting data it is
important to discern the difference between causality and coincidence but also consider all
possible factors that may led to a result.

PREPARATION FOR INTERPRETATION: ESSENTIAL INGREDIENTS

Accuracy checks

Good quality data should satisfy the 3Cs which is Correct, Complete and Consistent.

 Routine & trends over time

 Per month, per facility, per district
 Minimum 6 months raw data & indicators: For one to make effective interpretation
there is needs for at least 6 months of good quality data.

Local knowledge

Local knowledge entails understanding the community metrics in terms of:

 Population data
 Health data
 Service data

These can be supplied by other government agencies like the Central Statistical Office
(CSO), other ways one can use is conducting effective Community Diagnosis.

Consider the following examples of analysed data:

1. If you discover that the percentage of fully immunised children is 90% you may feel
comfortable to conclude that 90% of the children in the catchment area are fully

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 immunised. However, it is important to know that this might not be the case. This is
because the 90% maybe out of the children who are coming for the under five clinic
and it may be that this is just half for the children in the catchment area.

There, when making interpretation, it may be necessary to find out what the number
of the children in that particular catchment area is.

2. Consider the HIV positivity rate (Number HIV positive/Number Tested). If we told
that the positivity rate is 20%, many people would conclude that 1 in 5 people in the
population HIV positive. But remember that positivity is calculated out of those who
went for VCT or were test after visiting the Health Facility following an illness. And
those people may have higher chances of being positive or suspect they could be
infected with the virus.
3. Sometimes they may be situation were a Health Facility is over performing when
compared with other Health Facility with a similar profile. This could be so because
they may be seeing a lot of clients from outside the catchment area or maybe their
Health Facility Demographical profile is not accurate. This happens when the Facility
is given a lower population that what is actually supposed to have.

The main tools that are used in the Interpretation of Information are:

 Explore
 Ask Questions
 Research

Explore

This entails making a care investigation of the information that has been availed to you. One
has to search, read between the lines and discover what is not readily open to the eye. What
may seem as a simple matter which is easily understood may just be a tip of an iceberg.

Ask Questions

When making conducting interpretation, some of the important questions that one may need
to ask are as follows:

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How did you manage to reach this level of performance? How come you reached this
indicator target but failed to reach on this other similar indicator. For example if from the
analysis a facility indicated that they reached 85% Antenatal visit but only 20% postnatal. It
will be necessary to probe further on how come that is so.

Or if the Health facility record a high rate of family planning and also high rate of Antenatal
booking

Why didn’t you reach the target? This is an important question if you notice that a facility has
reached its set target or constantly fails to reach the target.

The possible explanation could be that people are preferring going to the neighbouring
facility.

Or may be why is that their STI incident rate is very high while the HIV prevalence rate is
very low.

Where did you go for you to reach those numbers? This can be asked if a facility records
unusually high numbers of clients or the coverage is more than 100%. For example, if you
discover that the proportion of children weighed (number of children weighed/ number of
children targeted in the catchment area) is 110%, it would be important to find out how come.

What did you do for you to make that marked improvement? This can be asked when you
realise that the facility has made sharp improvement when trends are analysed overtime or
when compared to the previous periods.

Research

Sometimes, it may be necessary to carry out a research following interpretation. These does
not always have to be a long complicated process. A research can as well be a desk review
where one simply analyses the data that the facility has. It can also be done by simple have a
meeting with the community and discussing issues that you would have particular interest.

The research can be for various reasons such as:

i. Finding out why people are women are coming in numbers for antenatal but are
shunning postnatal services.

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 Possible reasons: Incentive for those coming for antenatal while those incentives are
not provided for those who are coming for postnatal.

ii. Finding out why a lot of clients prefer to go to the other facility and not yours OR
why they prefer yours than their other.

Possible reasons: One facility may be offering a comprehensive care or more or better
services than the other.

iii. Finding out why the cases of STIs are markedly higher than those of HIV

Possible reasons: It may be the that particular community have no receptors required
to contract the HIV virus or they had run out of test kits for HIV hence conducted
very few tests.

iv. Finding out why children weighed is more than the 100% target.

Possible reason: Some of the possible explanations could be that they were a lot of
children who were seen from outside the catchment area and added to the target. Or
maybe the target given by CSO was under estimated

v. Finding out why there is marked improvement in the general health facility indicators.

Possible reason: The facility has improved staffing levels.

