Unit Four

Health Information System

(HIS)

Kassahun D.
Learning Objectives

At the end of this session students will be able to:

Explain concepts of Health System and Health Information System
Describe Routine health information system
Explain concepts of Health Management Information System
Describe Community Health Information System
 Concepts of Health System

What is Health system?

It is the sum total of all organizations, people,

resources and all activities whose primary purpose is
to promote, and maintain health.
Health system building blocks

WHO health system framework (six core components /building blocks)

What is HIS?

It refers to any system that captures, stores, manages

or transmits information related to activities of
organizations, which will improve health care
management decisions at all levels of the health
system.
Components of HIS (six)

 According to the Health Metrics Network’s

“Framework and Standards for Country Health
Information Systems”
a. Health information system resources
b. Indicators
c. Data sources
d. Data management
e. Information products
f. Dissemination and use
Components of HIS by inputs, processes, and outputs
category

Inputs Process Outputs

1. HIS resources. 2. Indicators. 5. Information
 HIS coordination and 3. Data sources products (Data
leadership Censuses transformed in to
 HIS information Civil registration information)
policies Population surveys
 HIS financial and HR Individual records 6. Dissemination
 HIS infrastructure Service records and use
  Resource records
4. Data management

Data storage

Data quality

Data processing &
compilation
Functions of HIS:

Four key functions

1. Data generation,
2. Compilation,
3. Analysis and synthesis
4. Communication and use
Goal of health information systems

The ultimate objective of a health information system is to produce

information for taking action in the health sector.
Routine Health Information System (RHIS)

“RHIS is a system that provides specific information

support to the decision-making process at each level of an
organization.” (Hurtubise, 1984)
How RHIS works?
Information Generating Process

Info-needs / indicators
Resources
Data Collection

Data Transmission Management

Data Processing

Organizational
Data Analysis
Rules

USE OF INFORMATION
FOR DECISION-MAKING
RHIS objectives and goals
GOAL:
Contribute to evidence-based decision-making in the
health sector.

OBJECTIVES:
1.To generate quality information.
2.To use information for action.
Basic requirements for RHIS

1. Information needs adapted to the management

functions of health system.

2. Well-functioning data handling process

3. Sufficient and appropriate resources and

management
Provide sufficient and appropriate resources

 Adequate staffing.

 Adequate logistic system for printed supplies.

 Computer hardware/software and maintenance.

 Communications equipment.

 HIS recurrent budget.

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 RHIS Performance Diagnostic Tool

Performance of Routine Information System Management

(PRISM)
 Designed to help health professionals understand
RHIS performance and its factors.
 Factors
– Technical
– Organizational
– Behavioral
PRISM Framework
PRISM Framework for Understanding RHIS Performance

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Organizational factors

 Resources.
 Structure of the health system.
 Roles and responsibilities.
 Organizational culture.

Example:
•Political or other costs to making the decision.
•Clear roles and responsibilities related to decision-making.
Technical factors
• Standard indicators.
• User-friendly format for reporting.
• Trained people.
• Timely data availability.
• Appropriate technology.
• Data collection forms.

Example:
User-friendly data collection form
User friendly interface

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Behavioral factors

• Motivation.
• Attitudes and values.
• Confidence.
• Sense of responsibility.

Example:
•Feeling of confidence to make decisions.
•Empowerment.
•Individual political or other costs to making the decision.
•Does my decision matter?
Linking PRISM Tools to PRISM Conceptual Model

INPUTS PROCESSES OUTPUTS OUTCOMES IMPACT

RHIS determinants
Technical factors: Performance Diagnostic and
•Complexity of reporting Electronic RHIS Assessment RHIS Performance
forms, procedures Tools Diagnostic Tool
•HIS design
•Computer software Behavioral factors:
•Information technology •Level of knowledge of
complexity RHIS processes:
content of HIS forms •Data collection
•Data quality checking •Data transmission Improved RHIS
skills •Data processing performance Improved Improved
•Problem-solving for HIS •Data analysis •Data quality
tasks
health system health
•Data quality check
•Competence in HIS performance status
•Feedback
Organizational factors: tasks
Critical management •Confidence levels for •Information use
functions & information HIS tasks
needs •Motivation
•Governance
•Planning
•Training
•Supervision
•Quality MAT
•Finance Overview Tool

• Promotion of a culture of
information OBAT

• Availability of resources
Facility/Office Checklist
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 Application of the PRISM Tools
Tools Levels of application
1 RHIS Overview Tool Mainly at national level, but can be used
at subnational levels

