Surveillance and Health

Information System
By

Dr Jean Claude NKURUNZIZA

Emmanuel SSENDIKWANAWA
MUCHS
Clinical Epidemiology Unit
CEU, 30th August 2018
Plan
1. Surveillance
• Key concepts of surveillance: Definition, Uses, Planning a
Surveillance System, What Should be Under Surveillance
• Methods
2. Public health surveillance systems: Health
Information System
1. Surveillance
KEY CONCEPTS OF
SURVEILLANCE:
Epidemiologic surveillance
• “Ongoing systematic collection, analysis, and interpretation
of health data essential to the planning, implementation,
and evaluation of public health practice closely integrated
with the timely dissemination of these data to those who
need to know.”
Use of Surveillance
• To assess public health status,
• To define public health priorities,
• To evaluate programs, and
• To stimulate research.
 How can surveillance data be used?

• Hypothesis
Estimates oftesting
a health problem
• Evaluating
Natural history
control
of disease
and prevention measures
• Monitoring
Detection ofchange
epidemics
• Detecting
Distributionchanges
and spread
in health
of a practice
health event
• Facilitate planning
What Surveillance is doing for
countries/states
Providing decisionmakers
with guidance
• For developing and
Requirements
implementing the best
 standardized definitions
strategies, of disease and diagnostic
• To develop coordinated criteria (ICD)
public health approaches  Forms used for reporting
 Surveillance is outcome
oriented
• Can measure frequency of an illness or injury (e.g., number of
cases, incidence, prevalence)
• Can measure severity of the condition (e.g., hospitalization rate,
disability, case fatality)
• Can measure impact of the condition (e.g., cost)
• Orient data by person, place, and time
 PLANNING A SURVEILLANCE
SYSTEM
• Establish objectives
• Develop case definitions
• Determine data source or data collection mechanism
• Field test methods
• Develop and test analytic approach
• Develop dissemination mechanism
• Assure use of analysis and interpretation
What Should be Under Surveillance?
Establish priorities based on:
• Frequency (incidence, prevalence, mortality)
• Severity (case-fatality, hospitalization rate, disability rate,
years of potential life lost)
• Cost (direct and indirect)
• Preventability
• Communicability
• Public interest
• Will the data be useful for public health action?
 Cycle of Surveillance
• Data Collection
• Pertinent, regular, frequent, timely
• Consolidation and Interpretation
• Orderly, descriptive, evaluative, timely
• Dissemination
• Prompt, to all who need to know (data providers and action
takers)
• Action to Control and Prevent
• Evaluation
 Surveillance Methods
• Case definition
• Date collection
• Interpretation and dissemination
• Evaluation
 Surveillance Methods: Case
definition
• Important to clearly define condition
• Ensures same criteria are used by all
• Makes the data more comparable
• Include person, place, time
• May define suspected and confirmed cases
• May include symptoms, lab values, time period,
population as appropriate
 Surveillance Methods: Case definition
(ex)
• Weak Definition - Measles
• Any person with a rash and fever, runny nose, or conjunctivitis
• Better Definition - Measles
• Any person with a fever >101 F, runny nose, conjunctivitis, red blotchy
rash for at least 3 days, and laboratory confirmation of IgM antibodies
• Case Definition: Clinical, Probable, Confirmed
• Outbreak case definition
• Differs from routine surveillance
• Epidemiologically linked cases often included
 Surveillance Methods: data analysis