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USE OF INFORMATION FOR MANAGEMENT

Information is the centre core of the planning cycle and should provide the answers to the
planning questions. These will be discussed in more details below.

However, just having information does not mean that managers will use it. Information use is
made easier if its use is ritualised and routines are set up as part of the “information culture”.
In other words, everything done at a facility must be on the basis of information. Every
action an activity should be based on information provided.

Every decision made, every action taken, and every change made should be guided by
information coming from within the facility and influenced by outside policies, norms and
regulations. Acting without information is like shooting in the air and hoping to kill a bird.
You may kill one by chance but your success is doubtable.

For information to be used effectively it must be:

 Relevant
 Good quality
 Presented in user-friendly ways
 Available where it is needed
 Available when it is needed

Without an effective information system, information will not be reliable and will not be
trusted and used by managers. Use of unreliable information is a waste of resources in terms
of finances, human resource and time.

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Planning questions that can be asked include:

v. Where are we now?

This is referred to as the situation analysis where health facilities checks on their
current status in term of the disease trends and health service. Indicators need to be
analysed so that they can see where they are against the set targets and objectives.

When this is done, they can then put the priority health problems that the facility is
facing, the resources (human, financial, transport etc).

vi. Where are we going?

What are the goals we wish to accomplish? What objectives will we set ourselves for
the next period of time (usually a financial year)? What indicators will we use to
measure progress towards these goals and objectives?.

vii. How will we get there?

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 What is our strategy for action? Who will do what activities over what time period
and with what resources in order to achieve the targets we set?

This is a road map which shows how the target will be met. This is what is referred to
as the Action Plan. It is done by outlining the activities that will be done and
interventions to implement in order to reach the targets. Care need to be taken in
choosing the interventions so that the input and the output are the best. The most
costly intervention is not always the best.

viii. How will know when we arrive?

This is where the concept of Monitoring and Evaluation comes handy. What data
needs to be gathered in order to monitor and evaluate progress?

Types of Planning

They various types of plans depending on the objective of the organisation planning and these
include.

i. Operational Plans
ii. Tactical Plans
iii. Strategic Plans
iv. Contingency Plans and
v. Action Plans

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 • Both cycles are important for effective planning and monitoring of services and
programmes.
• Indicators are the link between the two cycles. Let us take an example of
Immunisation coverage. The manager has to know how the district is performing
presently and where they want to move to in terms of coverage (planning cycle). If
however facilities collect the data incorrectly (they do not understand the definition of
“fully immunised < 1 year” or forget to tick the element when they do the measles
injections) key strategies and interventions might be inappropriate (for e.g.
unnecessary expensive campaigns) if the data is incomplete or incorrect.
• Managers should always link activities in both cycles.
• Effective indicators (sensitive enough to monitor changes in the health environment)
will enable managers to monitor the progress made toward set goals and targets as
well as to identify challenges in the processes involved to produce good quality
reliable information.

TARGETS
- Operational Objectives

 State exactly what has to be achieved.

 A realistic point at which to aim to reach an indicator which measures an objective.

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  Turning the objective into number terms

Targets:

 Steps to aim for along the way to the objectives (in shorter time periods)

Benchmarks:

“Expected targets”

 Minimum standard that should be aimed for

To use or not to use

People will spend a lot of time collecting data and ensuring that the data is of good quality
but not used. They are many reasons why officers would not use data and these could not be
exhausted here. Some of the reasons could be that:

 People want data just for academic purposes.

 Information overload.
 Bad management

PRINCIPLES OF HEALTH MANAGEMENT INFORMATION SYSTEMS

In order to meet the needs of health facility, district, provincial, national and international
levels including partners in health, a number of principles have been adopted in HMIS.

It is important to appreciate the use of information at local level hence the concept of
‘Information Pyramid’ or the ‘Information Filter’ will be discussed. After which ‘DART
Principles’ will be explained.

DART Principles

The DART principles are summarised as follows:

Decentralisation In support of decentralised management of services, health information
must be available locally. HIS must also be able to be adapted to address local information
needs (for example, quantification of the influx of refugees who use the health services)
Action oriented Information should be used to improve service delivery, not just to address

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reporting needs to higher levels. The information system should be designed to support the
needs of its users – this motivates them to provide quality data.
Responsive This characteristic refers to the ability of the information system (the database
and the processes related to the data collection, collation and analysis) to be adapted to
respond to changing needs, and to the timeliness of the data. The latter is often a function of
the processes related to the information system, rather than to the data base itself.
Transparent Data should be made available to all partners, and should be able to be
aggregated and disaggregated to obtain different degrees of granularity. Analysis should
highlight inequities so that these can be rectified.

