HIS implementation in Ethiopia: case studies from AAHB Woinshet Abdella PhD Student Department of Informatcs University of Oslo

HIS implementation in HIS implementation in Ethiopia: case studies Ethiopia: case studies from AAHBfrom AAHB

Woinshet AbdellaWoinshet AbdellaPhD StudentPhD Student

Department of InformatcsDepartment of InformatcsUniversity of OsloUniversity of Oslo

CONTENTSCONTENTS

BackgroundBackground• Ethiopia / Health Care SystemEthiopia / Health Care System

HISP EthiopiaHISP Ethiopia DHIS Implementation in Addis & DHIS Implementation in Addis &

OromiaOromia ChallengesChallenges

EthiopiaEthiopia

Population - 72+ million Population - 72+ million Area – 1.1 million kmArea – 1.1 million km22

Decentralized administrative structureDecentralized administrative structure• 9 regional states & two city 9 regional states & two city

administrationsadministrations 580 weredas (districts)580 weredas (districts)

Regional sates are autonomousRegional sates are autonomous Poor literacy, education, health statusPoor literacy, education, health status

Health Care SystemHealth Care System MOH, Regional health bureaus, Zonal MOH, Regional health bureaus, Zonal

health departments, Wereda/Sub-city health departments, Wereda/Sub-city health offices, Health Facilitieshealth offices, Health Facilities

Under developedUnder developed Health service coverage – 61%Health service coverage – 61% MMR – 871/100,000, U5MR – 140/1000MMR – 871/100,000, U5MR – 140/1000 High Infectious & communicable diseasesHigh Infectious & communicable diseases HIS is primarily manual & under developedHIS is primarily manual & under developed

HISP-Ethiopia HISP-Ethiopia

Project InitiationProject Initiation• Through a collaboration of the Through a collaboration of the

Department of Information Science, Department of Information Science, Addis Ababa University (AAU) and the Addis Ababa University (AAU) and the University of Oslo in February 2003.University of Oslo in February 2003.

PartnersPartners• AAU; regional health bureaus of AAU; regional health bureaus of

Ethiopia; global HISP Ethiopia; global HISP


Objective Objective • Introducing computer based HMIS in Introducing computer based HMIS in

Ethiopia in view of supportingEthiopia in view of supporting local local analysis and use of dataanalysis and use of data


HISP MembersHISP Members• 4 PhD students / 7 Masters students 4 PhD students / 7 Masters students

(one Norwegian)(one Norwegian)• 5 DHIS facilitators hired by HISP5 DHIS facilitators hired by HISP

Research Sites for HISP EthiopiaResearch Sites for HISP Ethiopia• Addis Ababa, Oromia, Tigray, Amhara, Addis Ababa, Oromia, Tigray, Amhara,

Benishangul-GumuzBenishangul-Gumuz DHIS implementation is being carried outDHIS implementation is being carried out

• Addis & Oromia – since Jan 04Addis & Oromia – since Jan 04• Others – since June 04Others – since June 04

Different stages of implementationDifferent stages of implementation

Case Studies from AddisCase Studies from Addis Research ObjectiveResearch Objective

• key research objective is to broadly understand the key research objective is to broadly understand the challenges and opportunities with respect to the challenges and opportunities with respect to the integration of existing paper-based HIS with computer-integration of existing paper-based HIS with computer-based systems in Ethiopia.based systems in Ethiopia.

Theoretical PerspectiveTheoretical Perspective• ANT ANT

Research Approach & contextResearch Approach & context• PARPAR

AR intervention: AR intervention: HIS implementation Intervention into health organizations HIS implementation Intervention into health organizations

(AAHB & OHB)(AAHB & OHB) One DHIS facilitator for each regionOne DHIS facilitator for each region

Research Approach & contextResearch Approach & context

Research SiteResearch Site• Addis Ababa health bureau (AAHB) , Addis Ababa health bureau (AAHB) , • 10 sub-cities (districts)10 sub-cities (districts)• 500 public & private health facilities, 500 public & private health facilities, • located in Addis Ababa city located in Addis Ababa city

Administration (Province). Administration (Province). • Addis Ababa is the capital city of Addis Ababa is the capital city of

Ethiopia (540 km2 )Ethiopia (540 km2 )• Population is 3 millions. Population is 3 millions.


