AFRO-NETS> HMIS reform

Health Management Information Systems (HMIS) reform
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While observing the fascinating discussion stimulated under the topic
"Health Cards", I have been intrigued by what seems to be a recurrent
phenomena in the area of Health Management Information Systems reform.

We (especially those of us who may be classified as technocrats), are often
easily seduced and distracted by components of the HMIS system rather than
examining these components within the larger context and processes related
to meaningful HMIS reform.

In fact, it appears that many efforts to strengthen the role of HMIS in
health management decision making have led to little more than 'tinkering
around the edges'.

Home-based client cards/passports are introduced, colours are changed or
deleted from a road-to-health card, age and gender columns are added to
registers, a computerised data base is designed to aggregate data or a
geographic information system is utilised to present data in an attractive
format. Goodness, we may even one day see bar-coding introduced in rural
health facilities!

Each of these HMIS (sub-)initiatives certainly have potential to contribute
to improved management, but I would question if any one of them alone is
sufficient to stimulate and institutionalise a more effective and efficient
health system.

During our efforts to review and reform the Health Information System in
Ghana, and now in Nepal, a number of questions have arisen which begin to
outline issues related to more comprehensive Health Management Information
System reform.

We are attempting to address these issues in our forthcoming book (August
1997) titled "Health Management Information systems in lower income
countries: an analysis of system design, implementation and utilisation in
Ghana and Nepal." This new book builds upon our earlier work which was
documented in "From Data to decision making in health". Both books are
available from the KIT press in Amsterdam (e-mail):

kitpress@mail.support.nl

I have listed a few of these issues below, and would be curious to know if
these questions might be introduced as a broader AFRO-NETS discussion
topic with a new discussion title such as: "HMIS reform".

The list of issues is in no way exhaustive and the questions are not
presented in any order of perceived priority. Discussants might choose to
address one of these issues or add their own: I would be eager to learn
from the experience of others in any one of these areas:

1 What are the most appropriate steps in comprehensive HMIS review and
   reform?

2 What is the relationship between HMIS reform and Health Systems reform?

3 How much emphasis should be placed on a participatory approach to HMIS
   reform? What are the trade-offs between extensive discussions with all
   potential partners at all levels, as against a rapid assessment of the
   existing reporting system strengths and weaknesses and utilising a small
   task force to move ahead with a more comprehensive HMIS design?

4 What is the most appropriate institutional home for an integrated HMIS?
   Where does HMIS belong in the organisational structure of the Ministry
   of Health? Should it be within a technical division with strong
   ownership and capacity to provide relevant technical feedback, or
   integrated in a broader policy or planning division ensuring regular
   access to information by all policy makers at the central level?

5 Can the HMIS be kept simple, in the face of growing needs for
   information?

6 Are routinely collected data sufficient? Is there a minimum essential
   list of indicators to monitor with routine data? Can routinely
   collected data be used to monitor quality of care? Alternatively, what
   information should be collected through Health Systems Research? What
   are the advantages and disadvantages of each? What proportion of
   technical and financial resources should be allocated to each source of
   information?

7 Without diagnostic skill and equipment, what is the validity/value of
   morbidity service statistics?

8 How can data accuracy and consistency be ensured?

9 What is the best source of denominator (or catchment population) data?

10 What happens to the old vertical reporting systems after the
   implementation of an integrated HMIS? Are vertical or integrated
   systems more efficient, effective or sustainable?

11 Is there evidence that HMIS information improves self-assessment, and
   thus positively changes behaviour at the level that information is
   generated?

12 Are data processing and analysis best done with pencil and paper,
   calculator, or with a computer?

13 Which should comes first, strengthened management capacity or
   strengthened information systems?

14 What is the most appropriate reporting and feedback frequency?

15 What is the operational relationship between HMIS and supervision or in-
   service training?

16 What is the role of routine peer performance review in the HMIS process;
   and how can it be sustained?

17 Once data is converted to information and recommendations are made based
   on that information, why are some decisions made and recommendations
   implemented while others are not?

18 What does it cost to establish an integrated HMIS and what proportion of
   a recurrent budget would be necessary to ensure its sustainability? Is
   HMIS, in fact, a cost effective intervention which can be proven to
   contribute to expansion in health care coverage or improvements in the
   quality of service?

Let me know what you think about these topics.

Kind regards,

Bruce Campbell

Royal Tropical Institute
Kathmandu, Nepal
mailto:campbell@mos.com.np
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