Data Analysis
• Ongoing review
• Descriptive statistics, multivariate analyses
• Automated analyses
 Surveillance Methods: data collection
• Data collection:Standardized instruments, field tested
• Passive Surveillance:
• Utilizes existing infrastructure of a country
• Even if reporting is required by law, there is no practical way of enforcing adherence
• Disease frequency is under reported.
• Useful in identifying outbreaks and trends over time.
• Health care providers report notifiable diseases on a case-by-case basis.
• Passive surveillance is advantageous because it occurs continuously, and it requires few extra resources.
• Cases in people without access to health care will go unreported.
• Active Surveillance: (Diverse methods)
• Occurs when a health department is proactive and contacts health care providers or laboratories requesting
information about diseases;
• Can involve case follow-up for verification
• While this method is more costly and labor intensive, it tends to provide a more complete estimate of disease
frequency;
• More resource intensive ( )
• Used for outbreaks or pilot studies
• Use mixed approach when appropriate
Surveillance Methods: interpretation &
dissemination
• Presentation of data in the form of tables, graphs,
maps, etc.
• Disseminate data via reports, presentations,
internet, etc.
 Surveillance Methods: evaluation
• Did the system generate needed answers to
problems?
• Was the information timely?
• Was it useful for planners, researchers, etc?
• How was the information used?
• Was it worth the effort?
• What can be done to make it better?
Surveillance bias
• Bias: systematic error in the design, conduct or analysis of a study
that results in a mistaken estimate of an exposure’s effect on the risk
of disease
• Surveillance bias (type of information bias)
When population is monitored over a period of time, disease
ascertainment may be better in the monitored population than in the
general population which leads to an erroneous estimate of the relative
risk or odds ratio.
2. Health Information System
 Some Definitions

• A System: Is a collection of components (elements or

parts) that work together to achieve a common Objetive.

• Information System:
A system that provides information support to the decision-
making process at each level of an organization
CONT..
• Health Information System: A system that integrates 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
 Some definitions
Management Information Systems:
• MIS is a system of people and resources used to convert data
from internal and external sources into information and to
communicate that information, in an appropriate form, to
managers at all levels
Exercise
• What is the difference between HIS and MIS
 HMIS
• Is a set of components and procedures organized with an
objective of generating information which will improve health
care management decisions at all levels of the health system.

• Is a routine monitoring system that plays a specific role in the

monitoring and evaluation process. It is intended to provide
warning signals through the use of indicators.

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 Uses of HMIS Data

• Epidemic reporting & prediction

• Epidemic detection and response

• Planning

• Designing Diseases specific Interventions

• Monitoring Work plan performance

 EVOLUTION OF HMIS IN UGANDA
Year Event/Activity and Commentary/Reason for review

1985 • Only collecting morbidity data for selected communicable and non-communicable
diseases
• Vertical and fragmented reporting system (directly collecting data from district facility)

1986 The current HMIS was first introduced into the Health Sector as a HIS with the objectives of (1)
providing information and indicators useful for health services management purposes; and (2)
enabling the development of indicators useful in monitoring the health status of the
population and the impact of health programmes. Reporting was mainly from health facilites,
Districts and national level

By 1992 Only 21 of 39 districts were covered. Timeliness of reporting was at 6-9 months late at MoH
from few units, and irregularly, with mainly disease related data and no
Administrative, financial or other management information demanded and reported.

1993 Following the move to decentralize in 1993, a needs assessment for health management
information is carried by the HPU (MOH) and EDMP to provide the new frame for the
development of the current HMIS.

1994 -1995 HMIS was introduced as pilot project and evaluated in two districts.
Greater emphasis was placed on managerial data rather than just health (disease) statistics:
Human resources, Financial resources, and Material resources (drugs, equipment, buildings,
transport, files, etc.)
Jan 1997 HMIS was introduced nationwide

1998 Assessment of HMIS implementation with emphasis on use of data and information for local decision-
making. HMIS was further strengthened as a system explicitly for management and decision making at
the level of collection. This meant creating the system from the bottom up and not from the top
down.It seemed very ambitious for a Health System in which about 53 % of health units are managed
by personnel without formal training. There were frequent complaints from the periphery about the
huge amount of data required:
 Over 200 different data required on curative services.
 About 350 (550 if one counts the duplication of information on different forms) on preventive
services.
 Cost-effectiveness of HMIS questioned because of high costs of its implementation and problems
in its sustainability.
 In 1998, due to funding problems, districts were encouraged to produce the forms on their own.
 The MoH provided only the database book and part of the supply of forms.
 It is comprehensive: all aspects and components of the activities and management at all levels are
taken care of.
 Great attention paid to “information for managers”, not just on medical records.
 Manuals and forms are very good potential training tools.

