HISP - Health Information Systems Programme

1. Research and development in the health sector

“South-South-North” software development & action research - Funding through NUFU & donors /health authorities in individual countries1994/96 - started in South Africa1998/99 started in Mozambique2000/01 started in India, Malawi2002/03 - Tanzania, Ethiopia, Nigeria, Namibia, Vietnam, etc

2. Educational program – Funding through Norad & QUOTEA. PhD program across academic fields focusing on HISP

Students from participating universities registered at UiO

B. Integrated Masters programmes in Informatics and public health in South Africa and Mozambique (+Tanzania & partly Malawi)

C. Continuous education and training of health workers and managersDevelopment & introduction of ICT require massive training!Training schemes base in the Masters programs

Dental unit 1PAWC

City HealthClinic 1

54 private medical pract.

GeriatricServices

MOU(Midwife&

obstetric unit)PAWC

23 private dental pract.

12 private pharmacies

Private hospital:31 medical specialists

Day HospitalDNHPD

UWC OralHealth Centre

City HealthClinic 2

City HealthClinic 3

City HealthClinic 4

City HealthClinic 5

Dental unit 2PAWC

Dental unit 3PAWC

12-15 NGOs

SchoolHealth

DNHDPPretoria

Groote SchuurHospital

PAWC

DNHDPWestern Cape City Health

MITCHELL’S PLAIN

Environmentaloffice

MandalayMobile clinic

RSCYouthHealth Services

PsyciatrichospitalPAWC

RSC

Outsidehospitals

BirthsDeathsNotifiable diseases

New /emergingflow of information

Apartheid legacy: a fragmented and top down health structureno local governance & control of information

The Problem: Unify and integrate fragmented structures and information flows- The health sector is “crippled” by uncoordinated vertical structures

Two registration forms of activities/patients; representing same events

NGOs(Non-gov.

Organisations)

Clinics

DISTRICTINFORMATION

SYSTEM& DATABASE

DISTRICTHEALTH

MNG. TEAM

Traditionalhealers

PrivateSector

HealthCommittees

Maternity/Midwife

units

Day hospitals

Psychiatricservices

Nutrition

TB

STD/ AIDS

LocalGovernment

SpecialInterestGroups

Health& Welfare

Forum

DentalServices Circumcision

Surgeons

Familyplanning

GOVERNMENT NON-GOVERNMENT

COMMUNITYSTRUCTURES

COMMUNITY

HEALTH PROGRAMS

Higherlevels

Unions

Referrals

HEALTH SERVICES

VERTICAL

SchoolHealth

EnvironmentalHealth

Information from other sources, e.g.Birth / death registers; TB register, census data, socio-economic data

Background – Started in South Africa 1994

• The Health Information Systems Program (HISP) has been part of developing the Health Information System in South Africa since 1994:

– developing software (DHIS),

– training programs,

– district based health information systems, – indicators, data standards

– “models” for use of information for action

• Best practices & software from South Africa later spread and further developed to a number of countries in Africa & Asia

• Since 2005 EU /BEANISH supported and strengthened thisBEANISH /HISP network

/ HISP

HospitalPAWC

ClinicRSC

ClinicRSC

ClinicPAWC

Private

Private

NGO

Cape TownRSC

Cape TownPAWC

MalmesburyPAWC

DNHPDWestern Cape

MOUPAWC

SchoolHealth Hospital

Clinic

PrivateNGO

A) South Africa: Post-apartheid: Inequity and fragmentation - No shared information resources- Process of standardisation based onKey information needs & indicators, data sets & reporting structures

SchoolHealth

Clinic

Clinic

AB

B) South Africa: Integrated model- Shared information Between and within health structures- Focus on information for action- Continuous training

South Africa - Legacy of apartheid: Inequity & fragmentation- Step 1: Focus on MUST know information & integration at district level

DatabaseInfo. office

Higherlevels

Healthprograms

MotherChild

/ HISP

Botswana: 2005 onwards ….• National Health Information System dysfunctional

– 2 years backlog of poor quality data; – “Rich” health programs develop their own systems

(HIV/AIDS, Infectious disease reporting, vaccination etc.)– “Poor” programmes have “nothing”, e.g. Mother & Child

• Fragmentation; no coordination and overview of key data and indicators

ADDRESSING THESE PROBLEMS:• Integration: data warehouse (DHIS) at district & national

levels: Starting integration at district level –All data reported through the districts

