176 Schwefel Marte MIS Philippines

8/3/2019 176 Schwefel Marte MIS Philippines

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ELSEVIER International Journal of Bio-MedicalComputing40 (1995) 107-114

Internat iona l Journal 01

BioMedicalComputing

The Philippine management information system for publichealth programs, vital statistics, mortality and notifiable diseasesBenjamin Ariel Marte*, Detlef Schwefel 1

Department of Health, Health and Management Information System (HAMIS), San La::aro Compound, Ri::al Avenue,1003 Santa Cruz, Manila, Philippines

AbstractStrengthening the information support for decision making has been identified as an important first step towardimproving the efficiency, effectiveness, and equitability of the health care system in the Philippines. A Philippine-Ger

man Co~peration is in partnership toward developing a need-responsive and cost-effective Health and ManagementInformation System (HAMIS). Four information baskets are being strengthened specifically to address these needs ina cost-effective way: public health information systems, hospital information systCClTIs,nformation syst~s oneconomics and financing, information systems on good health care management. BLACKBOX is the managementinformation system for public health programs, vital statistics, mortality and notifiable diseases of the Philippines. Ithandles and retrieves all data that is being collected by public health workers routinely all over the Philippines. Theeventual aim of BLACKBOX is to encourage the development of an information culture in which health managersactively utilise information for rational planning and decision making for a knowledge based health care delivery.Keywords: Health And Management Information System; Need-responsive; Cost-effective; Philippines; Public healthprogram; Vital statistics; Mortality and morbidity; Computer application; Information utilisation; Rational planning;Decision making

1. The Health and Management InformationSystem (HAMIS)Strengthening the information support for deci

system III the Philippines [2]. In answer to thisneed, since July 1989, the Department of Health(DOH) of the Philippines and the German Ministry for Economic Cooperation and Development


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108 B. Ariel Marle, D. Schwefel/ Inl. 1. Biomed. Comput. 40 (1995) 107-114

The need-responsiveness of HAMIS was arrived at by assessing the: need for accurate information, through a surveywith health personnel in two provinces; comparative information needs, as compared toEuropean and OECD experiences;

normative information needs, through an economic decision making model and a state-ofthe-art statement from public health experts;

expressed needs for data, information and understanding through case studies on good healthcare management, which cases were discoveredby a proper information system [9].

The cost-effectiveness of HAMIS was ensuredthrough a survey that identified the prioritisationof indicators by some 15 professions involved indecision making for health, and by eomparing thesources of data in terms of different eriteria ofavailability and eost [9].Based thereon, HAMIS has developed and

tested eertain strategie elements for strengtheningthe health and management information system inthe Phi!ippines. These 'HAMIS Elements' incl'Jde: standardised reporting of routine data on mortality morbidity and public health programs(BLACKBOX holds the routine data on vitalstatistics, mortality, morbidity, and publichealth programs of some 30 out of 75 provincesin the country) [9]; secondary computerisation and simplified presentation of routine data on hospital care (thisHOMISBOX system is ready for encoding ofthe national database of routine hospital statistical reports) [9];

support for the development of a hospital information system, starting with admissions, discharges, and medical records (this LUCENA

simplified collection and retrieval of cultural,social and economical background data (thisBROWNIES system has been implemented in 4provinces) [91;

promotion of a simplified community basedspot mapping of a seven-indicator health assessment matrix, in the hands of village healthworkers (the DATABOARD system that wasdiscovered by HAMIS and has become a national program) [9];

discovering good health care management bymeans of a nationwide contest, and learning thelessons of, and organizing the winners of thecontest in order to influence health managementand health policy development. (The 'HAMISContest' has become anational event after twosuch contests held in 1991-92 and 1993-94)[5,9].This paper shall focus on one such HAMIS

