strengthen hmis in tanzania operation plan

8/6/2019 Strengthen HMIS in Tanzania Operation Plan

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Strengthen HMIS in Tanzania - Operational plan

The MoHSW, with a consortium of partners, in October 2007, developed aProposal to

Strengthen the HMIS in Tanzania. Building on this document, during 2008, an operational

plan has been developed, presented to the MOHSW, revised according to their requirementsof early results, and redeveloped further through an extensive process. This current document

synthesizes the requirements and conclusions reached during this process into an operational

plan.

Key requirements and conclusions emanating from the 2008 process are;

Early national HMIS coverage and effective data flow from all districts to the

MOHSW are required, while at the same time ensuring longer term (5 years)

sustainability, system strengthening and improved data quality and information usage

o A plan for rapid HMIS rollout and system consolidation is now included

Budget needs to be within the limits of what is committed by the Norwegian, Dutchand Canadian Embassies (2.5 mill + 5 mill + 2-3 mill?) and distributed in such a way

that national coverage (Norwegian), system strengthening (Netherland) are included.

The HMIS process needs to be open and inclusive in such a way that other donors

involved in information related interventions are led to contribute into the same

overall process. For example, while JICA is funding the implementation of the

HIV/AIDS information system in Coast region, the Norwegian Embassy is adding to

this contribution in such a way that the Coast region becomes a test region for the

overall HMIS within this operational plan.

The operational plan and budgets need to contain phased and integrated componentsthat will be funded by the above mentioned donors.

A test region will be developed and maintained throughout the 5 years project. Here

the different types of intervention packages (e.g. software, revised data sets, training

manuals, and data use workshops) will be developed, tested and refined for further

rollout to all districts. Through the JICA initiative, the Coast region has now by

default become such a test region. Another test region may later be added (Mtwara

has been suggested).

The operational plan follows the agreed design of two integrated approaches; 1).top-down

National HMIS rollout and 2) bottom-up system strengthening, as illustrated in figure 1.

While the top-down approach ensures national coverage and consolidation of the revised

HMIS, the bottom-up approach ensures continuous system strengthening, further revisions of

data sets and more in-depth capacity building.


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MOH

&SW

Reg

ionReg

ion

Reg

ion

Reg

ion

DistDistDist

Dist Dist DistDist Dist

Bottom-up

System Strengtheningin first one,

then more Regions

-Analysis and use of information

- Regular data-use workshops

- Capacity d evelopment

- Revision of data & indicator sets- Training scheme & guidelines

- District based d ata warehouse

& Information Office

Top-down rapid rollout to all

districts and consolidation of

functional HMIS:- Databases in Districts and Regions

- Integrated National data warehouse

- Training and support

- Data transfer between districts

& MOHSW

Integrated National

Data warehouse

Strengthening

region by region

Test

Region

All Regions

All Districts

Facility reports

National dissemination

Revised HMIS

Training scheme

Tools & methodologies

Figure 1. Complementary combination of top-down rapid National HMIS rollout and consolidation, and bottom-

up system strengthening starting in one test region and gradually includes the other regions.

1. The top-down approach;

Rapid implementation in all districts over 3 years including 6 months initial phase

Overall objectives:

Implement and strengthen the integrated HMIS and DHIS in all districts and regions

and establish effective data flows to the MOHSW.

The aim and indicator of success is to reach level 1 of information usage according

to the TALI tool (see annex),

o Level 1; establish the basic system with quality data at all levels (including

completeness) and with the effective transmission of data between the levels

Develop a national data warehouse integrating all routine reporting and other data

sources and build capacity at the MOHSW. Establish the Coast region as a test region for the development and testing of tools

later to be rolled out to all districts (an additional test region may be added later)

The work is organized in two components called work packages:


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Work packages (WP):

WP1 National rollout of strengthened HMIS to all districts and regions. The rollout is

labelled top-down because an initial package of the revised HMIS is, first, tested in the

Coast region (WP2), second, rapidly deployed to all districts and regions, and third,

consolidated over the following two years, all in all a three years intervention. The initial

revised HMIS consists of HMIS and routine data sets and data reporting forms that are

currently in use or recently revised, and the DHIS software which is used for managing,

analysing, presenting and transferring the data. The HMIS data sets and reporting form will

be further revised during the process. These revisions will be accommodated when ready.

Rollout approach: Each district region will have two sessions of formal training (initial

training, and repeat training about 8-12 months later) and three sessions of on-the-job training

and support to be carried out by a team of facilitators. While the initial rollout and training

will be rapid, the following technical support and training covered by this WP will be carried

out over about 2.5 years; July, 2009 - December, 2011.

WP2 Coast Region initial test region. Implement DHIS using the existing and revised

HMIS reporting forms in all districts and regional administration in the Coast region.

Establish a first version of the data reporting forms and data sets to be included in the national

roll-out. Including the revised reproductive health and human resources data sets.

Later revisions of data reporting and data sets will be included when they are ready for

implementation. Changes in data sets and data reporting forms are easily accommodated by

the software (which is soft), but more problematic in terms of paper forms (which are

hard copied).

The first phase of this test region is planned for 6 months, until the contracts are formalised.

Thereafter the test region will be used to develop and test all intervention packages of the

overall project (another test region may be added).