/ HISP

Health Statistics

District - DHT

Facility 1 Facility 2 Facility n

IDSR – NotifiableDiseases

PMTCT

EPI

STD

Home Based Care

Nutrition Nutrition

ARV

MCH

Family Planning

HIV/AIDS

TBSchool Health

Mental HealthAnd more …

Facility 3

Botswana: Pre-intervention – Fragmentation – No shared IST resources “converging” at district level - Fragmentation at central level

/ HISP

Health Statistics

Facility 1 Facility 2 Facility n

IDSR – NotifiableDiseases

PMTCT

EPI

STD

Home Based Care

Nutrition Nutrition

ARV

MCH

Family Planning

HIV/AIDS

TBSchool Health

Mental HealthAnd more …

Facility 3

NationalHMISStat. unit

DistrictHMIS

Botswana:integration at District & National levels learning from South Africa

But: Adding “data-warehouse” to the model from South Africa

/ HISP

Introduction to (Health) Information Systems (1)

• What is Information Systems?– Wide understanding: from cell-phones to card based filing systems in a library

- or in a clinic - AND the SOCIAL ORGANISATION OF IT!

– Information and Communication Technology - ICT; OR just IT (Information Technology) - An even wider definition

– Technology is rooted in people (knowledge) not things= organisation, knowledge, learning, innovation - as well as artefacts

• Information Systems are best understood as social systems – a web of social and technical elements– nothing in a technological system is poorly technical (non-human)– the information system is part of the social context– information systems in a clinic (registers, forms, reports, information handling,

meetings) may be seen as a human activity system

Introduction to (Health) Information Systems (2)

• Large Information systems / and IT / ICT may be seen as

information infrastructure– Infrastructure has a wider meaning: the technical grid (roads,

wires, hospitals, cold chain/EPI, etc.) as well as the institutions, support systems, organisations, schools, training etc. necessary to run and maintain it.

– Information systems make up a web of more or less interacting information systems - more or less integrated through standards / lack of standards

– Web - network metaphor

– Develop over time - makes changes difficult

• Health Information Systems = Health Information Infrastructure

Introduction to (Health) Information Systems (3)

• The ‘installed base’ - what is already there - the point of departure– Information Infrastructure develop and grow over time– As the installed base grow it becomes increasingly difficult

to implement changes – Always something there beforehand - never possible to start

from scratch • Information Systems = Social Systems =>

– Information infrastructure “=“web of social systems– Installed base: social-technical web /existing information

infrastructure

Introduction to (Health) Information Systems (4)

Information systems as Social Systems:

Consequences for system development & design???

• Focus on people and not technical artefacts - design and development need to be based on the social system

• Participation in design and development• Local ownership and commitment need to evolve

– Leadership to the users!! (Politics?)• The existing social system - the people already there, their skill,

capacity and motivation - will form the basis for development

• HUMAN RESOURCE DEVELOPMENT - Training and support!!!

Introduction to (Health) Information Systems (5)

• Information systems as Information Infrastructure

Consequences for system development & design??? • Everything is part of something bigger - or rely upon something else

– Development needs to involve ‘negotiations’ with many other systems– Standards and interfaces with other systems (e.g. different health

programs)– A more comprehensive approach is needed:

development of health information infrastructure relies upon the wider infrastructureThe wider network of training and support of hardware, software and ‘humanware’ needs to be developed together with the health information infrastructure

Introduction to (Health) Information Systems (6)

• The ‘installed base’ - brings together social systems and infrastructure in an unruly mess

Consequence for change-planning - system development & change??? i.e. Health sector reform?

• Changes tend to be incremental and piecemeal

• When planning for change - a lot of historical commitments (ways things have always been done) will stand in the way

• A web of ‘social systems’ represent obstacles to change

Introduction to (Health) Information Systems (7)

Health Information Infrastructure

reflection & mapping of the health sector

- institutions, services, health programs• Hospital information systems

– Patient based registers, paper / computer based based / electronic patient journals

• Drugs /pharmacy• Transport• Finance• Laboratories• Tuberculosis• Extended Programme on Immunisation (EPI)• Sexually Transmitted Diseases • ‘Surveillance’ Notifiable diseases - rapid response• Death / Birth registers

•Human resources•Primary Health Care Information Systems•Environmental health/ water / sanitation•Epidemiological information systems•School health •Personnel /salary•etc. etc. etc. etc. etc.

•Patient billing•health insurance•tele-medicine•etc. etc.