Element, which deals with the public health information system, by way of elucidating that information translated into action means the improvement of health management in the Philippines.2. The Philippine public heaIth informationsystem (BLACKBOX)BLACKBOX is the management information

system for public health programs, vital statistics,mortality and notifiable diseases. It is a computerapplication developed by HAMIS in and for theDepartment of Health of the Philippines. Theprogram was written in dBASE/Clipper language,and has 2 modules: one for Public Health Programs (version 5.8), and one for Vital StatisticsMortality and Notifiable Diseases (M&M).BLACKBOX is capable of accessing the data filesfor any Regional Health Office (RHO) Provincial


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B. Ariel Marle, D. Sc/live/ei / Inl. 1. Biomed. Comput. 40 (/995) 107-114FHSIS is the computerised routine reporting system for Public Health Pro grams [I]. It was implemented nationwide in April 1990. The NotifiableDisease Module of the FHSIS (HISWK) wasimplemented in 1992. In the reporting scheme ofthe FHSIS, the data of the BHS, RHU, andDHO/CHO are encoded and processed at thePHO Computer Station. In return, the PHO isexpected to feedback information outputs to thereporting units, and to forward a copy of the datato the RHO. The RHO should also forward acopy of the data to the DOH Central Office [4].The reporting scheme of the Notifiable Diseasemodule is similar, except that the lowest reportinglevel is the RHU and not the BHS.Very often, computerised information systems

are actually data systems that tend to focus heavily on database management. This involves collecting, encoding, editing, deleting, backing upand generally assuring the quality and integrity ofdata [6]. Many such data systems genera te information that may be accessible and relevant onlyto a select group of high level users. These includethe programmers, analysts, and other technicalpersons who have an intimate knowledge of thecomputer system. Unfortunately, those who havethe most need of the information can often bethose with the lowest level of computer literacy.Most health managers belong to this category.For people such as these, the computerised systemappears to be a BLACKHOLE that sucks in data,but from which hardly any information comesout. This situation might, most aptly, be termedan electronic DINOsaur: Data In, Nothing Out.BLACKBOX was so named in order to dispel

the mystery and mystique of the electronic FHSISdatabase. It should be a BACKBOX that bringsdata back to those that produce it. The system iscompletely menu driven. It allows even a low leveluser to select from a package of analytic outputs,and to automatical1y generate health service re

3. Operating BLACKBOXBLACKBOX operates on the very simple computers found at PHO Computer Stations. These

are IBM eompatible 286 or 386 systems. To startthe program, a single command is entered:BLACKBOX. From then on, all the user has todo is select from aseries of menus by manipulating a lightbar, using the cursor keys.The user first has to indicate the health unit, oraggregate of units, that he would like informationon. He does this by selecting the Region,Province, District, RHU, or BHS of choice. Thisis the 'geographie aggregating sequenee' that allows the user to select the most elemental reporting unit, the BHS, or to aggregate units atdifferent reporting levels. Having made his choice,the user is then prompted to indicate the year ofreference.In version 5.8 of BLACKBOX, the user is nextpresented with the array of public health programs for which the FHSIS collects data. Heselects one, and is then prompted to select ananalytic output. If the data is reported monthly,the user can specify the number of months andthe starting month to aggregate. This is the 'temporal aggregating sequence' that al10ws the userto indicate the number of months or quarters forwhich he would like the data to be aggregated,depending on the frequency of data reporting. Ina similar manner, the M&M module of BLACKBOX al10ws the user to select the notifiable disease of interest, as wel1 as the number of weeksand starting week for which he would like thedata to be aggregated.Having processed the data, BLACKBOX then

offers to present the output in the form of a tableor a graph. The output tables contain just enoughinformation to be appreciated at a glance. Moreover, the tables were designed to be analytie outputs in themselves. The health manager need only


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110 B. Ariel Marte, D. Schwefel / Inf. J. Biomed. Compuf. 40 (/995) 107-114Each table comes with a 'completion level'.

