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National Health Information Systems Sierra Leone’s Presentation at the National Health Information System, Bobo, Dioulasso, Burkina Faso, 17 -19 October 2012
Steps • • Background Goals and Objectives of Results and Accountability Framework Output Situation Analysis The Four main Information Systems in the Sector (HMIS, LMIS, IHRIS, IFMIS) Data management, storage and Feedback and ICT Roles and Responsibilities of Stakeholders Strengths, Weakness, Opportunity and Threats
Background Sierra Leone in recent years has made significant progress in delivering interventions to address health goals in areas such as maternal, neonatal and child health, HIV/AIDS, tuberculosis, malaria and non communicable diseases. However, these gains have not been sufficiently broad based and sustainable. Progress at national level has not been reflected in gains for most vulnerable population groups in specificly those in the rural settings. It is evident that health systems that deliver services equitably and efficiently are critical to the achievement of health goals. Global health initiatives have thus paid more attention to health systems strengthening as a key strategy to addressing health inequalities and achieving health goals. Sierra Leone adopted this strategy and has developed its first National Health Sector Strategic Plan (NHSSP) with a six year horizon (2010 – 2015), along the lines of health systems strengthening, mainly focusing on its six pillars of governance, service delivery, human resources, health care financing, medical products, technologies and health information While the sector has welcomed the increased attention to health systems strengthening, it has also recognized the fact that it will not be sustained in the absence of a solid monitoring strategy that enables decision-makers to track how health systems are responding to increased inputs and the impact in terms of improved health indicators. This demands the definition of core indicators of health system performance while concurrently developing and implementing appropriate and sustainable measurement strategies to generate the required data. The Ministry in collaboration with its partners and stakeholders have developed a document called the Result and Accountability Framework (2010 -2015 ) for the NHSSP with the overall goal of providing a comprehensive and robust health sector wide framework for monitoring evaluation and review of the NHSSP 2010 -2015 that serves as the common platform for tracking progress and performance at national and district level, with alignment of specific disease / health programmes as well as all key stakeholders and partners
Goals and Objectives Goal The overall goal of the Results and Accountability Framework 2010 -2015 is to provide a comprehensive and robust health sector wide framework for monitoring evaluation and review of the NHSSP 2010 -2015. Objectives • • • To establish a strong, integrated and well coordinated country health information system, including implementing a regular and coordinated programme of population-based surveys and facility assessments, strengthened routine HMIS and civil registration systems supported by a functional Information Technology infrastructure. To strengthen institutional capacity in all aspects of M&E including data collection, management, analysis, synthesis, data quality assessment, performance reviews, reporting and data dissemination. To enhance use of results for planning and decision-making, including policy development and corrective action as the basis for mutual accountability between country citizens, decision-makers and international community.
Output • • An integrated and well functioning national health management information system that provides timely and accurate monitoring at Villages, district’s and national level. A vital registration system that functions well, with increased quality of data and capacity for analysis. Strengthened maternal death surveillance and response mechanism including regular assessments of quality of care in health services. A regular mechanism for data quality assessment, including regular data quality reports. Improved transparency of data, methods and analyses through the establishment of the National Health Research Group, national health resource centre, including a national observatory and portal Regular and transparent evidence based performance review meetings as a mechanism to hold all stakeholders to account, including district and national teams of the Mo. HS, bilateral donors, private sector, civil society, etc. Establishing a Health Demographic Sentinel Surveillance (HDSS) Site
Situation Analysis • • • Since 2007 the Mo. HS, with support from the Health Metrics Network (HMN), has championed re-forms in creating a district based database. The Mo. HS/DP and DIC now collates district data through an electronic District Health Management Information System (DHIS). In 2007, a National Health Accounts Survey was also completed in collaboration with DFID and WHO. This NHA survey led to the establishment of the Integrated Financial Information Systems (IFMIS), which now collects data on government expenditures and financial activities of the various Ministries, Departments and Agencies (MDAs). UNICEF recently assisted the Ministry with Developing Logistics Management Information tool, which are used to manually collect data on health commodities. These tools are now captured electronically through the CHANNEL software introduced by the UNFPA. This systems has been modified to meet the needs of Sierra Leone and now captures consumption data on drugs and consumables in health facilities across the country The Ministry in collaboration with World Health Organization (WHO) has just completed the Integrated Human Resource Information System (IHRIS). The key challenge has been the lack of ICT in the rural area, but however the ministry has also developed plans of dealing with these challenge. All these systems are currently operating independently and not integrated into the DHIS, which at the moment is focusing on capturing data on service delivery Data flow from districts to national has been inaccurate and untimely thereby undermining it dissemination and usage by decision makers and stakeholders for proper planning
