Health Information Systems Challenges

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But first.. Some Concepts from Yesterday’s Readings/ Lectures

You should be able to explain to a friend what these concepts mean in relation to Health Management Information Systems:

1. Primary Health Care (preventive/curative care)

2. Routine Health Information

3. Individual/patient care / Continuity of Care

4. (Electronic) Medical Record

5. Epidemic disease / disease surveillance

6. Fragmentation

7. Integrated Health Information Architecture

8. Data Warehouse / Data Repository

9. Indicator (covered later in course)

Our goal with the Health Information System“is to produce relevant information that health system stakeholders can use for making transparent and evidence-based decisions for health system interventions” (HMN)

But the challenges here are many:– You need access to data– You need quality data (covered later in the course)– You need to know what to do with it

Picture: HMN

Accessible data?

Picture: HMN

The lack of access to health information

Why?

Multileveled fragmentation

Uncoordinated Health programs

Different Health information domains

Public/private

Many electronic formats (and paper still very common)

Some Global Trends and Goals

Towards more granular patient based dataGlobally, two-thirds (38 million) of 57 million annual deaths are not registered. And every year, almost 40% (48 million) of 128 million global births go unregistered.

Towards integrated and shared dataMany ministires of health are fragmented and have vertical programs with their own reporting and data analysis systems (+ donors)

From Paper to Digital (integration or more mess?)

From ‘data collection’ to evidence based decision making

Mobiles and ICT often proposed as solutions technical solutions to social problems??

Example Routine PHC data (clinic/outreach)

Special programme activities

Reproductive healthChild health & nutritionHIV/AIDS, STI and TBChronic diseases

Routine Service Activities

Minor ailmentsNon-priority activities

Epidemiological surveillance

Notifiable diseasesEnvironmental health

Administrative Systems

Infrastructure, equipmentHuman resourcesDrugs, transport, labs, finances, budget, staff

Population Census: age, sex, placeBirths & deaths registration

Registers/records Record data that need follow-up over long periods such as ANC, immunisation, FP, TB

some registers in Practice…

PaperReports

monthly,Quarterly

but there are many different reports….

Fragmentation of health programs

One information stream for Malaria program

One information stream for TB program

One information stream for… etc etc etc

Surveys

Data not available for comparison. Double counting, low data quality

Country X (e.g., Malawi): three national figures of HIV+ rate or infant mortality rate. All different…

Many official actors: risk of fragmentation

Ministry of Health is not alone…– Central Statistics office (census)– Ministry of Local Government (run the clinics)– Ministry of Education (school health programs)– Ministry of Defence (military clinics)– Special units on for example HIV

What does this look like In Norway?

Why program fragmentation?

Health services inherently fragmented due to high level of specialization

Donors (both from necessity and ignorance)

WHO is highly fragmented itself

Interests and ownership

Leads to lack of transparency, some people thrive on that (corruption)

WHO’s history of success with focused programmesSmallpox eradicated in 1977

Eliminating polio in the Americas in 1985

Eliminating measles in Southern Africa

Reducing guinea worm disease by 99% in 20 African countries between 1986 and 2005

Relative successful compared to other UN agencies (such as World Bank).

Each disease eradication program operated autonomously, with its own administration and budget and very little integration into the larger health system

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But health systems continued to be inefficientShort-term successes were not addressing poor populations overall disease burden

Health systems were urban based, high-technology, curative oriented.

Little contact with the population for preventive care

Health is socioeconomic:– Health services, economy, security, education,

nutrition…

More comprehensive approaches emerged in a number of countries

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Primary Health Care

Promotive, preventive, and curative

Involves related sectors (education, food, agriculture etc), and wider aims (equity, affordability etc)

Promotes community and individual involvement and committment

Came as a reaction to older, high-tech, curative approaches. Based on bottom-up experiences from ”developing world”

How to implement it? Comprehensive vs selective? Overarching question ever since

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Comprehensive vs. selective today?

Both exists

WHO is still very fragmented in specific programs, which are replicated at country level

Cross-cutting units have been created; Health Metrics Network

In other areas, new agencies have been created to target specific areas: Global Fund, UNAIDS, GAVI Alliance

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HMN Framework: An example of comprehensive appraoch to HIS

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A selective approach to HIS

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ARVARVARV patient

Paper records

CRIS

HospitalHospital

In & out patients

Records / registers

Compiled

monthly reports Data capture

Data capture

PMTCTPMTCT OtherOther

Data capture

ICSICSMorb

idity .

Morb

idity .

ICSSUM

Summary report

Summary report

District:

Fragmented

Data management

Facility:

Multiple Forms

& registers

ExcelExcelExcel

ExcelExcelExcel

ExcelExcelExcel

Data capture

ExcelExcelExcel

ExcelExcelExcel

Summary

reports

National: Fragmented reporting; gaps & overlaps

Data sources not linked

(hospitals - poor)

ExcelExcelExcel

SUM

CRISExcelExcelExcel

ICSOther

data

sources

Other

data

sources

Facilitysurveys

Excel

Facilitysurveys

ExcelExcel

Comprehensive vs. selective: ICTsComprehensive: integration, comprehensive information needs, varied outputs

Selective: Silos, fragmentation, inefficient development and utilization of infrastructure. Closed-boundary ICT systems. Potential for cross-comparison of indicators is lower.

Both: provision of health services decentralized. IS needs to allow local levels to collect, process, and use information

Scope for various technologies to contribute: Mobile phones, mobile modems to access online services

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The MDGs in the PHC tradition(millenium development goals)Adopted by UN in 2000, to reach by 2015 goals related to:

1. Poverty and hunger

2. Universal primary education

3. Gender equality

4. Child mortality

5. Maternal health

6. HIV/AIDS, Malaria, and other diseases

7. Environmental sustainability

8. Developing global partnership for development

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The MDGs in the PHC traditionDespite the comprehensiveness of the MDGs, selective approaches within health continues

Addresses some critique of selective PHC– Take into account the broader context of development– Does ackowledge the role of social and gender equity

Still challenges related to:– Donor-driven technocratic approach to priorities, rather than

grassroot approach of Alma Ata– Vertical objectives, fighting one disease at a time– Little coordination among vertical programs

New actors find legitimacy in the MDGs for focusing on specific areas, contributing to and sustaining fragmentation 27

In Conclusion

There is a strong trend towards individual and encounter-based data (drilling down)

– Security, patient confidentiality, robustness

Increased focus on Civil Registration and Vital Statistics will lead to new requirements for selective sharing of data

– Birth data: not all stakeholders should get all data– Who has access, who owns the data

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In Conclusion II

ICTs only as effective as the system they support

International health community becoming increasingly aware of the limitations of ICTs:

What ICTs can do? Help in integration, collection, storage, processing, presenting information. Decentralization. Community empowerment, but not without its challenges

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