This is the percentage of reporting units read fromthe database, over the total number of reportingunits expected for the specified level of geographieaggregation. Completeness is one component ofdata accuracy that ean be easily programmed. Ifroutine health reports must be taken 'with a grainof salt', the completion level is a measure of howbig that grain of salt must be. Consisteney is oneother eomponent that ean be satisfied by erosseheeking one report against another. For instance,the number of live births can be compared to thenumber of pregnant women seen; or, the ineidence of diarrhea ean be eompared to the ratio ofdeep wells to households. Regular updating is athird important eomponent of data accuracy thatdepends mostlyon the reporting proeedure. Regularity ean of eourse be improved by threateningdire eonsequenees if data reports are not submitted on time at specified intervals. It is probablymore effective however, to convince the healthworker in the field, that coming up with regularreports will 'make areal difference', e.g. in theallocation of health resources.The BLACKBOX outputs can be directed to

screen, printer, or file. The tables are saved in theform of ASCII text files while the graphs are inthe form of PCX files. The tables are viewed on aspecial word processing screen with full editingfeatures. This allows the user to type in his interpretation and, later present the printout as aformal report. Of course, this does not preventhirn from altering the figures in the table, but it isan incentive to be honest. In the sense that 'thesqueaky wheel gets the grease', the 'bad-Iooking'report gets to be alloeated more resourees. Besides, the database is in no way altered, and soanyone who would like to verify the report onlyhas to run BLACKBOX for hirnself. Anotherspecial feature of the BLACKBOX word processor is the ability to split the screen horizontallyand to view two tables in juxtaposition. For manyhealth managers t/lis is the most sophisticatedmethod of further analysis that they would ever

show' by pressing any key after each graph. Thisis the ca se when viewing the time trend series byage group in the M&M module.Finally, in the programming design of BLACK

BOX, a special feature is the modular nature ofthe output tables and graphs. What this means isthat a health manager can request more tablesand graphs to be programmed, as long as the dataelements are present, and the request can be answered in a matter of hours. All that has to bedone is to take the 'skeleton program', plug in thenew variables and calculations, then recompile theprogram.4. Utilizing heaIth informationThe health management information system ex

ists, essentially, to answer four very importantand pressing questions for the health managerand decision maker.I. What are our health problems? An importantfirst step in determining the health problems ofa given community or population is to look attheir mortality and morbidity profile. The mortality and morbidity profile answers the question 'What are people getting siek of? What arethey dying of?' It provides a starting point foranalyzing the health situation of the community or population.

2. What are we doing about them? Public healthprograms are interventive strategies designedto address some of the more important healthproblems of the population. BLACKBOX anaIyzes the performance of these public healthprograms. It provides some measure of theextent to wh ich these interventive strategieshave been addressing the health needs of thepopulation. It looks at health program performance from different perspectives, and tries todevelop a total picture of the activity of thehealth sector.

3. What else should we do? No interventive strategy can, of course, be perfeet. It would be


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B. Arie! Marle, D. Schwef'el /Inf. J. Biomed. Comput. 40 (1995) 107-114 111

dieate what else needs to be done, and whiehdireetions these strategies should take in thefuture.

4. How best should we manage our health resourees to this end? The optimal managementof health resources is all the more imperativewhere economic difficulty is the norm. Thescarcity of health resources may be more relative than absolute, in which case wise management may overcome, or at least attenuate, theabsolute scarcity of resourees. To some extent,a proper interpretation of the BLACKBOXanalyses may guide the health manager on howbest to manage health resources in order tomeet the specific demands of health pro gramintervention.Following is a ease example of utilizing health

information primarily on the basis of theBLACKBOX analyses. It is a situational analysisof pulmonary tubereulosis (TB) that tries to answer the four questions mentioned above. These'Facts and Figures' were submitted to the Seeretary of Health as a special report on September13, 1994. The report was eventually published inat least two of the leading daily newspapers in thePhilippines, the Manila Bulletin [3] and the TimesJournal [6]."Pulmonary tuberculosis (TB) continues to beone of the most important causes of illness anddeath in the Philippines. In 1992 and 1993, TBwas the fourth leading eause of death, comprising 6% of all deaths in both years. This is basedon the BLACKBOX analysis of data eollectedfrom the Field Health Services InformationSystem (FHSIS) of Region 10 (NorthernMindanao)."The top three causes of death in 1992 and1993 were pneumonia (18% of all deaths in

"About 1% of the total population 15 years andolder were identified to have TB. This was truefor both 1992 and 1993."

