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Health Information System

De
229 pages
The health information systems of developing countries have made significant progress these last years. Nowadays, the challenge they are facing is that of their use and the acknowledgement of their usefulness by all health-systems players. Indicators at the national level would be of interest if health information systems are effectively operational.
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Health Information System

© L'HARMATTAN, 2010 5-7, rue de l'École-Polytechnique ; 75005 Paris http://www.librairieharmattan.com diffusion.harmattan@wanadoo.fr harmattan1@wanadoo.fr ISBN : 978-2-296-13240-5 EAN : 9782296132405

Health Information System
2nd edition

L’HARMATTAN

HEALTH INFORMATION SYSTEM
The following people contributed to this document (in alphabetical order): Jean-Pierre d’Altilia Paul De Caluwé Jean-Pierre de Lamalle Isaline Greindl Frédérick Lecharlier Alain Wodon

The following contributed to the first edition that appeared in September, 1996 (in alphabetical order) with the collaboration of AEDES and MSF-Belgium Jean-Pierre d’Altilia Jean-Pierre de Lamalle Murielle Deguerry Myriam Henkens Pascal Meeus Vincent Vercruysse Alain Wodon

AEDES 34 rue Joseph II 1000 Brussels Belgium Tel.: +32 2 219 03 06 Fax: +32 2 219 09 38 Email: aedes@aedes.be www.aedes.be

Foreword

The first edition of this book, which appeared in 1996, was well received, for it tried to impart practical elements derived from the field experiences of its various authors. Eight years on, it has become necessary to adapt the first version by taking into consideration developments in information systems in the developing countries, the health situation (the AIDS epidemic, for example and the updating of reference data) and the kind of health information asked for by donors and governments. This second edition should, we hope, meet these new demands. Our intention in this book is to retain a very operational approach, without academic pretensions, by providing those people involved in a health information system with the latest references and practical support in their daily tasks.

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ABBREVIATIONS
AEDES ALS AMC AMI ANC ARI ARV BCG CDC CI CMR CSF DOTS DPT EPI FHS GIS HIV KB MCTP MOO MSF NC NCON NHIS NHIMS OC PLWA RP STD TD UNHCR VCS WCA WFP WHO WPY European Agency for Development and Health Average Length of Stay Average Monthly Consumption Absolute Maternal Indication Ante-Natal Consultation Acute Respiratory Infection Anti-retrovirals Calmette-Guérin Bacillus Centre for Disease Control Confidence Interval Crude Mortality Rate Cerebrospinal Fluid Directly Observed Treatment Short-course Diphtheria-Polio-Tetanus Extended Program of Immunisation Foetal Heart Sounds Geographic Information System Human Immunodeficiency Virus Koch's Bacillus Mother-Child Transmission Prevention Major Obstetrical Operation Médecins Sans Frontières New Case Non-covered Obstetrical Needs National Health Information System National Health Information & Management System Old Case Person Living With Aids Risk Pregnancy Sexually Transmitted Disease Thick Drop UN High Commissioner for Refugees Voluntary Counselling and Screening Women of Child-bearing Age World Food Program World Health Organisation Women Protection Year

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CONTENTS

PART ONE: GENERAL PRINCIPLES 1 Principles for organising health information systems ......................................... 23 1.1 General framework ........................................................................................ 23 1.2 The problem of defining health-information systems .................................... 25 1.3 The key role of field players .......................................................................... 29 2 The main elements of a routine health-information system ................................ 31 2.1 Generalities ................................................................................................... 31 2.2 Indicators ...................................................................................................... 33 2.2.1 Defining indicators ......................................................................... 33 2.2.2 The choice of indicators ................................................................. 39 2.2.3 Indicator types ................................................................................ 40 2.3 Recording the data ........................................................................................ 44 2.4 Compilation ................................................................................................... 44 2.5 Analysis and corrections ............................................................................... 45 2.6 Interpretation................................................................................................. 47 2.7 Use ................................................................................................................. 49 2.8 Transmission of the information .................................................................... 50 2.9 The necessary tools........................................................................................ 51 3 Target populations .................................................................................................. 55 3.1 The existing data sources .............................................................................. 55 3.2 Target populations and zones (areas) of responsibility ................................. 56 3.2.1 The first tier (front line) .................................................................. 57 3.2.2 At the second tier level (first referral) ............................................ 60 3.3 Target populations by activities .................................................................... 61 4 Using indicators for monitoring country performances ...................................... 63

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PART TWO: ACTIVITES, INFORMATION AND INDICATORS 1 Outpatient activities................................................................................................ 71 1.1 Curativel Consultations ................................................................................. 71 1.2 Immunisation ................................................................................................. 81 1.3 Antenatal consultations ................................................................................. 92 1.4 Family Planning ............................................................................................ 99 2 Hospital Activities ................................................................................................. 111 2.1 Inpatient activity monitoring ....................................................................... 111 2.2 Inpatient Morbidity...................................................................................... 117 2.3 Surgery ........................................................................................................ 123 2.4 Obstetrics & Gynaecology .......................................................................... 125 2.5 Laboratory ................................................................................................... 136 3 Nutrition Activities ............................................................................................... 139 4 Tuberculosis .......................................................................................................... 149 5 HIV-AIDS .......................................................................................................... 159

