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HEALTH INFORMATION SYSTEM MODULE
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11.1 Overview
The purpose of this module is to provide guidance on how to conduct an assessment of a
country’s health information system (HIS). Note that the intent of the assessment is not to
review, interpret, or analyze the values of health statistics or data produced by the system but
rather to assess the ability of the system to produce valid, reliable, timely, and reasonably
accurate information for use by planners and decision-makers. The outcome of the assessment
will allow the user to better appreciate the ability of a country’s HIS to “integrate data collection,
processing, reporting, and use of the information necessary for improving health service
effectiveness and efficiency through better management at all levels of health services”
(Lippeveld, Sauerborn, and Bodart 2000).
The goal of an HIS is to allow decisions to be made in a transparent way, based on evidence.
Therefore, the objective of the HIS is to produce relevant and quality information to support
decision making (Health Metrics Network 2006).
Note that a review of a country’s HIS should not be limited to the data that are routinely
collected and reported by health care facilities and other important population-based sources
such as census, demographic and health survey, and vital statistics reporting. Performance of HIS
should be measured both in terms of the quality of data produced and the evidence of continued
use of data for improving the performance of the health system and, ultimately, the population’s
health status.
The results of this assessment will therefore provide insights into how HIS strengthening might
be included in plans to support overall health system strengthening.
Section 11.1.1 defines an HIS and its key components, and Section 11.1.2 outlines how it works.
Section 11.2 provides guidelines on preparing a profile of the HIS of the country of interest.
Section 11.3 presents four topical areas around which the HIS assessment should be structured
and includes indicators to assess the performance of the HIS in these topical areas. Section 11.4
provides suggestions on how the assessment results can be developed into possible solutions to
strengthen the health system by addressing HIS-related issues that have been identified through
this assessment.
11.1.1 What Is a Health Information System?
For the purposes of this assessment, an HIS can be defined as “a set of components and
procedures organized with the objective of generating information which will improve health
care management decisions at all levels of the health system” (Lippeveld, Sauerborn, and Bodart
2000).
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An approach for describing the HIS in any given country is to consider the dimensions of
demand (i.e., who needs data and for what purpose), of supply (i.e., tools and methods available
to generate the needed information), and of level (i.e., the level of the health system at which
data are generated and used) (AbouZahr and Boerma 2005).
The HIS should address the following demand dimensions—
• Health determinants
• Inputs to the health system and related processes (e.g., health infrastructure, human and
financial resources, equipment, policy, and organization)
• Performance or outputs of the health system
• Health outcomes (e.g., mortality, morbidity, disability, well-being, and health status)
• Health inequities in determinants (e.g., coverage and use of services stratified by sex,
socioeconomic status, ethnic group, and geographical location)
As for the supply of health information, many methods and sources are available for generating
data. They can be divided into those that generate data relative to populations as a whole (census,
vital registration, surveys), and those that generate data about the operation of the services1
(administrative records, service records, health and disease records). Surveillance is considered
as a function and not a data source. The notifiable conditions—diseases or health events that
require enhanced notification and a public health response—are classified within the disease and
health records domain of health services-based sources.
Different data are needed at different levels of the system. At a lower level, data regarding a
patient, often presented in patient charts, are needed for patient management. At the facility and
district level, summary indicators are needed for management, planning and procurement
purposes. Indicators are also needed at district level for planning and reporting to the national
level. The national summary indicators are then used for the governance of the health system and
for regional/global reporting (for example, reporting on the Millennium Development Goals).
Feedback from the national levels to lower, or peripheral, levels is also important and promotes a
culture of information use. Even though the data needs are different for the management and
stewardship of the health system, policy making, resource allocation and patient care, these
needs are also linked along a continuum, as seen in Figure 11.1.
1 Health services-based data are referred to as health management information systems (HMIS), routine health
information systems (RHIS), management information systems (MIS), or even health information systems (HIS).
The framework presented here is in accordance with the Health Metrics Network’s framework that refers to health
information system to describe the total HIS, including population-based and service-based data sources (Health
Metrics Network (2006a). The term “health services based data sources” will be used throughout the document to
refer to data that originates in the health facilities.
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Source: AbouZahr and Boerma (2005)
Figure 11.1 Data Needs and Sources at Different Levels
of the Health Care System
11.1.2 How Does a Health Information System Work?
HISs generally evolve in an erratic way in response to different pressures faced by the health
system: administrative, economic, legal, or donor pressures. The result has been health systems
that are fragmented and have a dispersal and dilution of responsibility. Competing interests
between different stakeholders further contribute to the generation of parallel subsystems within
the HIS. Programs that are disease-specific also contribute to the fragmentation in their efforts to
respond to donor requirements and international reporting of indicators. All these factors result in
an overburdened and uncoordinated HIS.
The performance of an HIS is linked not only to technical determinants such as data quality,
system design, or adequate use of information technology. Other determinants are also involved,
such as (1) organizational and environmental determinants that relate to the information culture
within the country context, the structure of the HIS, the roles and responsibilities of the different
actors and the available resources for HIS, and (2) the behavioral determinants such as the
knowledge and skills, attitudes, values, and motivation of those involved in the production,
collection, collation, analysis, and dissemination of information (Lafond and Field 2003).
For the HIS to work adequately, certain prerequisites need to be in place, such as—
• Information policies—referent to the existing legislative and regulatory framework for
public and private providers, use of standards
• Financial resources—investment in the processes for the production of health
information (e.g., collection of data, collation, analysis, dissemination, and use)
• Human resources—adequately trained personnel at different levels of government
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• Communication infrastructure—infrastructure and policies for transfer and management
or storage of information
• Coordination and leadership—mechanisms to effectively lead the HIS
A functioning HIS should be able to provide a series of indicators that relate (1) to the
determinants of health, including socioeconomic, environmental, behavioral, and genetic
determinants or risk factors; (2) to the health system, including the inputs used in the production
of health; and (3) to the health status of the population. The list of indicators should be defined
by the users of information at different level in a consensus-building process.
To obtain the data required for the calculation of such estimations, different data sources must be
used. A very important function of the HIS is precisely the matching of a data item or indicator
with the most cost-effective tool for generating it. In many cases, however, one data item can be
obtained from two different sources. Understanding the strengths and weaknesses of each data
source and knowing what purpose the information is needed for contributes to making the right
choice as to what data source to use.
Because of the diversity in the design or composition of individual country HIS, developing a
single schematic flowchart that portrays the function and structure of a generic or universal HIS
is difficult. Constructing a flowchart for the HIS2 as a product of this assessment is helpful,
however, to show the flow of data, linkages with other elements of the HIS, and possible gaps in
the HIS. An example of a flowchart is shown in Figure 11.2, which illustrates the information
flow of a typical epidemiological surveillance subsystem. It shows, by level of government, who
reports to whom, at which frequency, and the type of data reported. It does not reflect the
completeness, accuracy, or timeliness of data that moves through the system. Considering the
context for the functioning of this flow is also important.
• Is it established by law?
• Are procedures standardized?
• Are international classifications being used for classifying diseases?
• Are control mechanisms in place to ensure the quality of data?