Health Management Information System (HMIS) • The routine health management information system typically yields regular administrative reports on inputs to the health system, including finances, human resources, commodities, equipment and infrastructure. These administrative reports is supplemented and validated with findings from periodic surveys. • Weaknesses and Gaps – There are problems with timeliness, completeness and quality of data. There are significant capacity issues at the PHU level which are compounded by fragmentation and the burden of reporting systems (HIV, TB, malaria) – Difficulty in accessing data from private sector – Challenges in accessing HMIS data at all levels Planned Activities to Address those Weaknesses and Gaps – Develop and implement plans for strengthening of nationally integrated routine HMIS that provides timely and accurate data quality checks and monitoring, including convening stakeholders to have a common plan – Design and implement harmonized data collection forms/tools – Customization of DHIS, including revised electronic forms, electronic medical records and improvement of overall performance and functionality – Strengthen and integrate IDSR into DHIS • Strategic options for improving hospital Information Systems – Development of software to capture information. – Training of staff in the use of the system. – Procurement of computers – Networking of computers for capturing data in hospitals. – Strengthen ICT for DHMTs and hospitals – Building capacity at PHU level for proper capture of data on manual tools – Research mobilization
Logistics Management Information System • • Logistics Management Information System, (LMIS) provides information on the stock status, between levels of the health system. LMIS can be either paper or other forms of communication to transfer data which can improve day-to-day management of commodities and inform forecasting and procurement decisions at the district or national level. As part of the process of strengthening the LMIS, the Ministry of Health and Sanitation, in collaboration with UNICEF, has developed standards for recording the essential data items. These include: – – – Stock Keeping records such as Stock Cards Transaction Records such as the Report, Request and Issue Voucher (RRIV) Consumption Records such as daily commodity dispensing register which tallies the amount of each drug used or dispensed to each patient on a daily basis In addition to the above, UNFPA has introduced a computerized form of Inventory Control mechanism (CHANNEL), which has been installed in the District and Hospital Medical Stores. The CHANNEL software has been recently modified to capture consumption data. However, the modified system is yet to be used effectively to get consumption data. To address this situation: – 13 IT CHANNEL operators have been recruited and deployed in all 13 districts to operate the electronic tool – Additional training will be provided to all health workers that handle drugs, to efficiently perform their respective roles in the LMIS chain. – Supervision will be increased to strengthen the capacity of health workers to use the paper-based LMIS. – An electronic LMIS system has been developed to help automate most of the LMIS processed. This system will be designed to take advantage of the supply distribution process and operate throughout the varying levels of telecommunication available in remote and rural areas.
Human Resource Information Systems • The existing HRH information systems in Sierra Leone depend on different sources such as payroll records, district staffing list, health facilities staffing, health training institutions, faith based organizations, censuses or surveys, payroll records and various other services in statistics for which the completeness, timeliness and comparability are widely variable, added with the challenges of combining and compiling information from multiple sources. • To address the critical need to improve the existing Human Resource Information System, a properly functioning HR information system has been established. The following will be done to ensure its effectiveness: – Health workers at district and central levels will be trained in the use of the system. – A computerized database on the health workforce will be developed using a unique identifier assigned to each health professional, to track health professionals from entry into health training institutions, through recruitment into public or private sector institutions, to transfer within the country or movement between public and private sector or emigration and retirement or death. – A national database will be launched to track the annual numbers graduating from all health training institutions.