6 Specific epidemiological surveillance .................................................................. 173 6.1 Epidemic alerts and follow up ..................................................................... 173 6.2 Mortality data surveillance ......................................................................... 177 7 Complementary studies and surveys ................................................................... 183 7.1 Drug consumption surveillance ................................................................... 183 7.2 Drug prescribing behaviour analysis .......................................................... 186 7.3 Financial analyses ....................................................................................... 189 7.4 Nutrition surveys ......................................................................................... 191 7.5 Immunisation coverage surveys................................................................... 194

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PART THREE: DATA ANALYSIS AND PRESENTATION 1 Notions of analysis and interpretation of information produced by the HIS .. 197 1.1 Causal analysis............................................................................................ 197 1.2 Process analysis .......................................................................................... 202 1.3 Score analysis .............................................................................................. 204 2 Introduction to using tables and graphs ............................................................. 209 2.1 Tables .......................................................................................................... 211 2.1.1 Definition ...................................................................................... 211 2.1.2 Examples ...................................................................................... 211 2.1.3 The table's positive points............................................................. 212 2.1.4 Golden rules.................................................................................. 213 2.2 Graphs ......................................................................................................... 214 2.2.1 Definition ...................................................................................... 214 2.2.2 The graphic types.......................................................................... 214 2.2.3 How to realise a good graph ......................................................... 222 How to choose the best graph ....................................................... 223 2.2.4

FIGURES
Figure 1: Information and decision-making ................................................................... 24 Figure 2: The role of the routine HIS in decision-making .............................................. 29 Figure 3: Player position regarding the HIS ................................................................... 30 Figure 4: The information network ................................................................................ 31 Figure 5: The transformation of information .................................................................. 32 Figure 6: The transmission of information ..................................................................... 32 Figure 7: An organisation's systemic components.......................................................... 40 Figure 8: The type of indicator according to the main elements of a health system....... 41 Graph 9: Variation of the number of new cases between 1985 and 2001 ...................... 80 Figure 10: Unmet obstetrical need ............................................................................... 135 Figure 11: Unmet obstetric need indicators .................................................................. 135 Figure 12: Ordering causes ........................................................................................... 199 Figure 13: Path analysis tree on the decreased use of a health centre .......................... 200 Figure 14: Path analysis for reduced accessibility to services ...................................... 201 Figure 15: The path analysis of reduced accessibility to services ................................ 202 Figure 16: Treatment time in an obstetrical emergency ............................................... 203 Figure 17: Geographical representation of the districts' functionality level ................. 208 Figure 18: Pie chart ...................................................................................................... 214 Figure 19: BCG coverage, Xyz Centre, YYYY [year] ................................................. 221 Figure 20: Changes in the Y HC coverage rates ........................................................... 221

TABLES
Table 1: Information-gathering methods ................................................................. 26 Table 2: The number of new cases per year ............................................................ 34 Tableau 3: Classification of pathologies ................................................................. 35 Table 4: The detection rates of a few pathologies in two health facilities ................... 37 Table 5: Crude birth rate ....................................................................................... 38 Table 6: Crude mortality rate ................................................................................. 38 Table 7: The classification of indicators by the systemic approach. .............................. 42 Table 8: An analogy between the individual and general diagnostic-treatment process 48 Table 9: Follow-up of the activities of health centres over time ................................ 53 Table 10: Comparison of the activities of health centres .......................................... 54 Table 11: Variations in the population data ............................................................. 59 Table 12: The population situation for a few countries in 2000 ................................... 61 Table 14: Examples of indicators used for program follow-up .................................. 68 Table 15: Examples of birth rates in a few countries ................................................ 94 Table 16: Calculation of Women Protected Years (WPY) ...................................... 107 Table 17: Minimum Emergency obstetric care (EmOC) resources .......................... 132 Table 18: Indicators commonly used in the fight against maternal mortality ............ 134

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Table 19: Admission criteria for a nutrition program.................................................. 143 Table 20: Results criteria for nutrition care. .......................................................... 146 Table 21: Tuberculosis in selected countries ......................................................... 153 Table 22: 1993 CDC HIV disease Classification ................................................... 166 Table 23: WHO staging classification .................................................................. 168 Table 24: Karnofsky score .................................................................................. 168 Table 25: ARV treatment regime codes ................................................................... 171 Table 26: Crude mortality rates ............................................................................ 180 Table 27: Infant mortality rates ............................................................................ 180 Table 28: Mortality rate thresholds used in situations with displaced populations .... 181 Table 30: Criteria for health district functions ....................................................... 206 Table 32: Classification by score (in sub-groups) .................................................. 207 Table 33: The districts presented according to their functionality level.................... 207 Table 34: Classification of a country's districts according to level of functionalityy . 208 Table 35: Using curative consultation .................................................................. 210 Table 36: Using curative consultations in a health district ...................................... 211 Table 37: Use of curative consultation, evolution over time ................................... 212 Table 38: The use of curative consultations per health centre ................................. 212