The Test region will be used to test all new tools, software customisation, and understand user

needs at facility, district, hospital & regional levels. Adapt support, training & tools

accordingly, and then roll-out to other regions.

WP3 Software development and Systems Integration. Developing District basedNational data warehouse and building capacity at MOHSW. The first version of the

national data warehouse will be similar to the DHIS used in the Coast region and will be used

to receive data from all over the country as the rollout advances. Gradually additional data

sources will be included and improved functionality such as Geographical Information

Systems and web reporting will be developed.

A key issue is to integrate and include the routine data being collected at facility level and to

remove double reporting and redundant data reporting. The aim is to achieve integration and

unification of all data reporting. This work on data and indicator sets is contributing to, and is

integrated with, the revisions of data sets in WP4.

A software team including the MOHSW will be built and become in charge of the further

development and improving of the DHIS software and related technical aspects at district and

national levels. A program for training and capacity building for MOHSW staff will be

established.

Total budget for WP 1-3 and top-down approach: abut 2.5 mill USD

To be funded by the Royal Norwegian Embassy.


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The attached budget includes additional basic interventions in the Test Region, which is

intended to become a permanent focus-region throughout the project (WP7).

Attached minimum budget 30 months test region: 310,000 USD

National rollout: Institutional base and coordination

The three WPs in the National Rollout are naturally based at the HMIS unit, MOHSW, and

will be located in an office here and managed and coordinated from the HMIS unit. However,UDSM and the University of Oslo will be responsible for the software component (WP3) and

the capacity building at the MOHSW in this regard.

The funds are to be managed in relation to the HMIS unit, MOHSW, with one part of the

budget allocated to UDSM and the University of Oslo for the software component.

2. The Bottom-up approach;

System strengthening, information usage and capacity building;

Objectives:

Develop capacity and ensure that information is analysed and used for informed

decision making and action in all districts and regions.The aim and indicator of achievements is to achieve Level 2 and 3 of information

usage according to the TALI tool (see annex) for 80% of the districts;

o Level 2; Information is analysed, disseminated and used (graphs on the walls,routine district quarterly reports, etc.)

o Level 3; Information is (documented) used for (district) planning and theevaluation of the implementation of these plans

Institutionalise quarterly / regular data-use workshops in all districts and regions;information from the HMIS is presented, analysed, discussed in the workshop and

concrete action plans are made for the improvement of the HMIS and data quality as

well as for the improvements of the services as according to the data.Work packages

WP4 Revisions of data and indicator sets and HMIS procedures - address and includenew data needs as they emerge during the process. Revision of data and indicator sets is an

ongoing process and includes interaction with the health programs. Initially the rollout will be

based on the existing HMIS forms and already revised data sets. Revisions will be included as

they are ready for implementation.

Aim is to arrive at a situation where a national committee is responsible for the harmonisation

of the total array of reporting requirements to the health facilities. Programs and agencies

wanting to introduce new data reporting forms will then have to approach this committee in

order to get acceptance for additional requirements. Requirements when introducing new data

reporting forms will include that they are harmonised within the overall HMIS framework and

that no double reporting is accepted.

WP5 Building district and regional capacity. Establish a HMIS training scheme on analysis

and use of information for management and decision making for program and district

managers at district and regional levels in the entire country.

The training will consist of repeated formal training sessions with individual and group

assignments and support in between.


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WP6 System strengthening; Improving data quality, information usage and healthmanagement. This WP consists of three major set of activities;

1: Institutionalise quarterly /regular data-use workshops in all districts and regions, where data

is analysed and discussed, problems identified (both regarding HMIS and health services),

and action decided upon.

2: Institutionalise the production and dissemination of quality district and regional quarterlyand annual reports based on the HMIS data

3: establish and strengthen the district and regional information office and DHIS data

warehouse as an active and competent information resource centre that is effectively

responding to the needs of the district /region: Create District Information Towers

Approaches to enable these activities in districts and regions are to establish a team of HMIS

facilitators and a support structure covering the country. WP 5 trainers and assignments

will make up an important part of the support structure to WP5

WP7 Establish and use the Test region to develop and test tools and methodologies

including revised datasets. (This WP will be combined with WP1, which has a preliminary

status until the project is formally established).The test region will be used to develop, initially implement and test all the interventions

described in the above WPs; data sets, software, training programs, guidelines for data

workshops, quarterly and annual district reports, strengthening the district information office

and data warehouse, etc.

The test region will be run by hiring additional staff based at the region, conduct particular

investigations and have increased support as compared with the other regions.

Total budget for WP 4-7 and bottom-up approach: about 5 mill USD.

To be funded by the Dutch Embassy.

Some basic components of the test region is included in the roll-out budget to be covered bythe Norwegian Embassy; 2 staff, vehicle, support, training of district and program managers.

This was done because of uncertainty as to when funding and contracts would be available.

Once this is decided the relations between the two budgets may be reworked.

System strengthening bottom-up: Institutional base and coordination

WP 4-7 consist of distinct tasks, such as running and coordinating

Revisions of data and indicator sets and procedures for their collection, management

and use (WP4); a committee of programs and stakeholders will be established (based

on the M&E committee), responsibility, coordination and management, clearly located

to the MOHSW.