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MONITORING AND EVALUATION

In every organisation and project there is need to assess whether or not it is making progress
in the activities it is undertaking. This progress is measure routinely in the day to day running
of the programmes (monitoring) and at the end of a specified timeframe (evaluation). This is
what is referred to monitoring and evaluation (M&E). Indicators are cardinal in the process of
monitoring and evaluation because they are the measuring sticks that we would use.

PROGRAM PLANNING

Program Planning refers to a system put in place in order to achieve agreed objectives.

In program planning, resources have to be put in place to ensure that the objectives are met.
As in many other areas, the reality in public health is that the demand will always out-balance
the resources available. Due to the above, prioritization of the health programs cannot be over
emphasized.

Managers should endeavour to seek a balance between population, health and service so as to
ensure equitable distribution of available resources. It is their responsibility to monitor and
evaluate progress towards providing improved coverage and quality on an on-going basis. To
do this, they need current and relevant information.

Some of the areas that need to be considered include:

 Expenditure – per level (Primary Health Care verse Hospital)

 Promotive & preventive health care
 Preventive disease control
 Curative services
 Reasonable access
 Training of HCW’s
 Adequate resources & supplies

It is cardinal to know that investing in Primary Health Care, Promotive and Preventive Health
Care and Disease prevention are mostly cheaper and more economical.

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WHAT IS MONITORING?

This is defined as a routine process of data collection, analysis and measurement of progress
towards objectives.

It is the routine, on-going assessment of activities applied to assess:

– resources invested (inputs) in programs

– services delivered (outputs) by programs
– outcomes that are related to programs

TYPES OF MONITORING

Monitoring is the systematic and routine collection of data during project implementation for
the purpose of establishing whether an intervention is moving towards the set objectives or
project goals. In this case, data is collected in all areas of the generate HMIS data. There are
several types of monitoring in M&E and they include process monitoring, technical
monitoring, assumption monitoring, financial monitoring and impact monitoring.

1. Process monitoring/ physical progress monitoring

In process monitoring, routine data is collected and analyzed in order to establish whether the
tasks and activities are leading towards the intended project results. It authenticates the
progress of the project towards the intended results. This kind of monitoring measures the
inputs, activities and outputs. In other words, process monitoring answers the questions “what
has been done so far, where, when and how has it been done?” Most of the data collected
during project implementation usually serves this kind of monitoring.

2. Technical monitoring

Technical monitoring involves assessing the strategy that is being used in project
implementation to establish whether it is achieving the required results. It involves the
technical aspects of the project such as the activities to be conducted. In a safe water project
for example, physical progress monitoring may show that there is little or no uptake of
chlorination as a water treatment strategy. Technical monitoring may establish that this could
be a result of installing chlorine dispensers at the water source and women are too time

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constrained that they have no time to line up to get chlorine from the dispensers. This may
prompt a change of strategy where the project might opt for household distribution of bottled
chlorine.

3. Assumption monitoring

When one is tasked to run a project, it will have its working assumptions which have to be
clearly outlined in the project log frame. These assumptions are those factors which might
determine project success or failure, but which the project has no control over. Assumption
monitoring involves measuring these factors which are external to the Health Facility or
project. It is important to carry out assumption monitoring as it may help to explain success
or failure to meet a set objective.

For example, you may be working with a partner in the promotion of the use of
contraceptives (i.e female condoms) then you realize that uptake of use of contraceptives has
dropped. The drop in use of the contraceptive could however, be attributed to increased
taxation on the importation of contraceptives in the country which makes them more
expensive for the partner to procure, rather than on project failure.

4. Financial Monitoring

Just like the name suggests, financial monitoring simply refers to monitoring the expenditure
and comparing them with the budgets prepared at the planning stage. The use of funds
allocated for activities is crucial for ensuring there are no excesses or wastages. Financial
monitoring is also important for accountability and reporting purposes, as well as for
measuring financial efficiency (the maximization of outputs with minimal inputs).