2001 HMIS was revised. This is the year when the “Health Centre Quarterly Assessment Report” introduced…

To date To date there have been two reviews as well as the push to integrate all disease reporting… the
introduction of the DHIS2… HIV and Malaria reporting is already functional within DHIS2. TB reporting
through DHIS 2 is still not functional due to the peculiarities involved in the R&R system for TB patient
management.
Year Event/Activity and Commentary/Reason for review

2005 HMIS was revised

• To provide data for monitoring the HSSP- II implementation
• OPD data disaggregated into Male & female (made review to address
gender sensitivity)
• Certain disease categories were broken down

2010 HMIS has been revised

• Address the information needs of the Health Sector strategic
Investment Plan (HSSIP) in line with the new/revised indicators
• Integration of program information needs into the routine HMIS

2013/14 Mid term review

• To establish a one integrated HMIS that contributes to a single
M & E system for the health sector
GOALS OF HMIS

• Provide quality information to support decision-making

• Setting performance targets

• Measuring performance

• Provide evidence of lack of information use

• Enhancing information use

HMIS Components
1. Data processing
• Financial data
• Curative info
• Preventive info
• Drugs Management info
• Lab info
• Management of Resources info e.g. HR
• Others sources of data: Surveys, Record reviews,
special studies, CBHMIS
HMIS Components
2. Data analysis
3. Dissemination of data/information
4. Supply and logistics
5. Staff development
6. Coordination, cooperation and communication among
stakeholders
 HMIS Reporting Structure

MINISTRY OF HEALTH 15th of the next month

District/Health Sub-districts 07th of the next month

Community-VHTS
HEALTH UNITS SENTINEL SITES

Flow of routine HMIS data

Data Need in HIMS (5 Domains)

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HIS Data Sources
 Categories of HMIS data collection tools

Pre-primary Primary Secondary Management

• Medical form 5
• Registers • Report forms • Record of mgt
• Requests (Lab, x- meetings
ray,) ­Out patient ­Notification(HMIS033a)
• Record of support
• Treatment sheet ­In patient ­Weekly(HMIS 033b) supervision
• Treatment follow- ­Antenatal ­Monthly (HMIS 105) • Tool for HMIS
up form support
­Laboratory ­Quarterly (HMIS 106a)
supervision
• Patient cards
­Child ­Annual(HMIS form 107)
• Inventories tools
• Referral notes
­Operating theatre • Summary tables
• Medical and
• Log books ­Annual other health
supplies
­Daily consumption ­Monthly
log • Finance and
account
• Record books
­Cash analysis
 Source Documents
No. Source document Data source

1. Outpatient register Med. Form 5, Referral Note

2. Antenatal/postnatal register Client Cards, Referral Note

3. Child register Child Health Cards

4. Family planning register FP Cards

5. HIV Counseling & Testing (HCT) register HCT Cards

6. Cash analysis book Debtors book, Receipts, Work plans,

Invoices
7. Inpatient register Inp. Treatment sheets, Follow-up forms,
discharge forms,
8. Laboratory register Lab. Requests, Med. Form 5

9. Maternity register ANC Cards, Follow-up forms, discharge

forms
10. X-ray register (Ultra Sound, CT scan X-ray requests, Med. Form 5, request forms
Investigations)
11. Operating theatre register Med. Form 5, In patient treatment sheets

12. PMTCT registers (HCT, Delivery, ARV) PMTCT Cards, ANC Cards, HCT Cards,
ART Cards, Inpt. Treatment sheet
HMIS Reporting Tools
 Daily reporting tools
• Health unit notifiable disease report – HMIS 033a

 Weekly reporting tools

• District weekly surveillance report – HMIS 033b, Option B+ sms

 Monthly reporting tools

• HF monthly OPD report HMIS 105
• HF monthly OPD report HMIS 108
• District Monthly OPD Report -HMIS 123
• District Monthly Inpatient Report HMIS 124

 Quarterly reporting tools

• Health unit quarterly assessment report – HMIS 106b
• HU quarterly report

 Annual reporting tools

• District Annual Profile – HMIS 106
E-HMIS
• Electronic health information systems are singled out as one
of the various ways in which information technology (IT) can
be applied to improve the health system,
• The role of IT ranges from aiding service delivery, data
collection, storage, analysis to the dissemination of
information,
• E-HMIS is “Expected” to improve accuracy, timeliness,
reliability and integrity of data are attributes that have been
associated with electronic HISs

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Current E-HMIS in MOH
• DHIS2
• mTrac
• OpenMRS

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