Introduction to (Health) Information Systems (8)

Health Information Infrastructure

flow of information reflection & mapping of the health sector

- institutions, services, health programsVertical - centralist - top-down -structure

National level

Provincial level

District level

Facility level

TB STD Mother EPI Rural Nutrition Notifiable Drugs Transport & Child Hospitals diseases

National Health Information System (SIS)

Introduction to (Health) Information Systems (9)

Health data: the health facility is the entry point for all data!

- Quality of data at the facility level crucial for all information at all levels

- garbage at the facility level - garbage everywhere!!

Events (patient - facility) counted and registered daily - when happening•registers (e.g. per health program), books, files, forms•green (deliveries), red (children), yellow (adults) etc. beans put in a bottle •tally sheets with pictures•tally sheets with text•computers - patient record system

Aggregating data and reporting upwards every month (typically) at the facility•data reporting forms

•huge amount of forms - one for each health program, or•Minimum Dataset based forms (e.g. South Africa)

Keeping/organising the data at the facility•Paper: in a file organised or disorganised•computer - spreadsheet - or database

The role of information and “problems” with the action led approach1. How is it possible to solve problems outside the scope of health management?2. May information make an difference?

Influencing Decision making with different information approaches3 Decision making outside routine & formalised areas will often rely upon

mobilising support from a wider range of actors

e.g malnutrition & infant mortality

scope of action for health management

Problem area - “Health for all” &

Primary Health Care provision

Scope of (political) action byCommunity + other actors

Comprehensive approach action-led approach

1. The “action-led” approachDeveloped by a collaborative research project in Kisarawe in TanzaniaMinisty of Health, African Medical Research Foundation,

Liverpool School of tropical Medicine, Superior institute of health, Rome. Ministry of Health, Tanzania (1991); Sandiford et al. (92, 94)

Influential within “health information” - much cited

A. Define the scope of decision-making by level of managementB. Provide information C. Act!

Focus : who are the users and specific information needs

Information must be analysed and used at the level it is generated

If action is the aim: It is as important to know how a decision may be made - how to use the information - as to know what decision should be made

Maternal mortality (1990 -92), Mongolia

05

101520253035404550

City AimakCentre

Sum(district)

Home

1990

1991

1992

Increasing Maternal Mortality at peripheral levels in Mongolia- following the economic crisis & break down of Soviet Union

Problem:

•rest-houses used 2-4 weeks prior to delivery were closed•lack of equipment in district hospitals•poor ambulance service /lack of petrol

Solution:Opening up rest housesEquipment & training in its useimprove ambulance services

Actors and factors: National health management, WHO, INFORMATION international donors (money), district hospitals & equipment & skill & trainingPetrol ( - > general economic crisis)

Bssically within the (international) health system - apart from petrol

WORKLOAD

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Strandfn

tn

Rockla

nds

Tafels

ig

Eastrid

ge

Lente

geur

West

ridge

CLINIC

patients per Nrs

Uneven distribution of nurses in 6 clinics in Mitchell’s Plain

Solution: move nurses between clinics

Actors involved (or to be “enrolled”)in efforts to rectify the problem:

•health management•nurses•unions•information

All within the scope of the health services ?

Children <6: stunted (under height for age) Khayelitsha

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Wes

tern

Cap

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Khaye

litsha

tota

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unse

rvice

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servi

ced

shac

k

hous

e

stunted

Nutritional status among children in Khayelitsha in relation to housing and services as water and toilets- Housing & level of services have impact on healthSOLUTION: Build houses & develop general infrastructure

“Problem”: the health sector is not building houses & toilets- not action-led information?Scope of action - & actors - needs to be extended

Actors:Health sector, Community groups,Non Governmental OrganisationsEnvironmental & sanitation &water sectors, local government (ANC), provincial government.INFORMATION., etc.

Information as ‘information’- the rational of the information system

Feldman and March (1981) provide four useful explanations for the often observed “over-consumption” and lack of use of information:

•Organisations provide incentives for gathering extra information. These incentives are buried in conventional rules for organising, as the division of labour between information gathering and information using.

•Much of the information in organisation is gathered and treated in surveillance mode rather than decision mode: the focus is on negative trends, which trigger action.

•Much of the information in organisations is subject to strategic misrepresentation.

•Information use symbolises a commitment to rational choice.

Information as ‘institutional glue’- a consequence (but not purpose) of information systems

Information as trust, relationship and (social) structure

•The structures and ideology instituted by the information systems make up considerable obstacles to change

•The processes and structures being institutionalised - or structurated - by the information systems often seem to be their most important property and outcome

As a concequence:

•using information system as a tool for ‘structurating’ new structures - e.g. the new health district

Let the changed/ transformed information system produce - and through routine activities re-produce the new organisational structures