Health information systems

The role of a health information system (HIS) is to ensure the production, analysis, dissemination and use of reliable and timely data by decision makers at all levels of the health system. A well-functioning HIS provides information on which to base programme decisions, to support the development of solid national health policies, strategies and plans, to monitor progress of interventions against national priorities and to contribute to reliable procurement and supply of health products through accurate data on needs and usage. Information is also essential for effective health system governance and regulation, health research, human resources development, health education and training, service delivery and financing.

At the policy level, decisions informed by evidence contribute to more efficient use of resources and, at the delivery level, they provide information about the quality and effectiveness of services. A well-functioning HIS should, among other core functions:

• generate and compile information from service delivery points to district level routine information systems, disease surveillance systems, laboratory/procurement information systems, hospital patient administration systems and human resource management information systems
• detect events that threaten public health security
• analyse, synthesize and communicate information for use in planning and implementation.

The COVID-19 pandemic has further underlined the crucial role of health information systems in enabling countries to effectively respond to disease outbreaks. Weaknesses in surveillance systems and capacities to collect, manage and utilize data, particularly at the community level, undermine the delivery of life-saving health services, most notably in the face of global health threats.

UNDP’s approach

Many countries in which UNDP supports systems for health, particularly through its partnership with the Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund), are low-income countries or are characterized by challenging operating environments. These tend to have young or fragmented health information systems (HIS), sometimes set up in an ad hoc way in response to different donor requirements. UNDP works to assess what is in place and how this can be strengthened to form a sustainable HIS. Working closely with national entities, UNDP’s support includes work to:

• assess the country requirements based on the national health strategy and priorities
• support the development of national health information strategies
• support the integration and harmonization of data management systems, to reduce silos
• implement electronic patient management systems and/or District Health Information Systems (DHIS) and promote their interoperability with electronic Logistics Management Information Systems (LMIS)
• support the assessment of where information and communications technology (ICT) can deliver better data and information for decision makers
• assess needs for other elements of a comprehensive HIS, such as logistics management information systems or human resource management information systems
• strengthen data literacy of the health workforce
• strengthen reporting and communication of results at all levels of the health pyramid
• support the development of study protocols and implementation of related databases and research projects.

When UNDP serves as interim Principal Recipient of the Global Fund programmes in a country, support to health management information systems is often a key area for capacity development, in line with national priorities and the Global Fund guidelines for strengthening data systems. This includes doing so through capacity-building to enable health sector personnel to move beyond a focus on data solely for reporting, to the active use of real-time data in decision-making at all levels, such as in the management and evaluation of programmes and the formulation of budgets. UNDP likewise supports countries with the development of applications to the Global Fund to ensure inclusion of activities to strengthen national HISs, including those to promote enhanced integration across data systems. Examples of focus areas that can be included in the Global Fund funding applications are:

• routine information systems (the establishment, maintenance and strengthening of national health information systems, district HISs, mobile platforms for community-level data collection and reporting, and support for human resources for data systems)
• programme and data quality (activities related to assessments of programme and/or data quality, as well as monitoring of quality improvement activities)
• evaluations, reviews, data analysis and use
• surveys and studies
• administration and financing of data systems
• civil registration and vital statistics systems.

Tools and guidance

To support comprehensive improvements to HIS, UNDP aligns its focus with international standards and recommendations developed by the World Health Organization (WHO). The WHO UHC Technical Brief: Strengthening Health Information Systems, for instance, details seven strategic areas for actions that are required to strengthen national HIS:

• Improve governance. HIS strengthening requires an enabling environment and robust collaboration between health and other sectors, including the information and communications technology (ICT) sector.
• Invest in data sources and capacities. These investments strengthen health information, workforce skills and capacities for using health statistics and data.
• Align stakeholders in support of HIS. Development partners and national institutions should make sure that their investments are complementary. Data, monitoring and accountability should be integrated into one plan and one budget for the health sector, and should be aligned with the health Sustainable Development Goals.
• Use the digital revolution. The power of ICT innovation can help improve the availability, completeness, timeliness, quality and use of data for decision-making in health. Minimizing the burden of data collection, analysis and reporting through eHealth strategies can improve health service delivery and management.
• Strengthen the capacity for systems and applications to be reusable. The use of scalable, affordable and open access software systems should be promoted and common health information architecture, standards, guides, tools and solutions to data management and analysis should be developed.
• Use data to improve policy and service delivery. With a focus on equity, disaggregated data and access to needs-based, good–quality services, health information should be provided to decision makers at all levels for improving health policy, systems and services.
• Strengthen accountability and reporting of results. There should be national oversight mechanisms for key indicators of national health targets and goals and mechanisms for regular transparent reviews to assess progress against national health sector targets.