Researcher Role.Researcher Role.• The role assumed was an involved The role assumed was an involved

researcher through action research.researcher through action research.• Qualitative data collection method was Qualitative data collection method was

employed includingemployed including photography, observations, interviews, photography, observations, interviews,

discussions, meetings, workshops, training, discussions, meetings, workshops, training, action experiments, document analysis, action experiments, document analysis, telephone calls, visit related institutions, telephone calls, visit related institutions, informal lunch/tea meetings.informal lunch/tea meetings.

Research subjectsResearch subjects• managers and planners at different managers and planners at different

levels of the health structure, the health levels of the health structure, the health workers responsible in data collections workers responsible in data collections and analysis. and analysis.


DHIS Implementation in AddisDHIS Implementation in Addis

Negotiate research access (KK)Negotiate research access (KK) Situation analysis (Mar 03 – Aug 03)Situation analysis (Mar 03 – Aug 03)

• Visits to Health bureaus & HFsVisits to Health bureaus & HFs Initiating the Design / Initiating the Design /

implementation process with implementation process with AAHB/OHB (Dec 03) (Bureau)AAHB/OHB (Dec 03) (Bureau)

EPR was just introduced thenEPR was just introduced then Prototype system was developed Prototype system was developed

and populated with 9 months own and populated with 9 months own datadata

DHIS Implementation in Addis DHIS Implementation in Addis AbabaAbaba

Demonstration of the prototype DHIS Demonstration of the prototype DHIS Addis (Jan 04)Addis (Jan 04)• The experiences gained revealed the The experiences gained revealed the

problems with the existing HMISproblems with the existing HMIS Data duplication, fragmentation, … Data duplication, fragmentation, …

• Local requirement (Morbidity/Mortality Local requirement (Morbidity/Mortality data handling) identified that DHIS does data handling) identified that DHIS does not support efficientlynot support efficiently

Developing minimum health data set Developing minimum health data set & health indicators was proposed& health indicators was proposed


Major decisionsMajor decisions• The proposal for standardizing data The proposal for standardizing data

set/health indicators acceptedset/health indicators accepted• Adapting DHIS based on new dataset Adapting DHIS based on new dataset

and reporting requirementand reporting requirement• Adding module to accommodate M/M Adding module to accommodate M/M

data handlingdata handling• Implementing DHIS to Implementing DHIS to ALLALL Sub-cities. Sub-cities.

Team formedTeam formed

The research team was composed ofThe research team was composed of Bureau levelBureau level, ,

• Bureau head; Bureau head; • health service head (leader of the project on the part of the health service head (leader of the project on the part of the

bureau), team leader, and senior expert; bureau), team leader, and senior expert; • family health head, team leader and expert; family health head, team leader and expert; • Disease Prevention and Control head; IDSR team leader, TB / Disease Prevention and Control head; IDSR team leader, TB /

Leprosy and HIV/Aids program team leader and senior expert; Leprosy and HIV/Aids program team leader and senior expert; • IEC expert; IEC expert; • Network administrator; Network administrator;

Sub-city LevelSub-city Level• two family health expertstwo family health experts

Facility LevelFacility Level• two health facility managers; two health facility managers;

And the researcher. And the researcher.