Training scheme (WP5); while being coordinated through the MOHSW, clear

responsibilities for the development of programs and the running of the courses are

given Ifakara and UDSM.

test region (WP7); need to be closely linked to the other WPs as a test-bed, but the

responsibility to run it may be delegated Ifakara


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continuous system strengthening (WP6), which is a further strengthening and after

the first three years the continuation of the National rollout process, should be

managed and coordinated by the HMIS unit, MOHSW.

The funds are to be managed in relation to the HMIS unit, MOHSW, with items of the budget

allocated to Ifakara in relation to the training scheme and the Test region..

WP8: Management

& coordination

WP1: National rollout of strengthened HMIS:Rapid deployment, consolidation, strengthening

WP2 & WP7: Test RegionInitially Coast Region (WP2)

Develop & Test,HMIS revisions

WP3: Software Development

& systems Integration

District & NationalData Warehouses

WP5: Capacity development;courses, support & facilitation

Continuous education

Overview Work Packages (WP)

WP4: Revision of HMIS;Data and indicator sets,

procedures & tools

WP6:System StrengtheningImprove USE of information

District Information Tower

Figure 2: Overview work packages (WP)


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3. Management and coordination

Facility Information Warehouse

MONITORING AND EVALUATION SECTION

Administration & Logistics

Health Systems

Research and Surveys

Unit

HMIS Unit

InformationCommunication and

Technology(ICT)

Con

Demographic

Surveillance Systems

Unit

HMIS Strengthening Program

Ph

Regional InformationWarehouse

District Information Warehouse


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Description of a Monitoring and Evaluation Organization chart

Monitoring and Evaluation (M &E) is one of the five sections operating under the Directorate

of Policy and Planning. Its key function is to monitor and evaluate health sector performance.

In this regard its principal function is to supervise data collection, storage data analysis

interpretation and dissemination. Data collection is done through different systems which

are distributed in different ministries, departments and institutions. Some of the systems are

directly managed under this section however; some are run and managed in other

departments of the MoHSW. The plan is to keep such systems continue operating in their

department but coordinated under Health Management Information System (HMIS) which is

one of the units of M & E Section. Detailed explanations are provided under HMIS project.

The M & E section lead by the head of section who report to Directorate of Policy and

Planning. The technical support is provided by M & E Technical Committee which is under

SWAP Technical Committee. The committee has its members from health information

stakeholders like Development partners, National Bureau of Statistics (NBS), Retention

Insolvency Trust ship Agency (RITA), NGOs, Special Programs. M & E section is a secretariat

to this committee.

Administration and logistic: Considering the volume of operations to be managed under

this section, a post of Administrator and Logistic Officer is proposed. The administrator

would report to the head of section. Other staff to operate under this unit will be accountant,

procurement officer, personal secretary, drivers and office attendant. This unit its services

will have cover core units in the section. Job description for the new post with all staff under

him will be developed soon once the M & E structure is approved.

Information Communication Technology Unit (ICT): This unit would provide its services

to all core units in the section. It will be responsible for data management like data storage,

analysis and dissemination using up to date technologies. At the national level, the unit

would perform as Information were-house whereby different health statistics will be kept

and maintained. The unit would be responsible in maintaining hard and soft-wares for

MoHSW.

Health systems Research and survey unit: This is one of the three core units which are

responsible for operation research and surveys. Its main role is to conduct operational

research or to assist other departments to do so. At regional and district levels the unit do

train RHMTs & DHMTS on how to conduct operational research in order to get detailed

information of its locality. Also, the unit has a role to plan and conduct surveys like Service

Availability Mapping (SAM). The unit does work very closely with NBS in conductinghousehold based surveys like Tanzania Demographic and Health Survey (TDHS) Tanzania

HIV/AIDS Malaria Indicator Survey (THMIS) etc.

Demographic and surveillance Systems (DSS) Unit: The unit is responsible for community

based information from selected clusters. Systematically health workers do collect mortality

events as well as conducting population censuses in those clusters. Population censuses are


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useful in establishing factors linked to cause of deaths. Information from this source is

important in absence of the strong vital registration in the country.

Health Management Information Unit: It is another core unit that is responsible for routine

data systems that are collected from all health facilities. Another responsibility is to up-date

data collection tools as well as to coordinate other sub-systems based in other departments.

More information in regard to this unit is provided under HMIS strengthening program.

Were-houses for regions, districts and health facilities: At regional, district and facility

levels there will be information were-houses to ensure health information is managed at one

point. This would be coordinating centers for sub-systems operated by special programs or

by different departments.

Phone for Health project: This is a special project which will contribute to the strengthening

of HMIS. The system would help to transfer quickly some of the HMIS data into HMIS

system using mobile phones. To start with the project is currently piloting Integrated Disease

Surveillance System in Tabora and Mwanza. Other components to be included are blood

transfusion and PMTCT information.