m - HEALTH Overview Background: Through research and case studies , the potential of mhealth and the use of mobile communication through its (mobile phones and PDAs) for health services and information. This field has the potential to transform and approach to a variety of healthcare challenges in Sierra Leone by accelerating the collection and storage of patient data, training rural staffs with health updates and guidance, and personalizing to new levels the process of patients receiving and engaging in available medical treatment. Governments, companies, and non-profit groups are engage in the m. Health applications to improve healthcare and consequently save lives. These new mobile applications, bypassing the fixed-line solutions, are creating new pathways for sharing health-related information, even in the most remote and resource-poor environments. Source: World Vision Sierra Leone has incorporate the need for implementing m. Health, in Sierra Leone to enhance the health sector by: • Increased access to healthcare and health-related information, particularly for hard-to-reach populations • Improved ability to diagnose and track diseases • Timelier, more actionable public health information • Expanded access to ongoing medical education and training for health workers • Aims: • Reduce child mortality specifically the under-five mortality rate. • Improve maternal health: Reduce, the maternal mortality ratio. • Combat HIV/AIDS, malaria, and other diseases: Have halted by 2015 • Objectives: There is a great pride in MOHS/WVSL in trying tremendously in their effort to improve the lives of their citizens. Yet formidable obstacles remains. Health challenges present arguable the most significant barrier to sustainable development. Disease and the lack of adequate preventative care take a significant toll on populations. Depending on whether governments make the link between telecommunication policy and health, and the extent to which donors encourage transparency in sourcing and the participation of local entrepreneurs. Ultimately, the takeup of mobile communications in the health sector isn’t really about technology at all
Data Management, Storage, Feedback and ICT Data Management • • • Routine data is collected in the public sector through a network of 1, 119 Peripheral Health Units (PHUs), and 25 hospitals that are distributed throughout the country across 13 health districts. The PHUs and hospitals gather data from client/patient registration forms, using tally sheets. These are collated onto paper based integrated reporting forms which are sent to the district office. Data from the community is included in the PHU’s reporting forms. DHMT capture this data into an electronic District Health Information System (DHIS) and the electronic data is forwarded to the Directorate of Planning and Directorate of Information and Communication in the Mo. HS. The electronic DHIS database also allows integration of Open MRS software that will permit development of a Hospital Information System. This electronic medical recording process has started with data for anti-retroviral patients being recorded at the nation’s teaching hospital and will be scaled up to all hospitals as a second step. The DHIS database will progressively be extended to capture data from other sources such as specific surveys, civil registration (births and deaths), research, supervision, private sector, civil society, resources and administrative records to give a broad picture of the country. Data and reports on key indicators and reports of National reviews will be stored in a National data repository/observatory.
Data Flow Chart MOHS/DP and DIC DHS, Surveys, Births and Deaths Registration Tertiary Hospitals DHMT PHUs District & Regional Hospital Private, NGOs, FBOs
Data Storage Data is received and stored at all levels: • At PHU level, monthly paper based data reports are stored locally in files • At district level, data is captured into a district database application using the DHIS 2. 0 application software and stored in the district’s Integrated Data Ware house (IDW). • At central level, DP and DIC electronically compiles raw data (pivot tables) received from the 13 districts and are stored in the central Integrated Data Warehouse (IDW). The DHIS database is capable of producing standardized reports, providing monthly feedback to each health facility and each district on its performance, thus giving an overall national health statistic
Information Communication Technology (ICT) • • Integration of health information is important for data from various programs at all levels to be managed as a whole in a well coordinated and transparent fashion. Computers and internet communication facilities are already in use in most offices at national and district levels to permit rapid compilation and transmission of health data as well as automation analysis and report generation. A fully integrated health data warehouse is designed and installed at national and district levels. This pull together data from all key health programmes and activities (routine services, surveillance, human resources, drug supply, maternal and child health services, HIV/AIDS control, tuberculosis control) and other data sources essential for health decision making (census, household surveys, vital statistics) and provide decision makers at all levels with user friendly reports and access to essential statistics. The Directorate Information and Communication has been recently established.
