IMPLEMENTATION AND USE OF CENTRAL HEALTH INFORMATION SYSTEMS

SUPPORTING DECENTRALIZED HEALTH ACTORS

Experience of Rwanda

Adolphe KamugungaManagement Sciences for Health, Rwanda

December 16-18, 2015 Cotonou,Benin

Rwanda Profile• Eastern Africa Country, bounded by Uganda, Tanzania,

Burundi, and DRC• Population 10.537 millions (2012 census)• 5 Provinces with 30 Districts • 42 District Hospitals and 508 Health centers (HMIS 2015

public facilities only)• Per capita utilization of health facilities : 0.9 visits per

inhabitant/year• Mobile phone network coverage at 98% (RURA 2015)• Phone usage penetration rate at 70.6% (RURA 2015)

Rwanda Health System Structure

National

Province (5)

District (30)

Sector (412)

Cell&Village (2148)

MOH, Rwanda Biomedical Centre, Referral Hospitals (8), TWGs

Provincial unit in charge of social affair and governance, Provincial

Hospitals (4)

District Health, DHMTs District Hospitals (42)

Health centers(508)

CHWs(45,000) in 500 Cooperatives

HMIS & Program Data managers and

M&Es

Provincial data quality Officers

DHMTs, District Health Unit staff

(M&E, statistician, etc), and Hospitals

Data managers, M&E, Supervisors

HC coordinators, Data managers,

Management Commitee

CHWs and Cell coordinators

Levels Operational Actors HIS Actors

Data elements selection and collectionData variables selection and reporting is guided by:

• HSSP III M&E data requirements• National published indicators (MDGs, EDPRS)• Partners and stakeholders data needs• Needs of data to measure health outcomes and health status at

decentralized levels• Vertical programs data needs• Performance contracts

• All health actors work towards the national targets• Every actor sign performance contract with supervisory unit/ institution

HIS solution selection processHard to find HIS solution that

• can respond to all levels data needs• can minimize the workload to data collection levels• Supports and empowers coordination and supervisory mechanisms in place• is less demanding in terms of time, resources(HR, Money, Materials)

Before 2012, MOH has been using standalone application (SQL & VB.net) as HMIS solution of routine health data management

At that time Vertical programs were using different systems• Burden to decentralized levels collecting and managing data• Contributed to resources and efforts misuse

Resource-related data (HR, materials, and infrastructure) were collected through Excel sheets, and compiled to generate a national Excel database• Doesn’t improve data sharing and use at all levels• ICT skills gaps challenge the quality of data sent

HIS solution selection processTo respond to these data needs

The MOH together with partners adopted DHIS2 platform since 2012 as then national data management system

DHIS-2 is an open source software:• Globally implemented in more than 47 countries • Supports health systems integration • Runs on every device (PC, Tablets, etc)• Supports data management and analysis at national and decentralized

levels• Strong capacity building mechanisms through DHIS2 Academy and

global community of developers Also the Ministry adopted iHRIS software to support the

management of health sectors staff at all levels, • Open source product for Human Resource information management

Use of DHIS2 as integrated HIMISR-HMIS is DHIS2 bases data collection and reporting

system. It is integrated health data management systemIt combines routine health data, case based and

individual dataHMIS Database

• Holds routine aggregated health data from public & private health facilities countrywide (approx. 700 HFs)

• TB quarterly data from all CT and CDTs• Malaria data• Weekly child deaths reports• Immunization, FP, NCDs monthly reports

Use of DHIS2 as integrated HIMISHIV/AIDS database

• HIV/AIDS monthly reports on VCT,ART,PMTCT, etc from all health facilities Health Financing Database:

• Community based monthly reports• Support the billing process for Community Performance based financing

(Community PBFIndividual Records database:

• collects all details on neonatal and child deaths cases• TB patients tracker during treatment period

IDSR database:• Diseases surveillance case reporting, and management

Rwanda PBF database• Support PBF management• Quarterly PBF payments calculation• Reports

R-HMIS Organization

R-HMIS

DHIS2-Based Systems

HMIS HIV SIScomIndividual Records IDSR PBF

RwandaRapid SMS iHRIS

• HFs have access to these nationwide databases any time for evidence based practices and monitoring local health status within the catchment areas

• System have built-in data analysis function requiring minimal efforts to generate charts, map, summary tables, and standard reports