2 RHIS Performance Diagnostic Tool Health facility and district or higher levels
(Data Quality & Use of Information)

3 Electronic RHIS Assessment Tool • Functionality at national level

(Functionality and Usability) • Usability at each level using the electronic
RHIS
4 Management Assessment Tool (MAT) District or higher levels

5 Facility/Office Checklist Health facility and district or higher levels

6 Organizational and Behavioral • Part 1 at all levels

Assessment Tool (OBAT) • Part 2 at district and higher levels
• Parts 3 and 4 at health facility
How to access the PRISM Series
• Participant’s Manual and a Facilitator’s Manual.

• PRISM Toolkit

• Available on MEASURE Evaluation’s website, here:

https://www.measureevaluation.org/prism
HMIS in Ethiopia
Health Management Information System (HMIS)

It’s an information system specially designed

to assist in the management and planning of
health program, as opposed to delivery of care.
(WHO 2004)
Milestones of HMIS development in Ethiopia

 Before 2008 G. C
 The health sector didn’t have a standardized HMIS:
There were no:
 Standardized set of core indicators, and
 Standardized recording and
 Reporting tools and procedures
 The HMIS was not fully institutionalized
 Poor information use at all levels
 Very Limited resources for HMIS
 Limited application of information technology
Milestones of HMIS development in Ethiopia
 2008 to 2013 G.C
 HMIS has been reformed to capture core indicators
 A set of 108 core indicators were selected
 Standardized data recording and reporting tools were
developed
 Individual medical records,
 Registers,
 Tally sheets
 Reporting formats
 Huge investment on capacity building and HMIS
infrastructure
 HIT curriculum was developed
Milestones of HMIS development in Ethiopia

 2014-2016 G.C.
 The HMIS was revised for the first time
 A total of 122 core HMIS indicators were selected.
 The recording and reporting procedures and tools were
revised
 Since then some improvements have been observed with
regards to:
 Data quality and
 Information use for evidence-based decision making
 
Milestones of HMIS development in Ethiopia

 2017 till now

The HMIS indicators were revised
A set of 131 core indicators were selected
The recording and reporting procedures and tools were
revised
Information revolution roadmap development with a focus
on pillars of:
 Cultural transformation in information use and
 Digitalization
HMIS reform guiding principles

 HMIS reform is necessary to improve

 Efficiency (Time & money)

 Effectiveness (Meets performance expectations).

HMIS reform guiding principles

Guiding principles for HMIS Reform include:  

1.Standardization: Common definitions throughout the health
sector
2. Integration: One reporting channel
3.Simplicity: Reduce number of data items, limited to those
required by indicators selected and user friendly user friendly
forms and procedures
4.Institutionalization: ensure its implementation at all levels of
the health system.
Components of HMIS

1. Information management
• Data collection: Recording of health data using
registers, tally, individual and family folder etc. for
routine and non-routine activities.
• Data processing: is a process of cleaning, entering
and aggregation of data.
• Data analysis and presentation: is a process of
interpretation and comparison of generated
information in the form of sentence, tables and
graphs.

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Components of HMIS…

2. Using information for management purposes

• Problem identification: identifying problems using key

indicators
• Prioritizing problems and decision making : Problems
identified should be prioritized and decide what types of actions
need to be taken.
• Action taking: Implementing the agreed action.
• Result monitoring: Assessing the desired result has been
achieved.

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HMIS tool and procedures

Common Tools

•Individual medical recording tools

•Registers

•Tally sheets

•Reporting formats
Individual Medical Records Tools
• Individual Folder • Women’s card
• Individual Summary sheet • Appointment card
• Admission and discharge card
• Patient form/Patient card
• Vital sign sheet
• Service Identification (ID) card • Order sheet
• Master Patient Index Card • Medication administration record
• Tracer Card • Laboratory form
• Integrated RH card • Referral form, etc.