EXAMPLES
Example 1: Outpatient Consultations Yearly Summary ................................................. 74 Example 2: monthly immunisation report ...................................................................... 82 Example 3: Annual child immunisation report ............................................................... 86 Example 4: Annual measles cases report ........................................................................ 86 Example 5: Monthly antenatal consultation report ......................................................... 92 Example 6: Monthly family planning report .................................................................. 99 Example 7: Specific monitoring of users from the beginning of the current year ........ 103 Example 8: Annual Protection Report by contraceptive type ....................................... 104 Example 9: Monthly inpatient activity report ............................................................... 111 Example 10: Monthly paediatrics morbidity and mortality ward report ...................... 118 Example 11: Monthly surgical activity report .............................................................. 123 Example 12: Monthly obstetrics activity report ........................................................... 126 Example 13: Monthly laboratory activity report .......................................................... 136 Example 14: Monthly nutrition activities report .......................................................... 140 Example 15: Tuberculosis report (three monthly) ........................................................ 149 Example 16: HIV/AIDS Admission file ....................................................................... 160 Example 17: Monthly consultation and pre- and post-HIV test counselling report ............. 161 Example 18: Monthly voluntary HIV test report .......................................................... 162 Example 19: Annual HIV seropositivity rates and marital status ................................. 162 Example 20: Annual HIV seropositivity rate by age sex and mode of contamination . 162 Example 21: Patients starting ARV treatment .............................................................. 163 Example 22: Admission and follow up of patients on ARV ........................................ 164

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Example 23: Weekly cholera cases report in a health Facility ....................................... 175 Example 24: Weekly demographic surveillance report in a refugee camp ...................... 178 Example 25: Weekly cause of deaths surveillance report in a refugee camp ................... 178 Example 26: Nutrition Survey Report .......................................................................... 191 Example 27: Immunisation coverage survey report ..................................................... 195

INTRODUCTION
Some ten years ago in most of the health facilities in many developing countries there were very many forms that had to be filled out and regularly transmitted through the "health pyramid". The time periods for transmitting these forms were highly variable, and the forms emanated not only from national health-system bodies (the centralised administration and national programs) but also from international organisations. Not infrequently several forms gathered the same information for these different channels; moreover this information often repeated long lists of diseases or data that health facilities had a hard time supplying. Introducing the health district model followed the rationalisation of health services planning, and the need to dispose of more reliable information has progressively become a necessity. So "health information systems" have started to be talked about, and a wave of reforms of information-gathering "systems" has spread to most of the countries that have adopted the district health model and committed themselves to an administrative reform for greater decentralisation. The common characteristics of the systems that were implemented from this period on are the following: the replacement of disparate systems by unified ones simplified systems with reduced quantities of information and the abandonment of precision diagnostics wherever diagnostic means are not available a reasoned and negotiated choice of information to be gathered, with broad consultation with potential users, including those in the specialised national programs and the gathered information having to correspond to a need and priority use.

At present we have acquired a certain experience in the implementation, organisation and management of these health information systems, which have made real progress over the past few years. Yet the challenge that today faces these health information systems has become how they will be used and whether they will receive the acknowledgement of their usefulness by all health-system players. Although the progress made in organising information has often been spectacular, the use of gathered information still does not meet expectations; indeed the information systems have above all been used at the central level. Decentralised decision-making has often remained weak with information being sent unanalysed to the higher levels of the health pyramid, and indeed often does not even appear in annual national health data publications. This relative deterioration provides an excuse for specialised programs to push for the reestablishment of specific information channels (the most frequent example being the monitoring of EPI activities and the eradication of poliomyelitis).
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Contradictory forces will always exist between, on the one hand, the will to maintain a simple, reliable unified system that tries to respond satisfactorily to a maximum of needs and, on the other, the will of certain users to implement additional specialised information channels at the risk of enfeebling the whole, the excuse often being a call for effectiveness and a declared dissatisfaction with the reliability, the completeness and the timeliness of the existing system. In fact, this duality hides the power play between a systemic approach based on the health district as a health-system operating unit and the more traditional approaches of vertical programs for fighting specific diseases. The viable approaches will result from compromise organised around a unified basic core with additions responding to the specific needs of certain departments or programs. At stake is preserving a balance that provides required minimal information for everyone in the system. Effective access to quality current information and the real ability of players to use the most relevant possible information nonetheless remains the indispensable preconditions for rational decision-making. The growing attention paid to measuring social progress as part of the strategy for reducing poverty has led to the establishment of selective lists of indicators at national levels. Rationalisation efforts should continue as these indicators will only be of interest if the health information systems function correctly. The purpose of this manual is to contribute to limiting the technical obstacles for using health information so as to ensure the availability of clearly presented health information at the right moment for decision-makers.

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The contents of this manual are divided into three distinct parts: 1. Part one presents the main constituent parts of health information systems and some key elements with respect to organisation. Part two presents the necessary information and indicators generally used for monitoring various health activities, for epidemiological surveillance or for studies and surveys in complement to routine information system. It is thus more technical. It also includes Part three is more substantive in its explanations of how to analyse and interpret health information and recommend techniques for presenting commonly used information.

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