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HMIS Consortium Team

HMIS Strengthening Program

Assist. Program

Manager

(Reproductive &

Child Health

Statistics)

MODULE 1

Assist. Program

Manager

(Morbidity &

Mortality Statistics)

MDULE 2

Assist. Program

Manager

(Health Systems

Support Statistics)

MDULE 3

Assist. Program

Manager

(Health Related

Statistics)

MDULE 4

- Expanded ProgramFor Immunization(EPI)

- Family Planning (FP)- Safe MotherhoodInitiatives (SMI)

- IntegratedManagementof ChildhoodInitiative (IMCI)

- PMTCT- School HealthProgram

- Nutritional and ChildGrowth

- Outpatient &Inpatient

- NACP- TB & Leprosy- NMCP- IDSSR

- Dental Health- Mental Health- Neglected TropicalDiseases

- Diagnostic Services

- Human Resource- Financial Statistics- Logistics & Supplies- Equipment- Health Facility

Inventories

- Social Welfare Statistics- Environmental and

Sanitation Statistics- Tanzania Food &Drug

Authority- Tanzania Food

Nutritional Center


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The consortium team behind the HMIS Strengthening program consists of the following

partners:

The Ministry of Health and Social Welfare (MOHSW)

Role: MOHSW is the owner of the HMIS Program and is responsible for its overall

management, financial management and coordination. The HMIS unit within the Monitoring

and Evaluation section in the Directorate of Policy and Planning of the MOHSW is the

operational base of the HMIS Program. The MOHSW regional and district offices are the

operational bases for the HMIS Program at these levels.

A financial entity will be put in place in order to manage the finances as in accordance with

the specifications for reporting and management given by the donors.

Ifakara Health Research Institute (IHRI)

Role: responsible for the health professional components of the HMIS Program, including

epidemiology, M&E, using information for health action and operational health research.

Furthermore, IHRCD is responsible for the development of training manuals and guidelinesand for assisting in the running of the training scheme (WP5) and the test region (WP7).

IHRD is also taking part in the System Strengthening (WP6) and overall management.

University of Dar es Salaam (UDSM)

Role: UDSM is responsible for the Information Technology, software and implementation

components of the HMIS Program (WP1, WP2, WP3) as well as for the training programs in

WP5. The training program will use the NORAD funded Masters in Health Informatics as an

institutional base. The Muhimbili University of Health and Allied Sciences (MUHAS) is a

partner in this Masters Program.

University of Oslo (UiO)Role: UiO represents the international expertise and advisory role on HMIS/HIS and Open

Source software in the HMIS Program. UiO will work closely with UDSM and the HMIS unit

on the software, implementation and system strengthening issues.

MOHSW the operational base and responsibilities

The MOHSW is the owner of the HMIS and the HMIS unit of the Health Information and

Research (HIR) section of the MOHSW is the operational base of the HMIS Program. In order

to render the HMIS sustainable, the HMIS Program will focus on developing capacity within

the MOHSW in all aspects of the management of the HMIS and data analysis and

dissemination. In order for this to be possible, it is the responsibility of the MOHSW to

prioritise the HMIS and give it high level support, which will entail the allocation of

sufficient resources. For the HMIS Program to succeed the following actions are needed:

Health Information and Research section & HMIS unit need to be strengthened in theareas of database management and epidemiology

Regions and districts need information officers responsible for the HMIS and datareporting, analysis and dissemination across programs and staff responsible for thedatabase. The district information officer needs to be member of the DHMT


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All facilities need identified person responsible for the HMIS.

The identification and allocation of HMIS staff is the responsibility of the MOHSW. Trainingand supporting these HMIS staff is the responsibility of the HMIS Program.

Project management and reporting overview

The HMIS Program is managed by a joint management team consisting of all consortium

members and is headed by a program manager from the HMIS unit. The program team, withthe program manager as responsible, will report on the progress of the HMIS Program every6 month. The responsibility for tasks and deliverables related to the various Work Packages,such as particular training manuals, software or implementation components, are distributedbetween the partners and given to individuals, who are then responsible for reportingprogress to the joint management team.

Financial Management

The MOHSW is responsible for establishing a financial entity able to manage the budget andthe funds, and report on expenditures as according to the requirements of the donors.

Particular budget items related to tasks and responsibility are to be allocated to particularpartners and consortium members who will then report on the utilisation of these funds asaccording to the requirements to the financial entity at the MOHSW and on work done anddeliverables achieved to the joint management team.

Implementing the top-down approach; National rollout and software component

Specification of the operational plan for the National rollout (WP1) and the building of theNational, District and Regional data warehouses (WP3).

This specification is following the attached budget.

4. Specification of the top-down National HMIS rollout

The rollout process will start with a one week training session for MOHSW and nationalhealth program staff.

The top-down rollout consists of 3 interlinked work packages;

WP1; National rollout

WP2; Coast region as initial test region. Budgeted separately.

WP3; Software development and systems integration, building the data warehouses

These three WPs are directly interlinked as follows; the data from the national rollout will

become the content of the data warehouse, and the data warehouse is the software applicationthat will be implemented during the rollout. The Coast region is where the rollout strategy,

tools and data sets are initially tested.

The team that will carry out these components is composed as follows:

6 MOHSW staff,

6 DHIS /HMIS facilitators, from UDSM and the HISP group

International and regional consultants


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4.1. The Coast region (WP2)

In collaboration with JICA and funded by JICA and the Norwegian Embassy, the team

is

identifying the HMIS data reporting forms and other data sets that are to be included

the initial phase

customizing the DHIS database according to these requirements; data entry forms and

data analysis and reporting functionality

testing out software and the technical configuration to be used in the districts, regions

and national level; which is based on the Linux operating system and which enable the

data to be accessed by all computers in the district offices via wifi.

Training users in technical aspects as well as in HMIS management and developing

training guidelines

The output of the Coast region work Package, as well as the initial output of the software

work package to be explained later, will be the initial HMIS package to be rolled out

nationally.