Integrated Data Warehouse Information Services (SSL) Common User Interface Decision Support & Executive Dashboard Extract, transform and load data into warehouse Census Vital Event Registry Surveys Admin Records Service Records Health & Disease Records Formerly fragmented data collection methods and tools Data Warehouse at DP and DIC
Reporting and Feedback The success of reporting on Key Performance Indicators depend on feedback between and amongst the various levels of service delivery in the health sector Table 1: Reporting and Feedback Processes for Key Performance Indicators Feedback Process Deadlines Responsible Party Facility monthly reports received by District M&E Office 5 th Facility Head/ Nurse District Monthly Report received by DP and DIC 15 th DMO Feedback received by facility from District 30 th M&E Officer Feedback report received by District from National Level 30 th DP and DIC District Monthly data received by programs (EPI, RCH, Malaria, HIV, TB, etc) 25 th DP and DIC Feedback Report from DP and DIC/National to Districts 30 th HMIS Notifiable diseases and diseases under epidemic alert, reports received by DPC weekly M&E Officer
Analysis, Synthesis and Quality Analysis and Synthesis: • Analysis of data is done at various levels of the health sector. Data is analyse and presented in the form of tables, charts and graphs. Data from routine HMIS are disaggregated by district/local Councils and when required by chiefdom or facility. Data from surveys further disaggregated by sex, urban/rural and wealth quintiles. The main focus of analysis is: – Tracking progress and trends (based on measurement of baselines and targets for core indicators (as in the progress and performance report) – Equity analysis (main stratifies: region, district, level of income, gender etc) – Efficiency (value for resources) Data Quality: This involve more details and includes. – Involvement of independent groups (national institutes, universities) for data quality ascertainment – Processes for data quality assessment and adjustment including assessment of completeness of reporting, assessment of denominators, comparison/analysis of results from facility data, population surveys data and use of well documented methods for adjustment. – An annual system of verification through annual facility surveys (combined with the service readiness surveys - as described above) – Development of data quality report cards – Sharing of data, reports, and methods in the public domain, – training and supervision
Evaluation Exercises • Evaluation is carried out periodically to assess the health status of Sierra Leoneans as a result of implementing the NHSSP. The major evaluations are (i) Annual Programme Reviews; (ii) Mid Term Evaluation; (iii) End of Term Evaluations and (iv) Participatory Community Monitoring and Accountability Evaluations. Specific questions in these evaluations focuses on: – – – – Relevance of programme (s) objectives Relevance of strategies employed Effectiveness of the programmes Efficiency of implementation Sustainability of programme(s) Gender mainstream in programme(s) implementation Human rights approach to programme(s) implementation
Data Dissemination • In order to facilitate the usage of information for decision-making among the different stakeholders, a number of communication and feedback mechanisms are instituted as part of the Health Information System. Table below shows the stakeholders and the HIS products that are required. HIS products are disseminated as appropriate through: • • • Email Post Courier Quarterly Bulletin Delivered by hand Website
Table 3 : Health Sector M&E lines of Communication and Feedback Mechanisms Stakeholder M&E Information Requirement and Use Communication and Feedback Mechanism District Councils Performance of the district to assess progress, experiences, challenges and resolution process National Quarterly Bulletin, Quarterly and Annual Reports; Briefs, meetings DHMTs Performance of the project to assess progress, experiences, challenges and resolution process National Quarterly Bulletin, Quarterly and Annual Reports; Briefs, meetings PHUs Performance of the facilities/PHUs to assess progress, experiences, challenges and how they have been resolved National Quarterly Bulletin, Quarterly and Annual Reports; Briefs, meetings HSCC, HSSG Compliance with the NHSSP, rules and regulations. Challenges impacting project implementation National Quarterly Bulletin, Quarterly and Annual Reports; Briefs, meetings Mo. HS Contribution in progress towards MDG indicators 4, 5 and 6. Compliance with rules and regulations. Challenges impacting project implementation National Quarterly Bulletin, Quarterly and Annual Reports; Briefs, meetings Funding Development Partners Compliance with NHSSP rules and regulations. Challenges impacting project implementation National Quarterly Bulletin, Project supervision missions, Quarterly and Annual Reports; Briefs, meetings Non funding development partners (NGOs, CBOs, FBOs) Compliance with NHSSP, rules and regulations. Challenges impacting project implementation National Quarterly Bulletin, Quarterly and Annual Reports; Briefs, meetings