A number of tools are also available to strengthen monitoring and evaluation (M&E) systems for health programmes and systems, as a distinct but interconnected component of broader HIS strengthening. Most notably, in the context of the Global Fund programmes, stakeholders should refer to the guidance and tools made available on the Global Fund website, which includes information related to national M&E system assessments, data systems for HIV surveillance and DHIS-2 strengthening.

For additional guidance related to UNDP’s support to strengthen electronic logistics management information systems and their interoperability within HISs, visit the Logistic management information systems (LMIS) page. Further details on digital solutions that UNDP has employed to strengthen systems for health information, M&E and logistics data can be found on the Real-time data solutions page.

Purpose

The role of a health information system (HIS) is to enable the use of reliable and timely data by decision makers at all levels of the health system. The HIS is therefore reliant on, and is only as good as, the quality of data collected. High-quality and up-to-date data are necessary for countries to respond quickly to public health crises and ensure the effectiveness of ongoing health service delivery. This includes making information available on vulnerable groups and key populations most affected by health issues, to ensure that services can be effectively tailored to the needs and unique barriers to health access faced by those communities. The strength of the HIS also ensures that when an emergency health situation arises, decision makers are aware of it early and can divert the necessary resources to prevent epidemics.

In many countries, the quality of data gathered at health facilities and the capacity to analyse and use these data remain inadequate to support decision-making that will accelerate the achievement of universal health coverage. Most countries have health facility registries and service-use reporting forms; they maintain medical record rooms and may have health information units overflowing with data. Despite this abundance of data, many still find it challenging to collect high-quality data in a timely manner, produce disaggregated data and use them for policy and planning.

Among the challenges is the fact that data may be incomplete or of poor quality or that there may be duplication and fragmentation of data across reporting systems developed by different users. This makes it difficult to connect the resources invested to the results achieved. Data needs and demands are also changing with the rise in non-communicable diseases. More technical skills in key areas such as epidemiology, biostatistics and database management are needed, as well as skills to analyse statistics across different programmes and sectors. Responsibility for data entry, verification, validation and management is distributed across various individuals, professions, units, departments and facilities at the different levels of the HIS. Programmatic or patient care data are often collected and managed separately from health products or stock data. Staff rotation is another concern in relation to maintaining appropriate standards, as such a situation affects data quality. In addition, data quality is rarely seen as a priority and the resources available are limited.

UNDP’s approach

As Principal Recipient of the Global Fund grants, UNDP is highly committed to improving health data quality, analysis and use to support decision-making within health programmes and systems. UNDP provides capacity development and good practice support during data collection and data management processes. More specifically, UNDP supports ministries of health and other partners at various levels of health information chains in their processes to:

• assess regularly the quality of project data through internal routine tools and external processes
• formulate and implement a health data quality development plan
• facilitate high data quality standards at all levels of the health information system
• develop tools and methods for data collection and use
• strengthen the capacity of health information system professionals in data collection, management and analysis
• strengthen the data flow at all levels of the health pyramid.

Tools and guidance

Further information on core data components that constitute a health information system (HIS), to inform the entry points for capacity development, can be found in this UNDP guidance note.

UNDP’s technical assistance to strengthen data collection and use for better health outcomes considers the capacities required across the interconnected components of national HISs. This includes the following six components of HISs defined by the World Health Organization (WHO), as detailed in the Framework and Standards for Country Health Information Systems (2012):

1. Health information system resources. These consist of the legislative, regulatory and planning frameworks required to ensure a fully functioning HIS and the resources that are required for such a system to be functional, such as personnel, financing, and information and communications technology (ICT).
2. Indicators. A core set of indicators and related targets are the basis for an HIS plan and strategy. Indicators need to encompass determinants of health, health system inputs, outputs, outcomes and health status.
3. Data sources. These should include population-based approaches (censuses, surveys and civil registration), institution-based data (individual records, service records and resource records) and additional information from occasional health surveys, research and information produced by community-based organizations.
4. Data management. This includes the collection, storage, quality assurance, flow, processing, compilation and analysis of data.
5. Information products. Data must be transformed into information that will become the basis for evidence and decision-making.
6. Dissemination and use. The value of health information can be enhanced by making it readily accessible to decision makers.

Additional resources from WHO, the Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) and other global health partners can be found under key resources below. They include tools to inform the selection of data collection indicators, facilitate data quality reviews and strengthen processes and capacities for data analysis and use to achieve national health priorities.