4.2. The National HMIS rollout and consolidation (WP1)

It involves getting HMIS working, based on existing registers and books, with monthly return,

and use DHIS as tool to collate, analyse and report. Train at least 2 people in every district

& region, plus follow-up visits to sites.

The national rollout and following consolidation will be carried out over two and a half years

following the initial 6 months of testing in the Coast Region. It will consist of 2 formaltraining sessions and three support missions in each region which will cover all districts. The

first initial deployment will be carried out by a rapid training scheme, where (if computers

may be purchased), district and regional information staff do their training on the new

computers with the software installed, and bring them with them back to the districts.

Training will be followed by a first support mission to each region and district. Support

missions to the districts will be carried out together with the regional information officer, with

the aim to enable him/her to carry out the first level of system support as an institutional new

practice. Budget (travel) will later be allocated for such support. During the first 6-8 months,

the first basic coverage of the country will be completed, and during the following 2 years the

district HMIS and the reporting structure from the districts to the MOHSW will beconsolidated.

The objective is to achieve Level 1 of Information usage for 80% of facilities and 90% of the

districts by the end of this period.

During the two and a half years basic training and support will be carried out as follows:


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For each Region:

Formal training. Two sessions of one week (5 full days of) training will be carried out in all

regions, first the initial training at the start of the implementation. 7-10 months later a second

one full week training session will be conducted.

District support and HMIS facilitation missions. 3 interventions of an average of 20 days

will be carried out in all districts in each region, by a team of 3 from MOHSW /HISP and 1

from the regional office (information officer). On the job training, facilitation and support will

be carried out. In order to save travel cost, the first two of these interventions per region are

sought carried out after the formal training sessions.

After the first 30 months further strengthening of the HMIS

After 30 months this rapid rollout and consolidation process will merge with the more in-

depth regional (bottom-up) approaches; training of health managers in WP5 (capacity

building) and the strengthening of the district HMIS in WP6 (system strengthening). WP6,

System strengthening and use of information, will represent the continuation of the on-site

support and facilitation in the rollout WP, but with increased sophistication in terms of

information use.

The data-use workshops to be organized in WP6 will be of particular importance as a way to

institutionalize the use of data for management, and thus the HMIS.

4.3. Software and system integration. Strengthening the MOHSW HMIS unit and

building the integrated district and national data warehouses

4.3.1 General training of MOHSW staff

Develop Software team

A dedicated software team is being built consisting of

4 MOHSW staff,

4 UDSM /HISP staff

This team is partly overlapping with the technical rollout team described above

The software teams main tasks are to develop the national and district data warehouses and to

customize DHIS and additional software tools as according to the needs of the MOHSW,Furthermore, to integrate the data warehouse with other data sources by extracting the needed

data. GIS functionality will be developed as part of the collaboration with WHO on the

OpenHealth project.

The software team will work with, and be part of, the global network of DHIS developers and

work closely with the WHO and HMN on the developing of appropriate Open Source tools.


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This work has already started as three members of the software team (one of them form the

MOHSW) took part in a two weeks DHIS workshop in New Delhi, India, in March.

Regional and international experts will assist the MOHSW in the development of the data

warehouse, at national, regional and district levels, as well as in the rollout of the system.

Capacity building MOHSW; data management, DHIS data warehouse and open sourcetechnologies

Capacity will be developed in the MOHSW through the activities of the software team

described above but also through the building of a solid base for managing the overall

National HMIS.

All staff in the HMIS and ICT units will be part of this effort.

As the building of the National data warehouse and the National HMIS will take place in the

HMIS unit, capacity building will be part of every step of the process.

In order to achieve capacity development in the MOHSW, the project needs to recruit

additional regular MOHSW staff, train existing staff, allocate skilled project staff to the HIR

section and engage them fully in the development of the system and its rollout.

Based at the UDSM and the NOMA Masters Programme, which is running courses on these

issues, the project will engage in a wider national capacity development in this area, as well as

targeting individual HMIS and ICT staff for training (several are already included).

Training of regional and zonal HMIS staff will also be part of this effort.

4.3.2. Software development and systems integration

The software development and integration work package will be a continuous activity and will

be handled by the UDSM-MOHSW software team. The team will be responsible to;

Design database and software for rapid rollout based on existing HMIS.

Update software and data warehouse design based on revised tools.

Integrate DHIS with other related applications (e.g. LGMD)

Revise database & software once new registers & tools finalised

The customization and further development of the DHIS software and its integration with the

WHO OpenHealth application for web based Geographical Information System (GIS), is

specified in a separate document. The DHIS-OpenHealth development is in cooperation with

WHO and Health Metrics Network. The WHO-OpenHealth is the new web-based application

developed by WHO to replace the HealthMapper (see figure).

The DHIS-OpenHealth is a scalable district and web-based data warehouse, which may work

as a stand alone application without internet connection in a district, or as a web based

national repository at MOHSW.


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Integration with other computer based application such as Electronic Patient Record systems

in hospitals and other facilities is handled through a standardised data interchange platform.

This, of course, is depending on the use of open standards also by other computer

applications, which will be ensured through the strategic planning process. and other

computerised data sources; establishing web-based data warehouse, electronic reporting etc.