This part of the report was based on the data inFigs. 2 and 3 for 1993 as weH as the corresponding figures for 1992."All identified eases of TB were subsequentlyplaced und er treatment: 2/3 on short coursechemotherapy (SCC) and 1/3 on standard regimen (SR). SCC eonsists of rifampicin, isoniazidand pyrazinamide taken over aperiod of 6months. SR consists of streptomycin and isoniazid over aperiod of up to 12 months. SCCwas highly effective, with 97'Yo sputum conversion after the first 2 months of treatment. Thismeans that 9 out of 10 TB patients were nolonger infective 2 months after starting treatment on SCc. Moreover, 50% of patients onSCC complete the treatment within the year.---~------~-------~'HAMISEGION Reqion 10 Northern KindanaoLEVEL Reqional Health OfficeVITAL STATISTICS MortalityTABLE proportionate 'tlortality ratio.

CAUSE OF DEATIL . .NO _ _ OFHRDEATHS (')Accidents 885.41Cancer 562.34Diabetes 191.82DiarrhoA 173.64Diphtherie. 43.41Hypertension 597.68Influenza 7.07Kidnay dicoasG 177.68Leprosy 11.10Liver dis. , cir50.38Malaria 56.53Heasles 8'.84Meningitis 61.58Whoopinq couqh 12.11Pneumonla 15855.07Poliol:lyelitis 1.01Schistosomiasis 34.32Septlcemla 279.65TB. Meningitis 38.36TB, Pull1lonary 669.36TB. other fortlS 99.94Tetanus 28.27Vll.scul11.r disell.se 11581.01Unknovn 577.49Other causes 29387.93TOTAL 1051900.0

Data vere consolidated for 12 months starting January 1, 1993.Tho. do.nominator us~d was the total n \Ul1bQrof doaths.completion Level of Reports:

Janull.ry 91 of 131 reports in ( 70t)February 100 of 131 reports in ( 76%)March 92 of 131 reports in ( 70t)April 92 of 131 reports in ( 70t)


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112 B. Ariel Marte, D. Sc/llrefel / 1111. 1. Biomed. Comput. 40 (/995) 107-114

Number ot' Married Couples ot' Reproductive Age (MCRA) 296447

~----~---~---~-----~--_HAMIRegion 10 Northern MindanaoRegional Hea1th OfficepopulationPopulation by Age and SexAGEGROUP MALEEMALEOTAL

Less than 1 year26163542015831 - 4 years 10748803230107185 - 6 years 46217345796747 - 14 years 151895449929688715 - 49 yellrs 3218522231844170:>0 - 64 YOIlJ;'S S6~S5

8:1241527965 yeaJ;' s l! lndover

228010650929310TOTAL

73337110425018~7621

REGIONLEVELVITAL STATISTICSTABLE

community organisations in particular, couldbenefit from volume procurement of drugs.This approach is being spearheaded by theCommunity Health Service."TB is definitely still a major public healthproblem. The difficulties do not seem insurmountable, however. Short course chemotherapy especially, appears to be a cost-effectivesolution to invest in."It is interesting that prior to the 'Facts and

