Assessment of HIS(HMIS,CHIS and PHEM) implementation in South West Shoa,Oromia,Ethiopia.

1. I
Assessment of Health Management Information System, Community
Health Information System and PHEM implementation in South West
Shoa Zone, Oromia Regional State, Ethiopia.
By: Addisuu Bogale (BSc, MSc-HE)
Email: addisuub@gmail.com
January, 2019
Walisso, Ethiopia

2. II
Summary
Background: Health management information system (HMIS) is a System that allows for the collection,
storage, compilation, transmission, analysis and usage of health data that assist decision makers and
stakeholders manage and plan resources at every level of health service. IDSR is a part of Health
Information Management System which is one of the building blocks of a health system.
Objective: To assess implementation status of HMIS /IDSR and barriers of effective implementation in
South West Shoa, Oromia Regional State, Ethiopia 2019.
Methods and Materials: The assessment was conducted in South West Shoa from January 17 to 25,
2019. Cross sectional study design was employed. Total of 22 health facilities were included in the study.
Collected data was entered and analyzed by SPSS version 23.
Results: Among 12 health centers assessed only (58%) had HMIS unit Fifty (50%) of the health posts and
(8%) health centers had no electric power access. In all Woredas HMIS/CHIS focal person was assigned
and trained on DHIS2 and information use. Health post level birth and death notification was not started
and health center level 42% and 33% starts birth and death notification respectively. At health center level
HMIS recording and reporting, indicator reference, NCoD and Data quality and information use manuals
available are 25%, 33%, 17% and 58% respectively. During this assessment interviewed midwives on the
service delivery unit only 75% of health center define and record new and repeat acceptor according to
the national standard. Also 67% of Staffs define new and repeat and filled in the register properly and
some of them didn’t use NCoD to classify HMIS disease classification.
Among HEWs interviewed only 70% know IDSR programs. Among those who express to know what
IDSR was, about 60% of know the meaning of IDSR and its importance. Functional and active emergency
preparedness committee was established 33% and 50% at health center and woreda level respectively.
Conclusions: HMIS/IDSR performance improvement challenges in South West Shoa zone relate mostly
to improving data accuracy, access to computerized HMIS data and competencies to analyze, interpret
and use HMIS data at WorHO and HF levels. Resources are insufficient and although some structures are
present on ground like the presence of reporting mechanism, feedback is poor from the higher to lower
levels.
Keywords: Assessment, HMIS, CHIS and IDSR

3. III
Acknowledgements
We would like to express our sincerely thanks to CUAM project for giving us chance to conduct this
assessment. The South West Shoa Zonal Health department would like to extend its appreciation to all those who
have been involved in the data collection and analysis for this assessment as well as the writing and production of
this report.

4. IV
Table of content
Executive Summary ................................................................................................................................... II
Acknowledgements ...................................................................................................................................III
List of Figures ...........................................................................................................................................VI
List of Tables........................................................................................................................................... VII
Abbreviations .........................................................................................................................................VIII
INTRODUCTION.......................................................................................................................................9
1.1 Background........................................................................................................................................9
1.2 Statement of the Problem.................................................................................................................10
1.3 Significance of the Assessment .......................................................................................................12
OBJECTIVES OF THE ASSESMENT ....................................................................................................13
3.1. Assessment questions .....................................................................................................................13
3.2. General Objective ...........................................................................................................................13
3.3. Specific objectives..........................................................................................................................13
METHODS AND MATERIALS ..............................................................................................................14
4.1. Study area and period of assessment ..............................................................................................14
4.2. Study Design...................................................................................................................................14
4.3. Population.......................................................................................................................................14
4.3.1. Source population ....................................................................................................................14
4.3.2. Study population ......................................................................................................................14
4.3.3. Study units................................................................................................................................14
4.3.4. Exclusion criteria .....................................................................................................................14
4.4. Sample Size and sampling Procedure.............................................................................................14
4.4.1. Sample size determination .......................................................................................................14
4.4.2. Sampling technique..................................................................................................................15
4.6. Data collection................................................................................................................................15