Data Access • At the district level, the integrated data warehouse automation, generate user-friendly bulletins, other reports and maps to feedback to health facilities and inform DHMTs and local councils. These will show comparisons between facilities and districts through indicators on coverage and efficiency (e. g. outpatient attendances per health professional). • Multiple agencies, partners and other information consumers (researchers, the media, civil society organizations) have web-based access to statistics via the portal of the integrated warehouse • Government health services statistics and surveys and census data collected by public agencies, in principle, are regarded as being in the public domain once the data has been rendered anonymous. Public access to this data is guaranteed by law
Reviews • • As Partners are increasingly showing commitments to the health sector, regular annual multi-stakeholder review meetings are conducted, as scheduled below. The reviews conducted by a good synthesis of the available monitoring data. The results of the review meetings are used extensively in the planning process. The national reviews have a strong sub-national focus which is well informed by data. Programme specific reviews (e. g MNCH reviews) also aligned with, and the results/decisions fed into the annual sector review. The National Annual review are culminated in an Annual Health Summit to which all stakeholders were invited to discuss progress and agree on the way forward. The Summit consist of Local Council representatives, District Health Management Teams, selected facility representatives, representatives of Parliament, NGOs, CSOs, the private sector, donor partners and other stake-holders. The summit also involves other key inter-sectoral ministries and partners in health, including ministries of, Education, Science and Technology; Finance and Economic development; Local Government; Gender and Children’s Affairs; Youth and Sports; Agriculture, Forestry and Food Security; Defense (ONS); and Information. The Government coordinated and chair the Summit. In order to provide information to guide strategic direction, data from the HMIS is used to assess coverage. Surveys and assessment are conducted to ascertain service availability and readiness. This, together with other administrative data, formed the basis of a draft sector performance report for the previous year that is expected to be completed by the end of May each year.
Table 4 : Timeline for Reviews Milestone Timeframe Sector performance report May Joint review mission by Health Sector Steering Committee June Health Sector Review Summit July District Reviews March, June, September, December Programme Reviews March, June, September, December
Roles and Responsibilities of Key Stakeholders Some institutions have a critical role in the implementation of the Results & Account-ability Framework. These include, the Mo. HS, Statistics Sierra Leone (SSL), University of Sierra Leone, Private Institutions, NGOs, FBOs, CSOs and Development Partners. • • The Mo. HS monitors the implementation of the plan as well as create a monitoring system that starts from the community, through the facility, the district to the national level. The Ministry also ensure that information collected through the country M&E system is disseminated and available to all partners. SSL, in line with its mandate, support all the household and facility surveys. Some surveys out-sourced, while for others SSL is requested to provide technical support for specific aspects, such as sample, data entry and analysis. The University of Sierra Leone and its constituent colleges are responsible for providing basic, in-service and post-graduate training of staff in Health Informatics and Epidemiology. It also has the responsibility for conducting various assessments and research. Private Institutions, with comparative advantage in conducting evaluations and research, are contracted to conduct such studies. They also contracted to provide training for staff in M&E and in the use of Information communication Technology (ICT). Non-Governmental Organisations (NGOs) and Faith-Based Organisations (FBOs) work with the Mo. HS to set up functional Monitoring systems at community, facility and district levels. Staff of these organizations are required to provide technical support for the development of the National HMIS. CSOs are trained to support data collection at community level, conduct data verification and use the information from the HMIS for advocacy. They also support, to conduct community monitoring systems and use data collected through the system to motivate staff to improve performance. Development partners and Donors provide both technical and financial support for setting up the national HMIS and sustaining it.
SWOT The ministries had difficulties incorporating the necessary access of internet communication, resulting in lack of communication from all angles. Implementation of web designing is currently being initialize, with the internet facility also need to be enacted upon to facilitate the needs of: • Intranet communication within the ministry • Upholding security mechanism, through the means of wired and wireless connection • Server devices to collect and correlate data • Application software for decision makers to provide statistical results. • Collaboration and teleconferencing • mhealth and e. HEALTH technology With the implementation of the internet facility, would create a fundamental results in the way we access and make decision base on real time information.
The End • Thank you for your Attention • Merci • Obrigado