5. Impact Monitoring

Impact monitoring is a type of monitoring which continually assesses the impact of activities
to the target population. Indeed, impacts are usually the long term effects of activities. In
HMIS, there emerges a need for measuring impact change in order show whether the general
conditions of the intended beneficiaries are improving or otherwise. In this case, Monitors
monitor impact through the pre-determined set of impact indicators. Monitoring both the
positive and negative impacts, intended and un-intended impacts of the activities becomes
imperative.

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For example, in a Water and Sanitation program, there may be a need to monitor the change
in Under 5 Mortality in the program area over time. In this case, rather than being identified
as an impact evaluation, this would be identified as impact monitoring.

WHAT IS EVALUATION?

Evaluation on the hand is a non-routine use of methods to systematically investigate a

program’s effectiveness and impact. It looks at outcomes and impact. It is concerned with the
evaluation of the program’s impact on the health and lives of the community involved. It is
important to note that sometimes there may be overlap between monitoring and evaluation.

Evaluation take place periodically and gives overall information on achievements and
answers question like who has benefited, in what way and to what extent.

Implementation of Plan

In order to implement any plan, resources are needed to perform activities to achieve
objectives, so as to reach the goal. Resource can range from human, material and financial.

Resource  Activity  Objective  Goal

Each of the steps of a plan has measurable components which are put in form of indicators.
Indicators reflect measurable components

NB: Refer to the Information Pyramid

Strategic and operational plans often have a lot of input indicators. They measure of events or
actions, but limited outcome and impact indicators.

Strategic and operational plans should also measure outcome and very importantly longer
term impact of health interventions.

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Effective indicators are sensitive enough to monitor changes in the health environment. They
will enable managers to monitor the progress made toward set goals and targets.

Elements of a Good M&E System

Data Collection, Analysis and Use

 Identification of common indicators that are RAVES

 Baseline data to get an idea of current status
 Setting of realistic targets that are SMART
 Ongoing data collection on identified indicators by all role-players.
 Data analysis at all levels.
 Reporting and dissemination of results.
 Data use for operational and strategic planning

Each of the above elements is important and neglecting any one element makes the
Monitoring and evaluation system less effective

Information Cycle Vs Planning Cycle in M & E

In carrying out monitoring and evaluation, both the Information and Planning cycles are
important. The Information cycles is concerned with the process while the planning is
concerned with the Planning Cycle is concerned with the Progress.

Both cycles are important for effective planning and monitoring of services and programmes.

Indicators are the link between the two cycles. Let’s take Immunisation coverage as an
example. The manager has to know how the district is performing presently and where they
want to move to in terms of coverage (planning cycle). If however facilities collect the data
incorrectly - they do not understand the definition of “fully immunised < 1 year” or forget to
tick the element when they do the measles injections (problems in the Information cycle) key
strategies and interventions might be inappropriate (for e.g. unnecessary expensive
campaigns) if the data is incomplete or incorrect.

Managers should always link activities in both cycles.

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Effective indicators (sensitive enough to monitor changes in the health environment) will
enable managers to monitor the progress made toward set goals and targets as well as to
identify challenges in the processes involved to produce good quality reliable information.

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NATIONAL INFORMATION COMMUNICATION TECHNOLOGY (ICT) POLICY

ICT is a generic term which is used to express the convergence of telecommunication,

information, broadcasting and communication.

The world has embraced ICT as an enabler of social and economic development. This is
because it is receiving focus at various fora as demonstrated by the United Nations MDGs
and the World Summit on the Information Society (WSIS). Both fora have resulted in the
promotion of information and knowledge based society as the basis for creating wealth.

Zambia acknowledged the importance of ICT and approved as a priority sector in the 5th
National Development Plan 2006-2010. It was therefore integrated into government
departments and line ministries.

i. Human Resource Development;

ii. Agriculture;
iii. Tourism, Environment & Natural Resources;
iv. Education;
v. Health
vi. E-Commerce
vii. E-Government
viii. Youth and Women
ix. Legal & Regulatory Framework
x. Security in Information Society
xi. Access, Media, Content and Culture
xii. ICT Services

ICT and Health

The potential of ICT in contributing to the efficient and effective performance of the health
sector is very high especially in remote diagnosis and treatment. Timely collection,
management and dissemination of critical information has significant bearing on the
performance of the sector in general.

To this extent, the health sector has embarked on reforms that include development of Health
Management Information Systems at various levels. Equally important is the Telemedicine

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programme being initiated as a deliberate effort to maximise the services provided by the few
but highly experienced medical personnel whose services can only be extended through
technologies such as Telemedicine. Therefore, connectivity of medical institutions to services
such as telecommunication and Internet is an important milestone in the use of ICTs in the
health sector.