Figures' report on TB, the policy of the DOH wasto cover only about 70% of TB cases with SCC, inthe belief that SR was the cheaper treatmentmodality. The report has made it possible for theTB Control Program managers to more stronglyconsider covering a much greater percentage ofTB patients with the more cost-effective treatmentmodality, namely SCc.5. The next stepsThe eventual aim of BLACKBOX is to encour

age the development of an information culture inwhich health managers actively utilise informationfor rational planning and decision making. Onestep toward this direction could be to develop a

COlllpleted treatment 69263.82\ JOer 873 of 1095 reports in ( 80t)December ... 855 of 1095 reports in ( 78t)

TOTAL ... 10585 of 13140 reports in (811)

On the other hand, it was observed that thedrop-out rate was twice as high for SR (12% in1992 and 11% in 1993)as it was for SCC (7% in1992 and 6% in 1993)."

......... ~ ..: ........ ~-.

--------~~------------_llAHIS_REGION Region 10 Northern MindanaoLEVEL Regional Hell.lth OfticePROGRAM National Tuberculosis Proqral:lTABLE Number and percentage of selected indicators tor bothshort course checotherapy (seC) and standard regilllen (SR).

Fig. 2. BLACKBOX repon showing the number of TB patients identified and treated with short course chemotherapy(SCC, consisting of isoniazid, rifampicin, and pyrazinamide)and standard regimen (SR, consisting of isoniazid and streptomycin) in Region 10 of the Philippines, aggregated for thewhole year of 1993.

The foregoing paragraph in the report wasbased on the data in Figs. 4 and 5 for 1993, andcorresponding data for 1992.


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B. Arie! Marle, D. Schwefel / Inl. J. Biomed. Compul. 40 (1995) 107-114 113___________ ~~~~ ~ HAMIS_SHORTCOURSECHEMOTHERAPYsec)o.arryover patients 3979- 6642OTAL (patients) 1.0621efarence

Data were consolidll.ted tor 12 months startinq January 1., 1993.The "reference" figura W'as the denominator usad to compute for thep'ilrc:ent~ge figures in the table.completion Lovel of Reports:

January 901 of 1095 reports in 82')Fcbruary 901 of 1095 reports in 82\)March 893 of 1095 reports in 82'>April 868 of 1095 reports in 79')May 882 of 1095 reports in an}June 876 of 1095 reports in 80')July 882 of 1095 reports in 8H)August 886 of 1095 reports in 8H)september 888 of 1095 reports in 81')October 880 of 1095 reports in 80\)November 873 of 1095 reports in 80\)December 855 of 1095 reports in 78\)

Region 10 Northern MindanaoRegional Health OfficeNational Tuberculosis ProgramNUlllber and percentaqe of selected indicators forstandard regimen (SR).

REGIONLEVELPROGRAMTABLE

--------------~~--~-----'HAMI=

eases' as the eentrepieee, present minireasearehesthat are diseussed with invited and involvedspeakers, and that lead to a strategie plan on howto eonvert information into implementation. Soeial proeesses are thus Iinked to information systems.Probably the most important, and quite urgent,

next step would be to develop an 'expert system'that uses the indieators to interpret the many dataand to seleet and eomment on those that arerelevant to improving health management, as weilas to develop scenarios far health planning anddeeision making. Most likely this will take thefarm of a systematised situation al analysis basedon a reading of the BLACKBOX outputs, plusother relevant information sourees. It will transeend mere data orientation by engineering thebroader body of knowledge of good health earemanagers that understand the interaetion between

....~ ............. ~~-:~:: ....

Region 10 Northern MindanaoRegional Hell.lth OfficeNational Tuberculosis ProgramNUI1lberand percentage cf selected indicators tor shortcoure chemotherapy (sec).

COlllpleted treatl:l.ent 53290.17-1 "7.85\ 3.0.67\ 163.53\ 77.7n 10..03t 253.38\:pretllature discharges) 11891.19ttreatment cOl:lplet ions 65181. 37tTOTAL

(continuing treatment) 41038.63t

REGIONLEVELPROGRAMTABLE

TOTAL ..... 10585 of 13140 reports in (8H)

Fig. 4. BLACKBOX report showing- the number of TB patients identified and treated with short course chemotherapy(SCC, consisting of isoniazid, rifampicin, and pyrazinamide),in Region 10 of the Philippines, aggregated for the whoIe yearof 1993.