The basic principle underlying the various software applications involved in this workpackage is that first a first customised, stable and useful application is implemented, and

thereafter it is continuously further developed and integrated with the patient record systems

such as the Care2X, and other systems in place.

OpenHealth-

DHIS SuiteMultiple Views (e.g. M&E,

surveillance) free combination of

components(e.g. only data dictionary or

web presentation)

Data

Quality &Validation

Data

Dictionary

Data

processing

DHIS

DHIS-Integrated

Data repository

GIS

Pivot

Tables Charts

OpenHealthWeb

Presentationplatform

Data Exchange and Integration Platform

Data Exchange and Integration Platform

Data

Entry

Other systems;e.g. Patient

recordshospitals, DHS,vital registration

Figure: The DHIS-OpenHealth data repository. The integration of DHIS and OpenHealth is

part of a global project managed by WHO.

Budget for top-down national HMIS rollout specified in attached Excel

National rollout: 2,043,000 USD

International technical support 280,000 USDTotal 2,323,000 USD

5. Specification of the Bottom-up approach

- System strengthening, information usage and capacity building

The bottom-up approach consists of 3 interlinked work packages:


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WP4; Revisions of data and indicator sets and HMIS procedures (continuous, but with initial

baseline revision)

WP5; Building district and regional capacity training scheme

WP6; System strengthening; Improving data quality, information usage and health

management

WP7; Establish and use the Test region to develop and test tools, methodologies and revisions

Work Package 4; Revisions of data and indicator sets and HMIS

procedures (continuous, but with initial baseline revision)

Background

An indicator set has existed in Tanzania since the 1990s, but this is now seen as being out of

date, fragmented and inadequate and needs to be reviewed in conjunction with all relevant

stakeholders. Numerous additional program specific data collection tools and routines are in

use. There is a need for international best practice standards to be applied to indicatorselection as well as to the harmonization of the routine data collection system.

There is a perceived need for harmonized set of indicators and corresponding data sets and

data collection tools and routines, clearly acknowledged by MoH&SW top management,

M&E chapter of HSSP III, donors and programs.

Objectives

First phase (first 2 months)

Review existing data collection tools and indicators being used by MOHSW and the

relevant programs

Identify key performance indicators for the health sector in Tanzania

Identify data sets and data collection tools and HMIS procedures to be part of the

initial phase. Make sure indicator numerator and denominator, with clear definitions of

all components, are covered (when possible)

Identify sources and frequency of all data and indicators

Hospitals; same procedure for hospitals. The first phase approach is to assess current

forms and effectively harmonize and use what is there.

Define and establish the data sets that are going to be part of the first rollout:

o The current book 2, together with data sets from

o Vertical programs: HIV, and subsequently EPI, Leprosy/TB, Malaria.

o Handle the overlaps: same data collected by several programs and data

collection tools: These data will as a start be harmonized within the DHIS

database (while one single data item might be collected in many forms, such as

e.g. First ANC visit, it will only be captured and registered once in the


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database /DHIS). During phase 2, they will also be harmonized in the data

collection tools.

Second phase (first 18 months timeline depending on time it takes to physically print,

distribute and replace book 2)

Replace current book 2: Harmonize all relevant data collection tools and routines to

be used at facility and district levels, and design, produce and distribute new forms

that will be the primary monthly manual return from facility to district.

Given the slower process to print and replace existing paper based data collection

tools, this process will go on beyond the initial phase.

Establish a permanent national committee to oversee ongoing revisions of data and

indicator sets.

The aim is to arrive at a situation where programs needing more data and reports will

have to present their new data demands for this national committee and arrive at anagreement on whether the new demands are justified, whether the needed data are

already collected, how, eventually, the new data needs may be incorporated in the

existing routine data collection system, or whether new data collection tools, provided

they are not overlapping any existing tool, are needed. This measure is to stop the

process of fragmentation.

Special focus on hospitals. Harmonize all relevant data collection tools, data sets and

indicator sets.

Scope of Work

Review existing data collection tools, indicator set and data definitions Conduct consultation meeting with all key HIS stakeholders and their implementation

teams

o MOHSW Policy makers, cooperating partners

o Relevant vertical program managers,

o HMIS managers, District, provincial managers

Develop draft national indicator set with defined numerator and denominator and

source, in accordance with international norms and HMN framework

Circulate indicators with numerator, denominator, data source, rationale, use, related

indicators Organize and facilitate consensus meeting on indicators with each program

Design, print and distribute new paper forms which are shared between MOHSW and

all relevant health programs. There will be no duplication and overlapping data

collection (paper) forms. HMIS, RCH, EPI, etc, will all be based on a shared set of

forms the new book 2.

This new book may be conceptualized as a set of forms based on programs and


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services areas; a paper sheet for each of the following (or several combined in one

sheet), e.g. OPD/morbidity, EPI, RCH, Leprosy/TB, HIV, PMTCT, Malaria.

A key design objective for the new, inclusive and extended book 2, which is a

compilation of program specific official forms, is to design and establish a way

whereby new data requirements in the future will be captured by official additions to

book 2, by e.g. replacing the HIV sheet when this is being revised, etc.THIS IS IMPORTANT. The inability to continuously being able to update book 2

over time is the root cause to many of the current problems of fragmentation.