Telemedicine also can be used to provide both basic and continuous skills transfer to health
professionals. This will help mitigate isolation of health professionals in rural areas. The
dissemination of medical information through ICTs will facilitate informed decision-making
particularly in hard to reach areas.

ICT is the backbone of an effectively operating HMIS.

Challenges in Implementing ICT policy in HMIS

i. Lack of appreciation of ICT by health care worker who feel it’s just unnecessary
increase of work pressure;
ii. Lack of power supply in some areas which make its continuous use a challenge;
iii. Limited internet access in some parts of the country;
iv. Low ICT literacy in the country, which is a major obstacle to the development of
Zambia’s information society;
v. High cost of technology acquisition, thus making ICT technology and skill
development programmes inaccessible to most Zambians;
vi. The ´Brain Drain problem, which is resulting in considerable loss of the few skilled
personnel from Zambia to other countries in search of better job opportunities;
vii. The need to improve ICT Infrastructure to support basic communication systems and
specialised applications such as telemedicine;
viii. Inadequate ICT awareness and skills among health professionals to effectively utilise
the ICT tools and services;
ix. Inadequate support services for installed ICT equipment especially in rural areas;
Exercise: What are the merits and demerits of using ICT in delivery of Health services?

SECURITY IN THE INFORMATION SOCIETY

In general, one of the greatest concerns in ´connectedµ societies is security of information

passing through networks and systems such as computers, financial transactions, health

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records etc. As Zambia embraces ICTs, more security concerns and abuse shall arise if no
counter measures are put in place.

Already, Zambia has experienced cases of misuse of ICTs especially with respect to
corrupting website content. The proliferation of Internet and other ICT applications will also
create opportunities for misuse. However, with measures such as implementing security
policies, laws and technology solutions aimed at securing information, networks and systems,
the impact can be mitigated.

Therefore, every effort shall be made to ensure that as the country adopts implements and
uses ICTs in all spheres of life, security measures are put in place to minimise negative
impacts on society at large.

Specific challenges include:

i. Security of government, public and private networks and communications systems

in general; and in particular those systems carrying sensitive and critical
data/information of great value to Government, businesses and individuals;
ii. Protection of networks and information systems to guard against various types of
malicious crimes and unauthorised access; safeguarding against undermining
consumer confidence in online services including those based on E-Commerce, E-
Government and E-Health systems;
iii. Privacy of individuals, businesses and Government arising from connectivity to
local, national and global networks.

COMPONENTS OF A STRONG HEALTH MANAGEMENT INFORMATION

SYSTEM

It is important that a country builds a strong HIS in order to foster better information, better
discussion making and better health. This topic will describe what makes a strong HIS and
the components that it should have.

Six Key Components

These components are put into three categories which are input, process and output.

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Input Process Output

1. Resources 2. Indicators 5. Information Products

3. Data sources 6. Dissemination and
4. Data Management use

1. HIS Resources: This looks at the structural and physical requirements that need to be
put in place before a strong system can be built. This includes legislative, regulatory
and planning framework. The resources include everything the system needs from
office supplies to computer systems, the staff and their capabilities and the policies
that allow the system to operate.

Others are personnel, financing, logistic support, information technology and

communication systems.

2. Indicators: these are cardinal in the measurement of progress or lack of it. Indicators
measure determinants of health, health system and health status. An ideal indicator
should be Relevant, Appropriate, Valid, Easy and Specific/Sensitive (RAVES)
3. Data sources: Data sources should be both periodic and continual. This provides the
best quality information most efficiently. An example of periodic data is population-
based sources such as population surveys and census. Continual sources are individual
patient records, service records etc.

An integrated HIS pulls together data from a range of sources and integrated them
into manful information products that can be readily accessed and used.

4. Data management: Good data management is important in order to get the best
collection, storage, quality-assurance, processing, compilation and analysis of data.

Once data has been collected and stored, it needs to be processed and compiled in
such a way that the data can easily be compared and collated with information drawn
from other sources, so that data is not duplicated, mistakes are identifies and
corrected, and accuracy and confidence levels can be measured.

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5. Information Products: Once data has been transformed into information, only then can
it be used by decision makers to improve health care. Information can only be
produced in form of dashboards, reports, queries and alerts.
6. Dissemination and use: the value of information is enhanced by being accessible to
decision makers and by providing incentives for information use. It is important to
connect data production to its use so that all those who contribute to the system have a
part in ensuring that the system is strengthened.