Patient’s medical record • Socio-demographic data

should provide accurate • Legal data
information on: • Financial data
• Clinical data
Purposes of Individual Medical Records
1) Communication
2) Continuity of patient care
3) Evaluation of patient care
4) Medico legal
5) Statistical purpose
6) Research and education
7) Historical purposes
Individual medical recording procedures
 Recording Procedure  Identify gaps in each
 Indexing Procedure
procedures ?
 Retrieving Procedure
 Articulate a research
 Filing Procedure 
question on identified
 Completion Procedure
 Maintenance Procedure gaps?
 Culling Procedure
 Rir f cmc
Types of registers

 To record the abstract information from each service/

department required by indicators.
 23 registers including logbook
 Two types of registers
 Serial (Case) Registers: Each subsequent visit is registered as
a new entry. E.g. OPD, VCT, Abortion registers..
 Longitudinal Registers: Each client is stayed in the register so
long as s/he is in the service. E.g. EPI, ANC, FP, ART, TB.
Tally sheets

 Used to mark the number of clients provided to specific

services
 A sole purpose of tally is to ease reporting
 17 tally sheets
HMIS data quality assurance techniques
LQAS
RDQA
Lot Quality Assurance Sampling (LQAS)
Lot Quality Assurance Sampling (LQAS) - is a technique
useful for assessing whether the desired level of data
accuracy/consistency has been achieved by comparing
data in relevant record forms (i.e. registers or tallies) and
the HMIS reports.

Description:
The data compiled in databases and/or reporting forms
Versus with what is in registers at facility level.
Similarly, when data is entered in the computers, data on
reporting forms versus computer file.
Lot Quality Assurance Sampling (LQAS)
It is a method for testing hypothesis whether data quality is
achieved or not.
It uses a sample size of 12 data elements and tries to check the
reporting accuracy.
If the number of sampled data elements not meeting the standard
exceeds a pre-determined criterion (decision rule), then the lot is
rejected.
Decision rule table is used for determining whether the pre-set
criterion is met or not.
Comparison of LQAS results over time can indicate the level of
change.
 Lot Quality Assurance Sampling (LQAS)
Who: Health facilities will maintain a registry to record the data
consistency check results and to look the trend of the data
quality improvement.
What: pick the aggregated serial number for those having
detail data element (eg FP new acceptors considered as two
data elements having by age & sex aggregation)
 Frequency: Monthly.
This is a method for testing hypothesis related with the level of
HMIS data quality whether it is achieved or not.

 
 Data Accuracy Check Sheet
Month/Quarter/Year: September 2006E.C 
Value in Consistent
Rando Register Tally Report Yes No
m# Reporting elements
2 New acceptors 15 20 20 
Number of weights measured for
16 children <3 years 10 10 10 
Measles immunizations for infant
21 <1 year of age 8 8 8 
Early neonatal deaths
11 (institutional) 3 - 1 
14 Low birth Weight 10 - 10 
TT does used (all ages)/dose
28 opened 7 7 7 
4 First antenatal attendances 20 - 20 
60 Arthemisin/Lumphantrine - 
87 Curative Visits<5::Repeat-female 15 - 15 
92 Practitioners working in OPD - *2 2 
32 VCT females aged >=25years 1 1 1 
10 Institutional maternal death 1 - 0 
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  Total (YES or NO)  8 4
 The “Decision Rule”

IS a slide on LQAS Table for sample size of 12 used to know for

deciding whether we have achieved the desired level of data quality
or not.
Decision Rules for sample Sizes of 12 and Coverage Targets /Average of 20-95%
Average Coverage (baselines)/Annual Coverage Targets (monitoring and
Evaluations)
Less
Sample than 20 25 30 35 45 55 60 65 70 75 80 85 90 95
size 20% % % % % 40% % % % % % % % % % %
12 N/A 1 1 2 2 3 4 5 6 7 7 8 8 9 10 11

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 LQAS… discussion point

What actions would be necessary if the data

accuracy/consistency at a health facility is not of the
desired level (90%)
 Desk review:
Visual Scanning (Eye Balling)
It is a simple method used at health facility to check for
consistency of reports before/after conducting data entry

The PMT members sit together and look across each line and
then from top to bottom to identify:
missing data values,
unexpected fluctuations beyond maximum/ minimum
values,
inconsistencies between linked data elements, and
mathematical errors.
 Visual Scanning (Eye Balling)
Examples:
Family planning acceptors by age and method
disaggregation.
Antenatal first attendance by gestational and age
disaggregation.
Delivery attended by skilled health personnel vs Sum of still
birth and live birth
Inconsistencies of data elements/indicators over time
Comparison of performance across health facility
Frequency: any time
Routine Data Quality Assessment (RDQA)

A tool helps to perform data accuracy/consistency at

administrative level by enabling quantitative comparison
of recounted data to reported data
Routine Data Quality Assessment (RDQA)

It is a simpler version of the DQA

RDQA is self assessment & usually done prior to DQA

The RDQA tool should be applied regularly to monitor

the trend in data quality.