Continuously incorporate revised forms and definitions of data, data forms and

indicators into DHIS database /data warehouse

Revise the entire package of paper based data registration tools used at the facility

level; design, print, distribute the new tools. IMPORTANT; design a strategy for their

continuous update and revision over time, i.e. design for addendums according to the

future updates of book 2.

Devise a mechanism to revise data and indicator sets annually (i.e. phase 2)Hospitals:

Similar scope of work, but in a different context. Many hospitals are introducing

computer based systems. The program needs to take this into account and plan for a

gradual integration of these systems based on electronic patient records.

The scope of work includes

o the aggregated data flows within the hospitals (wards), to be managed within

DHIS at each hospital (gradually)

o reporting from all hospitals to the HMIS/DHIS

o integration of the electronic patient based systems being implemented in the

hospitals with the system for aggregated statistical data reporting; HMIS and

DHIS

Establish a sub-group within the program for the revision of the hospital HMIS

Develop hospital indicators and data sets

Develop revised reporting forms for hospitals

Incorporate revisions in the DHIS

Implement DHIS in selected hospitals

Plan for implementation of computerized HMIS and DHIS at all 200 hospitals. Make

this part of the strategy to integrate electronic patient records with the DHIS and

HMIS

Develop a strategic plan for the Hospital Information Systems in Tanzania, where the

process of introducing electronic patient based record systems in hospitals are

coordinated and integrated within the wider M&E framework as according to the

HMN technical framework


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Work

To establish a national team responsible for co-ordination, consultation, and finalizing new

registers, tools, indicators. Each member of the consortium (MoHSW, Ifakara, UDSM, UiO)

will assign a staff member full time for this national team

Phase 1 the first 2 months; establishing the initial data and indicator setsThis task, in Dar es Salaam, will start together with the initial phase in the test region and go

on for about 2 months.

During the two months, one staff (equivalent) from MOHSW, Ifakara, UDSM and UiO will

each work 6 weeks; 3X30 days= 90 days @ 100.000 = 9.000.000 Tshs

Phase 2 revision and replacements of book 2 and other needed tools. Month 7 - 12

The same/equivalent task force will continue and work on the more radical revision of the

paper based tools used in all facilities. This work will start 4 months after the initial data sets

are implemented (in order to gain some experience), go on for 6 months, with slightly less

intensively; 250 days = 25.000.000.

Important will be to be realistic in designing the additional tools and books supporting book

2; paper based books/registers/forms are difficult to replace once printed. They need to

adhere to certain flexibility, i.e. include blank columns.

Printing and distribution need to be budgeted separately.

The timeframe for the total replacement of book 2 and other paper based tools will depend

on logistics.

Hospitals Phase 1 and 2

A task force from the same partners and of the same size and intensity as for Phase 2 (250

days, 25.0000.000) will carry out this work over the first year of the project. While the first

phase, reporting from district hospitals will be part of Phase 1, referral hospitals need

additional attention. Plans for further computerization and the electronic integration of

patient record systems such as Care2X, and the collaboration with projects of this type, will

make up an important part of this work.

The task force will also develop a strategic plan and framework for the development of the

overall Hospital information system in Tanzania, and its integration within the M&E

framework, beyond the initial 18 months.

Printing and distribution need to be budgeted separately.

Budget: 250 days, 25.0000.000 Tsh

For all phases above: UiO is covered through the international consultancy budget.

WP5; Building district and regional capacity training scheme


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Objectives:

Run courses and develop capacity in HMIS and data use at

Regional and national levels (training of trainers of district staff)

District level staff (training of trainers of facility level staff)

Facility level staff

Develop training materials and guidelines for the above training scheme

This capacity development scheme will have to be carried out in stages starting with the

regional and national levels, and about 3 months later, also with the district level staff in the

test region(s)

The first objective and stage for this work package is to establish a training program for

the training of trainers; regional and national staff.

Three staff from each region, including the HMIS focal person, totalling 63, and about 12

from national and zonal level, totalling about 75. Four training sessions of 2 weeks will beconducted over 2 years. The topics of the training will address HMIS and management,

analysis and use of information for health management and health services delivery.

Assignments to be completed between the training sessions will include; use HMIS and other

information for situation analysis, planning and target setting, as well as the organisation of

data use workshops at district and regional (i.e. for all districts in the region) levels.

The training will be conducted using the zonal training centres where appropriate.

The second objective is to devolve an adapted part of this training program to the district

level, starting in the test region(s).

Three times one week training over about 1.5-2 years will be carried out at the regional level

for 3-4 staff from each district. With about 25 persons per training session, some regions may

be combined.

The training will include the same issues as for the regional staff, but with an additional

emphasise on facility supervision and the training of facility level staff. Assignments to be

completed between training sessions will include, as for the regional level staff; use HMIS

and other information for situation analysis, planning and target setting, as well as the

organisation of data use workshops at district level for district and facility staff.

Regional level staff will be responsible for conducting the training, but with support from

national level, in particular during the first session.

The third objective is to devolve the training scheme to the facility level. The test region(s)

will be used to develop cost effective methods to train facility level staff (data use workshops

may be the primary methodology, linked to supervision an additional one). Details will be

developed later.

For long term HMIS sustainability, an HMIS module will be designed and integrated into pre-

service training. In addition, a diploma in Health Informatics programme will be established

for HMIS cadre.