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STANDARDS AND STANDARD OPERATING PROCEDURES

Standard: level of quality attainment.

An important aspect of a quality system is to work according to unambiguous Standard

Operating Procedures (SOPs). In fact the whole process from sampling to the filing of the
analytical result should be described by a continuous series of SOPs.

Let's say you worked at a pet store and a customer comes over asking if they can return a
used dog toy. How do you handle this situation? Perhaps if there were written rules or steps
that the company provided you, you would know how to respond. Or, maybe you are a
manager who trains employees over and over again how to properly build a counter top.
What could save you time in the future? You could write down exactly which steps to follow
and make them accessible to each new employee. These are called standard operating
procedures.

A SOP can be defined as:

"...a document which describes the regularly recurring operations relevant to the quality of
the service/program. The purpose of a SOP is to carry out the operations correctly and
always in the same manner. A SOP should be available at the place where the work is done".

They are written instructions intended to document how to perform a routine activity

A SOP is a compulsory instruction. If deviations from this instruction are allowed, the
conditions for these should be documented including who can give permission for this and
what exactly the complete procedure will be. The original should rest at a secure place while
working copies should be authenticated with stamps and/or signatures of authorized persons.

Standard operation procedures (SOPs) document the steps of key processes to help ensure
consistent and quality output.

Many companies rely on standard operating procedures to help ensure consistency and
quality in their products. Standard operating procedures are also useful tools to communicate
important corporate policies, government regulations, and best practices.

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Benefits

In order to provide quality health care to the clients, strict adherence to a set of instructions
need to be followed to ensure the intended outcome occurs. Even the best employees don't
have perfect memories, so having a set of written instructions they can refer to when
performing the steps of the process ensures everything is done correctly. When new HCWs
are trained, standard operating procedures help keep their training fresh and serve as
important reference tools. Copies of standard operating procedures should be available at the
actual location where the work is being done. This not only ensures the people that need them
can access them, but it also demonstrates the company's efforts to communicate policy and
regulation to employees.

The benefits of having SOPs in place are:

i. They ensure provision of quality health care service to the clients.

ii. Help newly trained HCWs to properly adjust to the tasks they are required to do and
do the tasks confidently.
iii. They save as a reference guide for the tasks that need to be undertaken

Examples of SOPs

The following are some of the SOPs used in health care service

i. SOP Laboratory Procedures

ii. SOP Pharmacy Logistic
iii. SOP Laboratory Logistics
iv. Standard Treatment Guidelines
v. STI Treatment Algorithm
vi. Art Treatment Guidelines
vii. Integrated Management of Childhood Illness (IMCI) guidelines

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 LIST OF ACRONYMS

Acronym Meaning
3Cs Correct, Consistent, Complete
Constructive, Relevant, Immediate, Selective and
CRISP Presentable
DART Decentralized, Action oriented, Responsive and Transparent
DHIS District Health Information System
DHS Demographic Health Survey
EDS Essential Data Set
HIA 1 Health Information Aggregation Form 1
HIA 2 Health Information Aggregation Form 2
HMIS Health Management Information Systems
ICT Information Communication Technology
IDS Integrated Disease Surveillance
IPD In-patient Department
M&E Monitoring and Evaluation
MDGs Millenium Development Goals
ND 1 Notifiable Disease Form 1
ND 2 Notifiable Disease Form 2
NDP National Development Plans
NHSP National Health Strategic Plan
NIDS National Indicator Data Set
OPD Out-patient Department
RAVES Reliable, Appropriate, Valid, Easy, Sensitive or Specific
SDGs Sustainable Development Goals
SMART Specific, Measurable, Appropriate, Realistic, Time bound
ZDHS Zambia Demographic Health Survey

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LIST OF PRESCRIBED BOOKS

1. Vaughan, J. P. and Morrow, R. H. (1989). Manual of Epidemiology for District

Health Management, Geneva, World Health Organization
2. Heywood, A. and Rohde, J. (2003). Using Information for Action: A manual health
workers at facility level, Equity Project, Belleville Cape Town
3. HMIS Procedure Manual
4. DHIS 1.4 operational manual.
5. Turban, E., Mclean, E., and Wetherbe, J (2003) Information Technology for
Management, Hoboken, John Wiley and Sons

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