It is recommended to be implemented quarterly by

administrative health unit

Components of RDQA
RDQA tool has two key components
1.Data Verification: facilitates a quantitative comparison of
recounted to reported data a review of the timeliness,
completeness and availability of reports.

2.System assessment: enables qualitative assessment of the

elative strengths &weaknesses of functional areas of a data
management and reporting system.
Data Verification
a) Reported Data against Recounted (register)

Indicator Description HF1 HF 2 HF3 HF4 HF5 HF6 HF7 ∑A / ∑B VF= A/B
s
ANC4 Recounted=A 10 50 70 20 30 40 20 240 0.89
Reported=B 12 65 70 20 25 45 30 267
SBA Recounted =A 111 44 2 20 10 9 15 211 0.93
Reported=B 121 43 0 12 25 9 15 225
Penta 3 Recounted=A 25 45 30 12 20 10 0 142 0.83
Reported=B 38 59 30 16 15 13 0 171
Currently Recounted=A 10 22 10 5 40 19 20 126 1.94
on ART
Reported=B 0 12 4 5 32 12 0 65
Meseals Recounted=A 20 55 34 14 45 25 27 220 0.79
Reported=B 12 42 23 22 95 36 47 277
TB all Recounted=A 41 71 29 78 9 1 12 241 1.14
forms
Reported=B 29 36 34 80 6 10 17 212
Data Verification decision rule
 System Assessment
• M&E Capabilities, Roles and Responsibilities

• Training

• Data Reporting Requirements

• Indicator Definitions

• Data-collection and Reporting Forms and Tools

• Data Management Processes

• Data Quality Mechanisms and Controls

 After the RDQA

Review the output of the RDQA

Plan on sharing the outcome with the levels and sites that
participated in the RDQA

Description of Responsible(
  Identified Weaknesses Time Line
Action Point s)
1        
2        
3        
4        
                 
HMIS Indicators
• It’s a measurement that measures the value of the change in
meaningful units that can be compared to past and future units

• It focuses on a single aspect of a program or project – i.e., an

input, output or the overarching objective.

Types of Indicators
• Count Indicators
– Measures the number of event without a denominator
• Proportion Indicator
– Values are typically expressed as a percentage
• Rate Indicator
– Measures the frequency of an event during a specified
time usually expressed per 1000
• Ratio indicator
– The numerator is not included in the denominator
Classification of Indicators

• Input
– Measures resource needed to carry out the activity
• Process
– Monitors activities that are carried out
• Output
– Measures immediate results of activities,
• Outcome
– Changes in knowledge, attitudes, behavior
• Impact
– Long term effects, effects in the health status
HMIS Indicators
The 122 HMIS indicators are divided into eight major categories
based on the HSDP IV Strategic objectives:
– Improve Access to Health Services (97 indicators)
– Community Ownership (2 indicators)
– Resource Mobilization and Utilization (4 indicators)
– Quality of health Services (6 indicators)
– Pharmaceutical Supply and Services (1 indicators)
– Evidence Based Decision Making (4 indicators)
– Health Infrastructure (4 indicators)
– Human Capital and leaders (4 indicators)
Reporting formats

By Type:
 Service delivery report forms
 Disease (Morbidity & Mortality) report form
 PHEM reports

By Health institution:
 Health post, Health center ,Hospital , clinics and
WorHO/ZHD/RHB
By reporting Period:
 Immediate/ Weekly report

 Monthly /Quarterly/annual administrative report

HMIS reporting hierarchy
Assessment of Ethiopian HIS

Assessment of the existing state of the Ethiopian HIS was

done in March 2007 using the Health Metrics Network
(HMN) framework and tools
•According to the assessment results, among the six major
components, three were very weak.
•These were HIS resources, data management, and
dissemination and use rated as “not adequate”.
•HIS resources, policy and planning, as well as HIS
institutions, human resources and finance were rated
inadequate.
HIS Weakness:

• The legal and regulatory framework of HIS is

not strong
• Unbalanced HIS development across the
country (greater support required in regions
where there is poor infrastructure)
• Lack of adequate and skilled human
resource leading to poor quality of data
• High attrition rate of the skilled human
resources.
 Purposes of CHIS

What are the purposes of CHIS?