Facility level routine data reporting

Capture PBF indicators data

Quarterly payment adjustments

Data analysis, presentation & sharing• Use built-in analysis and dashboard tools to display health status • All health sector levels have access rights to monitor status in catchment area

R-HMIS Usage statistics

Automatic Data statistics feature

Data warehouse • It’s for public health data access• Minimize loads to the already busy system with over 1000

users

Aggregated data

Individual & case data

Disease surveillance

RapidSMS iHRIS

• Routine health data public &Private HFs

• TB quarterly data• HIV, Malaria data• FP& Vaccination data• Weekly child deaths

• Neonatal & Child deaths audits

• TB patients

• CHWs 1000days MCH case reports

• Immediate notification• Outbreaks data• Cases reported by HFs

• Immediate notification• Outbreaks data• Cases reported by HFs

Data warehouse

• HSSP III indicators• National published indicators

• MDGS• EDPRS

Selected variables for national public indicator portal

Use of iHRIS as health sector HR Information system• iHRIS is an open source software for human resources

management • Globally implemented in many countries, and

recommended for resources limited health facilities• Reference for more details: http://www.ihris.org/ • In Rwanda the platform is customized to help with the

management of human resources for health• Depending on system access privileges, HR officer at

district can create, enter, edit, view, records and generate various reports related to employee.

Functions implemented • Employee Registration (education, gender, names, ….)• Salary information, positions management• Staff relocation management• Retirement planning• Contracts management (ending, status)• Staff turnover reports by positions• Different HR reports for any health facility, institution in the

health sector under MOH

iHRIS use case and output samples• Using the built-in tools, the HR can generate the similar

outputs

Personnel by cadre summary table at Health facility

Comparison with standards/targets at Health facility

Summary table of Actual staffs vs norms at District hospital

Advantages of using DHIS2 & iHRIS based systems

• Open source products• implementation and maintenance cost is moderate• No licensing and system modification costs• Availability of technical support within the region• Customizable, modular products• Interoperable with other systems (API,…)• Scalable• Specific for health• Used across many African countries• Strong users community that can provide support for free

How did we reach here?Consultation meetings to harmonize and optimize data collection tools

• Vertical programs (Malaria,TB, HIV,NCDs, etc)• Partners(aligning categories, age, gender, definitions)• District level staffs• Clinicians

Establish coordination mechanisms and regulations to minimize parallel and similar efforts

Introduction of integrated planning and M&E to ensure that Districts level plans and targets fit into/contribute to the national goals and targets

Establishment of Technical working group to regulate and validate new HIS deployments

• Ehealth TWG• Planning, Health Financing and HIS TWG

Establishment of HMIS unit for daily system support• Capacity building plans, and skills development• Availability of in country technical support

Strong commitment of health actors at all levels

How did we reach here?Ministry commitment to go for evidence based practices

• Meetings presentations should be supported by facts• Productions of annual statistical booklets• SOPs development of data management and data use guidelines for

all levels (National, District admin., DHs, HCs, and Community)• Standardizations of data collection tools countrywide(National,

Decentralized actors, partners • Health facilities shares on monthly basis data analysis results on

noticeboards with the public• Production of data analysis quarterly reports with discussion on

strategies and interventions planned to address the issues found• Data management and use supporting staffs (DM and M&Es) at all

health facilities and District health unit• Capacity building budgets to support in service capacity building• Development and adoption of data sharing policy

How did we reach here?Health facility and DHMT commitment

• Leadership • Every coordination & management meets at HF, data analysis

critical findings should be discussed and actions should taken• DHMTs hold quarterly meetings to discuss district level health

concerns • Reinforce supervision and data quality audits of Districts hospitals

to Health centers• Ensure inclusive and extended DHMT Committee for strategic

decision making • Train Head of Health Facilities and key staffs on data use and

HMIS bult-in functions of data analysis

Challenges iHRIS

• Changing mind set for HR managers to regularly use and update data

• Payroll module not implemented within the system, the application is for planning and routine HR management only

• Some health facilities don’t have fixed numbers of posts• Turnover of staff

DHIS2• How to keep pace with DHIS-2 development – new versions every

2 months?• Refresher trainings. System is dynamic, modifications may be

requested, or some few changes may happed to benefit from the new versions

THANK YOU