Health Cards (31)
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In the context of the Zambian Health Reforms a team of Zambian and
expatriate experts is working on the development of a new health management
information system. The work started in July 1996, and draws from
experiences in the Western Province Primary Health Care programme, which
started in 1986.
In the Western Province in Zambia the client based patient document is in
use since 1990 and is called Health Passport. The reason for introducing
this health passport were:
- absolute mess of the filing system in health facilities
- with the client based document patients carry their medical history,
where ever they go for health care.
The health passport is a simple "exercise book", that children use in
school. In some places rubber stamps are used to put in the antenatal data,
or the road to health card. In other places these cards are inserted into
the health passport.
Although there was a fierce debate among health care providers about
privacy and confidentiality, the clients never complained about such
issues. The experience is that the health passports are well kept, and
always presented during a next visit to a health facility. Of course, there
are incidents of loss, but much less than usual in facility based filing.
Most of the time, the health care provider does not need to dig deep into
the data, because the patient can give the medical history and 30 percent
is malaria anyway, but sometimes (e.g. surgery) it is useful to have a
history on paper to refer to.
The clients pay for the health passport, but it is a minor amount of money
(the price of an exercise book).
Next to the health passports, the health care providers enter some
essential information in client registers (OPD, IPD, Under 5, ante/post
natal, family planning).
In our experience, the client based documents are an improvement compared
to the traditional facility based filing system.
However, the HMIS Development Team of the Central Board of Health in Zambia
has rejected to suggestion to use a parallel system of data collection on
client contacts in an automated system, like IMPACT proposes (if I
understand it well). This would really be a duplication of efforts, not
feasible and not useful.
The Zambian Central Board of Health has decided that automation should not
go further than the district level, because of problems of electricity,
logistics (maintenance) and competence. If all patient data need to be
taken to the district office for entry in the computer database, it becomes
a bureaucracy on its own. Besides that, computers should have a enormous
capacity to allow millions of entries per year (district of 200,000
population). District use aggregated data from the health facilities for
entry in the computer and analysis.
In the view of the HMIS development team health workers should only collect
information that they can analyze locally, so that they are motivated and
understand why the do the "boring" counting work. Filling in patient forms
to be analyzed elsewhere goes against this principle.
In our view, it is not useful to enter all data in a database, because
there is no capacity to analyze all data available. The data presently
available at National level in Zambia are not analyzed, as we discovered in
our assessment in July 1996. Even programmes with heavy donor support in
information systems were not able to analyze all the data that were
reported by the health facilities and district offices. There is a general
tendency to collect data for the sake of data collection - for scientific
purposes, so to say. Especially technical experts want to know everything,
but never have time to analyze data.
The HMIS development team has chosen for a radical solution: only a minimal
set of data are reported upwards, i.e. those data required to monitor a
limited set of indicators. In the client registers more data are recorded
but not aggregated. Technical experts can use register reviews for
"scientific" research.
The HMIS is lean and mean: not much data collected and analyzed, but
various analytic tools are applied, used at facility level, which trigger
immediate action (e.g. changing disease patterns, lower than expected
vaccination coverage).
In monitoring and evaluation - next to HMIS - other data collection tools
are used, like health systems research, demographic health survey, specific
surveys, sentinel surveillance. These tools provide more reliable
information and are more cost effective than a bulky not functioning
routine data collection system. (The client based documents can be used in
community based surveys.)
The new HMIS has been introduced in 14 districts in Zambia (20% of the
country) and will be introduced Nation wide towards the end of 1997.
In short my contribution to the discussion is:
- Client based health care documents are OK as substitute for facility
based cards
- Parallel entry of client contacts in an automated system is not feasible
and not useful
- The HMIS should concentrate on a limited number of key indicators, which
can be analyzed by the health care providers (and community
representatives)
- Experts should use other methods for data collection for scientific
interest, which do not overburden the local health workers.
Dr. Jaap Koot
Public Health Consultant
Member of the HMIS Development Team
Central Board of Health
Zambia
mailto:100770.2022@CompuServe.COM
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