 To improve quality of data at community level

 To facilitate quick retrieval of data

 To create basic information at the community level for facilitating

evidence-based practices
Essential Functions of CHIS

 To promote community engagement in health

 To identify community needs
 To support case management and continuity of care
 To document individual-level needs to support care planning
 To enable bidirectional referrals
 To track lost to follow-up patients
 To monitor and evaluate performances
 To ensure accountability
 Overview of CHIS in Ethiopia

 Ethiopian CHIS is designed for the health extension workers (HEWs) in

rural and urban areas to manage and monitor their work

 CHIS:

 Family centered at rural and

 Community-centered at urban

 The aim is to create basic health information at the grass root level
 Overview of CHIS in Ethiopia _ Tools

 CHIS data is captured through:

 Master Family Index (MFI)

 Field book,

 Registers (for pastoralist area) service and

 Disease tally sheets/reporting formats, and

 Additional administrative and personnel records.

 Kebele/Woreda Profiling

 Formats were designed to compile Kebele’s demographic profile

 The purpose is for Planning, Monitoring and Evaluation of performances

 Information is updated annually

 Resource mapping format is to compile potential resources

 Working areas are captured for health promotion activities

 Once the household registration is completed, the family health profile

will be filled to compile the family information.
 Household Profiling

 Family folder is used for rural, while community folder is for urban
Health Extension Programs.
 Family Folder is a pouch that helps to record the household and
family characteristics.
 It’s issued to every household in the Kebele.

 It contains information about the household (preventive, promotive

& environmental health) service needs
 Household Profiling

 Community Folder is used to file/document family registers filled for

5-12 households (mostly 10 households), that are considered as a
community
 It uses to bind the family registers of a households.

 The information on the community folder helps the UHEp to identify

the Family/HHs
 CHIS Recording and Reporting tools
How Family Folder works?
Front and back sides are used for recording information on:

 House hold information.

 Household members' description

 Household’s Possession of LLITN,

 HDA/WDA and CBHI membership status

 HEP packages practices

 Competency based Training Status for (WDA leaders)

 CHIS Recording and Reporting tools

 Family folder is issued through a campaign by mobilizing the Gote

Gote: is a sub segment of the Kebele which has different meanings in
different areas like ‘Zoni’ in Oromia and ‘Kushet’ in Tigray regions.

 HEWs with Kebele administration will assign Gote-code

 In each Gote, volunteers issue serial unique Household numbers

 When new household is emerged, the last serial number is given

 CHIS Recording and Reporting tools
 Register household characteristics on cover page of Family Folder

 During household registration, every household is issued a unique

identifier number consisting of a 2-digit Gote code followed by 3-digit
household number (xx.xxx).
 Later, HEWs aggregate data from Family Folders to compile basic
demographic and environmental sanitation profile of the Gote/Kebele
 CHIS Recording and Reporting tools
 Within the Family Folder,
 Health cards

1. Family health cards,

2. Hygiene and sanitation card,

3. Integrated communicable card,

4. Integrated maternal and child care card and

5. Comprehensive integrated nutrition card

 These tools are stored for recording disease information, preventive and
promotive services to individual members of the household.
How Community folder pouch works?

 The front page contains basic information of HHs which includes:

 Community code,
 List of HHs,
 HH number,
 Category of the HH, and
 Status of the HH (active /inactive).

 These information helps the UHEP to identify health needs; and to

ensure every family member receive needed health services.
How Community folder pouch works?

 Community Code: Is a given code for the specific compound which

consist of 5 to 12 HHs in the community folder

 e.g. Naming could be Gote1/G1, G2, G3: Ketena 01, 02, 03, …

 The Community Code will be given according to the context of the

town or city

NB: Addis Ababa uses Woreda as the smallest administration level

CHIS Recording and Reporting tools
CHIS Recording and Reporting tools
CHIS Recording and Reporting tools
CHIS Recording and Reporting tools
 CHIS Recording and Reporting tools
Pastoralist CHIS:

The Health Extension Packages are all the same with rural HEP

The difference is only on record keeping.

Health Extension Workers in Pastoralist community don’t use

family/community folders

Instead they use integrated registers. This is because of the mobile life
style of the community.
 Overview of eCHIS

 The glob has been radically transformed by digital technology and

transformed daily lives.

 Health is an information-rich enterprise.

 A seamless flow of information within a digital health care improves

efficiency, quality and equity in health care.

 Electronic based Community Health Information System (eCHIS) is

the first step to transform primary health care under CHIS.
eCHIS in Ethiopia

In Ethiopia, e-CHIS is under

piloting
 Modules of eCHIS
eCHIS comprises of all modules included in the health extension Package.
Thank You!