Geographie Information System (GIS) that depiets the health indieators spread out on a map.The geographie spread of health indieators tendsto have greater appeal espeeially with politiealdeeision makers. It would also be a useful tool forrapidly assessing the spread of eertain indieatorswithin and aeross boundaries of health administration.Information based quality assuranee eonfer

enees that deal with this data in the eontext of

STANDARDREGIMENSR)o.I Carryover patients 3027e", patients --~-156-TOTALpatients) 5183eference

CO'Dpleted treatment 15970.81\Died

10..10'Transferred out 325.27\Defaulted 137.64'Mv.ra. r . ction .,.20\Retused 10..0ltLost 2.17\TOTAL (pretllature discharges) 10059.39\TOTAL ( trea tnent conpletions 26020.20'+ premo.ture. dischll.rges) TOTAL (continuing treatDent) 25819.80\

......... :::~.:.:.-:.: ...........h w ti:::-::.~:-t:::_ .. . . . ~._ .

Data were conso1ido.ted for 12 months starting January 1, 1993.Th'il t lroforonco" fiquro. " 'ao. ~ho. dominatoo,," '-'odto cornp~'to Eor toh.percentago figures in the table.Completion Level cf Reports:January 901 of 1095 reports in 82')February 901 of 1095 reports in 82')

March 893 of 1095 reports in 82\:)April 868 of 1095 reports in 79\)


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114 B. Ariel Marte, D. Schwefel / Int. J. Biomed. CompUl. 40 (1995) 107-114

data, information understanding, knowledge, decisions and deeds. Such a systematised situationalanalysis, as much as possible, should answer, atleast the four important questions, namely: Whatare our health problems? Wh at are we doingabout them? What else should we do? How bestshould we manage our health reSOUl'ces to thisend?Routine health data will prabably never be

good enough to satisfy the requirements, especially of those in the academe. But especiallywhere the health and the lives of people areconcerned, perhaps it may be good to bear inmind that 'it is always bettel' to be roughly correctthan to be precise\y wrang' [8].References[I] Department of Health: Field Health Services Information

System Manual 0/ Procedures. Department of Health,Manila, 1990 234pp.

[2] Pons Melahi C, Schwefel D: Strengthening InformationSupport for Health Care: A Goal-Oriented Project Plan-

ning Exercise in the Philippine Context. HAMIS Occasional Paper No. I Department of Health, Manila, 1993,168pp.

[3] Requintina, RR: TB patient found immune to drugs:Flavier alarmed on unique case. In The Manila BullelinManila, September 25, 1994, p. 28.

[4] Robey, 1M, Lee SH: Information System Development inSupport of National Health Programme Monitoring andEvaluation: the Case of the Philippines, World HealthStatist. Quart. 43 (1990) pp. 37-43.

[5] Schwefel D, Pons MC: Discovering Good Management:An Information System on Innovations in Health CareManagement in the Philippines. HAMIS Occasional Paper No. 5, Department of Health, Manila, 1993, 160pp.

[6] Study says: TB remains 4th top killer disease. In TheTimes Journal, Manila, September 19, 1994, p. 4.

[7] White KL: An International Perspective on Health Information Systems. In Health Information Systems (Eds: PELeaverton and L Masse), Praeger, New York, 1984 pp.3-12.

[8] White KL: The World According to Kerr White. Unpublished collection of aphorisms, c. 1991.

[9] Schwefel D, Marte BA et al., HAMIS: Towards a Healthand Management Information System for the Philippines.HAMIS Occasional Paper No. 1/, Department of Health,Manila, 1995 in press.

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176 Schwefel Marte MIS Philippines