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Development of training materials

The regional training program:

One staff equivalent from each of the consortium members; MOHSW, Ifakara, UDSM and

UiO, will each work 4 weeks up to and including the first 2 weeks training session forregional and national staff.

The district training program

The team of about 4 persons develops a down-scaled version of the regional training program

for the district level. This work will be conducted in the test region(s) and will include the

practical development of a methodology and guidelines for data use workshops both at the

regional level (for the districts) and at the district level (for district managers and facility

staff).

The practical development of data workshop methodology and guidelines will also feed into

the regional training program.Four staff equivalents will work 8 weeks on this task.

Annex Assessing levels of information usage

Table 1: Criteria for Assessing Levels of Information Use General, All Levels

Level Broad description Detailed description of criteria

Level 1 The information system is working

according to its specification: timely

and accurate data is submitted to the

district; district manages data indatabase, reports to region and

feedback to facility. Similar at

regional and central levels.

Clearly defined Essential datasets for all

compulsory reporting have been defined?

Has an information manager been identified?

Have all the expected routine reports beensubmitted?

Have feedback reports been issued?

User friendly guideline including information

handling at that level is available?

Level 2 Summary reports of data produced

and disseminated regularly

Indicators are being assessed against

performance / targets on a regular

basis.

Are summary reports available

Are indicators graphed?

Are indicators discussed in management

meetings?

Level 3 Indicators and information are used

by managers to inform their action

plans.

Indicators and information used to

document performance in all written

reports

Are indicators interpreted and understood?

Are problems identified based on available

information?

Have any problems been addressed, and can

these steps be documented, and an improvement

shown using indicators and data?

Table 2: Criteria for Assessing Levels of Information Use for District level

Criteria to be met for District Level 1:


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Criteria 1.1:

District has clearly defined Datasets for which they are responsible to collect, manage and report

data.

Criteria 1.2:

Information handling (data collection, management and reporting), including all programs, is

coordinated and integrated. AND The district has identified an information officer responsible

for information management.

Criteria 1.3:

All data for which the district is responsible to report is captured and managed in the district

database

Criteria 1.4:

Up-to-date and user friendly Guideline for collecting, managing, reporting and using

information in the district is available (encompassing all data requirements, such as from

different health programs). A detailed Guideline for managing the district database software is

also available.

Criteria 1.5:

The district has staff with sufficient skills responsible for managing the computer based district

database.

Criteria 1.6:

The district database contains 90% of the expected reports from the facilities for the last year.

75% of the reports from the facilities are received within the period set for the submission of

reports (for monthly reports; within the 15th

the following month).

Criteria 1.7:

The district has produced and submitted feedback reports to the facilities within the defined

time frames.

Criteria 1.8:

The district has a plan for capacity development related to HMIS (at both district and facility

levels) and the district database


Criteria 2.1:

District monthly/quarterly reports: Summary report on data collected (from all programs)

including key indicators compiled and made available for staff and managers at least each

quarter

Criteria 2.1:

Feedback reports to the facilities (including a summary of data reported and key indicators) and

other information from the HMIS actively used in the supervision of the facilities

Criteria 2.2:

At least 8 indicators (and at least one for each program) are graphed for the year and up to date

for the year and up to last reported month.

Criteria 2.3:

At least 1 meeting each quarter designated to evaluate the data elements/ indicators. District

meetings with facility representatives routinely using indicators and data from the HMIS

assessing and discussing performance


Criteria 3.1:

At least four problems have been identified and addressed through an action plan, with data and

indicators specified for assessing achievements towards targets.


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Criteria 3.2:

The effect of the action has been monitored using indicators & information from the HMIS and

can be shown.

Criteria 3.3:

The actions and achievements are documented using data and indicators in a written report to

the district management team and/or in the annual report.


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Table 3: Criteria for Assessing Levels of Information Use at Facility level

Criteria to be met for Facility Level 1:

Criteria 1.1:

Facility has an Essential Dataset defined; a clear set of data to be collected, compiled and reported.

AND; the needed and specified tools (e.g. registers, forms) are in sufficient stock

Criteria 1.2:

Up-to-date and user friendly Guideline for collecting, managing, reporting and usinginformation in the facility is available (encompassing all data requirements, such as from different

health programs).

Criteria 1.3:

The facility has identified an information officer responsible for information management.

Criteria 1.4:

The facility has submitted all (100%) of the expected reports in the last year within the period set

for the submission of reports.

Criteria 1.5:

The facility information manager has validated 80% of the feedback reports from the district

(checked, signed, and sent back to district if any errors were noted).


Criteria 2.1:

Summary report on data collected and reported (from all programs) compiled and made available

for staff at least each quarter

Criteria 2.2:

At least 4 indicators are graphed for the year and up to date for the year and up to last reported

month.

Criteria 2.3:

At least 1 meeting each quarter (assessed over the last two quarters) to evaluate the data elements/

indicators (i.e. at least one meeting each quarter)


Criteria 3.1:

At least one problem has been identified and addressed through an action plan, with data and

indicators specified for assessing achievements towards targets.

Criteria 3.2:

The effect of the action has been monitored using indicators & information from the HMIS and

can be shown.

Criteria 3.3:

The actions and achievements are documented using data and indicators in a written report to the

district, the facility committee, or the annual report.

strengthen hmis in tanzania operation plan

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