Digitalizing the health management information system in Zimbabwe

Digital solutions that allow for real-time data collection and visibility have the potential to enhance all aspects of health information management and the functioning of the overall health system. In Zimbabwe, the digitalization process was prompted by the rapid growth in programmes for HIV and other epidemics in the early 2000s and the limited capacity of health workers to manually process large volumes of patient information. The transition away from paper-based reporting, and the genesis of the modern national health information and surveillance system, began in 2010 with the national roll-out of District Health Information System 1.4 (DHIS-1.4), an electronic platform for aggregate reporting of health data from the district level upwards.

Moreover, recognizing the need for a tool to capture and monitor detailed patient-level data, the Ministry of Health and Child Care (MoHCC) resolved to establish an electronic patient management system (ePMS) in 2013, which initially focused on the collection of HIV and tuberculosis treatment data at health facilities based on the urgent need. While the roll-out of the computerized system helped to enhance data collection and accuracy of reports under specific disease programmes, fragmentation and timeliness issues remained across the broader health information landscape. To enhance the transmission of routine health information collected through DHIS-1.4, MoHCC sought to upgrade to District Health Information System version 2 (DHIS-2), starting in 2013. As an online system connected to a central server, DHIS-2 not only improved the timeliness of health information reporting, but also allowed for greater access to real-time data across all levels of the health system, from the national level to the health facility level. Most critically, the electronic system introduced the potential for the gradual integration of all health information systems into a single platform, reflecting a shift towards more integrated programme management. Building on this progress, MoHCC will work with partners to eventually bring DHIS-2 and the ePMS into an electronic health records platform that is currently being rolled out.

MoHCC has promoted the continued growth of the electronic information ecosystem to address information needs across the health system. Whereas the initial priority was to enhance information systems for high-level decision-making, MoHCC has increasingly invested in systems for data disaggregation and use at lower levels of service delivery, building on the systems and infrastructure already in place. This has been accompanied by a focus on developing policy frameworks and human resource capacity for the effective use of the data in the delivery of health services. Electronic systems now include those for rapid disease notification, laboratory services and patient information. Efforts to build data skills among the health workforce, along with investments in information and communications technology (ICT) infrastructure, have helped to drive and reinforce the development of all systems.

Since 2010, UNDP has invested substantially in health management information system activities through grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund), with a focus on strengthening governance, ICT systems and human resource capacity for data collection and use. In line with the areas emphasized by national ICT and monitoring and evaluation (M&E) policy guidelines, UNDP has supported the national health management information system, particularly through the following interconnected outcomes:

More information on UNDP’s multifaceted support to the health management information systems in Zimbabwe can be found in the UNDP Brief: UNDP and Global Fund Support to Strengthen the National Health Management Information System

UNDP Djibouti: the use of new technologies for data collection and management

UNDP has amassed a wealth of experience in providing technical assistance to national entities supporting national capacities for monitoring and leveraging emerging data sources for real-time monitoring in countries where UNDP is an interim Principal Recipient of grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund).

In Djibouti, UNDP supported the Ministry of Health (MoH) to introduce a mobile data collection and management tool in 2020 to address data collection and activity monitoring challenges faced under the Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) malaria programme. Specifically, within the context of Djibouti’s indoor residual spray campaign and adjustments made amid the COVID-19 pandemic, the programme faced challenges linked to delayed data availability, manual transcription errors and data duplication across activities. These issues meant a lack of complete and reliable data to guide decision-making and ensure quality control.

UNDP sought out technological solutions that could help to resolve some of these gaps. Among the solutions identified was the KoBo Toolbox and UNDP supported MoH to adopt this free, open-source suite of tools for data collection and analysis, and specifically designed for use in challenging environments. Through the KoBo Collect application, the tool offers a series of features to facilitate the data manipulation process from collection to analysis and visualization. Health authorities download the application to mobile phones or tablets to collect data from the field and upload it to a server for analysis. UNDP helped to train teams in charge of data collection on how to use the form, and conducted a pre-test exercise and debriefing. The graphic below outlines the implementation process used to launch the Kobo system for tracking indoor residual spray under the MoH 2020 malaria campaign.

The KoBo Toolbox has allowed MoH and UNDP to proactively monitor indoor residual spray activities through online applications that produce timely data, to troubleshoot implementation challenges and to inform or share decision-making with communities, without physically being present at the project sites. The real-time monitoring has improved the exchange and sharing of data by health authorities, supporting more regular problem identification, analysis and responses. The system also offers an online analytics module for conducting basic data analysis, which has helped to motivate staff to reach set targets.

Presentation (French): UNDP Djibouti, Jan 2021: Mobile Data Collection and Management Using KoBo Toolbox