Two Parallel activities performedTwo Parallel activities performed• Standardized data set, health indicators, data Standardized data set, health indicators, data

collection & reporting instruments & collection & reporting instruments & procedures (data flow, …) developmentprocedures (data flow, …) development

Draft prepared by the group presented for Draft prepared by the group presented for workshops, comments incorporated, the draft was workshops, comments incorporated, the draft was

further developed in a series of long meetings,further developed in a series of long meetings, • Development of Morbidity & Mortality moduleDevelopment of Morbidity & Mortality module

Iterative / incremental (involved one major revision)Iterative / incremental (involved one major revision)


Use of DHIS as a prototyping tool Use of DHIS as a prototyping tool to better understand user requirements for to better understand user requirements for

producing an improved & useful system – producing an improved & useful system – which potentially increases data usewhich potentially increases data use

The standardized data set is The standardized data set is implemented in all facilitiesimplemented in all facilities

DHIS adapted, the new module DHIS adapted, the new module incorporatedincorporated• ((Input FormInput Form, , DHIS Data FlowDHIS Data Flow, Data Entry (next slide), , Data Entry (next slide),

Pivot Table ReportPivot Table Report, , Standard Report Standard Report ))

Monthly Routine Data Entry/Edit

Form

Monthly Morbidity and Mortality Data

Entry/Edit Form

DHIS Implementation in Addis DHIS Implementation in Addis DHIS is implemented DHIS is implemented

• All districts (10 sub-cities) and AAHB initiallyAll districts (10 sub-cities) and AAHB initially• Scaled to health facility levelsScaled to health facility levels

18/23-Health centers & 5/5-Hospitals (when resource / 18/23-Health centers & 5/5-Hospitals (when resource / situation allowedsituation allowed))

Training (DHIS/computer basics) was given to Training (DHIS/computer basics) was given to sub-city/bureau/HF health staff / managers / data sub-city/bureau/HF health staff / managers / data clerk / DHIS facilitators (with own data)clerk / DHIS facilitators (with own data)

Technical support is being provided by the Technical support is being provided by the facilitatorfacilitator

Participatory designParticipatory design July 2005, Workshop for evaluating one year July 2005, Workshop for evaluating one year

experience of the use DHISexperience of the use DHIS

Observations …Observations …

DHIS Software is well-tested & supports DHIS Software is well-tested & supports • Data aggregation; data sharing; health Data aggregation; data sharing; health

structure implementation; easily adaptable for structure implementation; easily adaptable for new needs, which is inevitable; rapid set-up of new needs, which is inevitable; rapid set-up of DHIS application for a new settingDHIS application for a new setting

Complaints from different actors (use of Complaints from different actors (use of MS Access in DHIS – DHIS 2 is a response)MS Access in DHIS – DHIS 2 is a response)

DHIS Implementation in OromiaDHIS Implementation in Oromia

Collection/reporting instruments and Collection/reporting instruments and software prepared for Addis is shared by software prepared for Addis is shared by Oromia & other regionsOromia & other regions

Followed similar approachFollowed similar approach• Some of the differencesSome of the differences

The process was slower when compared to AddisThe process was slower when compared to Addis The minimum data set prepared for Oromia not yet The minimum data set prepared for Oromia not yet

adopted by the regionadopted by the region DHIS implementation status DHIS implementation status

• Some Weredas of East Shewa zone (based on computer Some Weredas of East Shewa zone (based on computer availability)availability)

• Is being rolled out to the remaining zones (at the zone Is being rolled out to the remaining zones (at the zone level only)level only)

CHALLENGESCHALLENGES Improving data quality, data analysis and Improving data quality, data analysis and

useuse Reduce / Improve dataset Reduce / Improve dataset Achieving partnership with MOHAchieving partnership with MOH Scaling & SustainabilityScaling & Sustainability Over burdened health workerOver burdened health worker Limited resourceLimited resource Negotiating with multiple actorsNegotiating with multiple actors Parallel systemsParallel systems

THANK YOU!THANK YOU!

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HIS implementation in Ethiopia: case studies from AAHB Woinshet Abdella PhD Student Department of Informatcs University of Oslo