5. V
4.6.1 Data collection Instrument........................................................................................................15
4.6.2. Data Collectors.........................................................................................................................15
4.6.3. Data collection Field Work......................................................................................................16
4.9. Data Analysis..................................................................................................................................16
4.11. Data Quality management ............................................................................................................16
4.12. Ethical consideration ....................................................................................................................16
4.12. Dissemination plan .......................................................................................................................17
RESULTS OF THE ASSESMENT ..........................................................................................................18
5.1 Overview of Health Center and Health posts ..................................................................................18
5.2. Resources available for HMIS/CHIS at Woreda and health facility level .....................................18
5.3. Performance Monitoring Team (PMT)...........................................................................................19
5.4. Status of Birth and Death Notification in health facility ................................................................20
5.5. Presence of manuals for implementation of HMIS and CHIS .......................................................20
5.6. Levels of HMIS Performance: Data quality and information use ..................................................21
5.6.1 Data Accuracy...........................................................................................................................21
5.6.2. Data Completeness...................................................................................................................22
5.6.3. Monthly Report Timeliness .....................................................................................................23
5.6.4. Data quality check....................................................................................................................24
5.6.5. Use of HMIS/IDSR Information..............................................................................................25
5.7. Integrated Disease Surveillance and Response (IDSR) implementation........................................26
5.8. Health Extension Program (HEP) implementation at household level ..........................................27
6. DISCUSSION AND RECOMMENDATIONS ....................................................................................28
6.1. Discussions .....................................................................................................................................28
6.2. Recommendations...........................................................................................................................29
References .................................................................................................................................................30

6. VI
List of Figures
Figure 1: Building blocks of Health system functioning ..........................................................................10
Figure 2 :-Schematic presentation of sampling procedure for HMIS/CHIS and IDSR assessment in
South West Shoa, Oromia Regional State, Ethiopia, 2019. ......................................................................15
Figure 3: Woreda report timelines of Service delivery report from October to December, 2018 ............24

7. VII
List of Tables
Table 1: Over view of Health Facility Assessment, 2018.........................................................................18
Table 2: Resources available for HMIS/CHIS at Woreda and health facility level,2018.........................18
Table 3: Establishment and Functionality of Performance Monitoring Team (PMT), 2018....................19
Table 4: Status of Birth and Death notification in health Center and Health posts, 2018 ........................20
Table 5: Presence of Manuals/Guidelines for implementation of HMIS and CHIS, 2018.......................20
Table 6: Monthly health facility reporting completeness of Service Delivery report from October to
December, 2018.........................................................................................................................................22
Table 7: Monthly report timelines of Service delivery report from October to December, 2018.............23
Table 8: Supportive Supervisions on data quality check, 2018 ................................................................24
Table 9: Displaying Information at Health facility and woreda health office level, 2018........................25
Table 10: Health Extension Program (HEP) implementation at household level, 2019...........................27

8. VIII
Abbreviations
CHIS………………………………………………. Community Health Information System
DHIS………………………………………………. District Health Information System
FMoH………………………………………………. Federal Ministry of Health
HEWs………………………………………………. Health Extension Workers
HIS………………………………………………… Health Information System
HMIS………………………………………………. Health Management Information System
IDSR………………………………………………. Integrated Disease Surveillance Report
WHO……………………………………………… World Health Organization
HSTP………………………………………………. Health Sector Transformation Plan
PMT…………………………………………………Performance monitoring Team

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INTRODUCTION
1.1 Background
Health information system (HIS) refers to any system that captures, stores, manages or transmits information
related to the health of individuals or the activities of organizations, which will improve health care
management decisions at all levels of the health system(1).Health management information system (HMIS)
is a System that allows for the collection, storage, compilation, transmission, analysis and usage of health
data that assist decision makers and stakeholders manage and plan resources at every level of health
service(3). Community Health Information System (CHIS) is a part of HMIS & is a family-centered health
information system designed for health extension workers (HEW) to manage and monitor their work in
educating households and delivering an integrated package of promotive, preventive & basic curative health
services to families.
The Ethiopian Health Management Information System has been implemented since 2008 to capture and
provide core monitor-able indicators used to improve the provision of health services, ultimately to improve
health status of the population(2). Federal Ministry of Health (FMOH) of Ethiopia designed Family Folder
as a comprehensive data collection tool for documenting family-centered HEP services provided by HEWs.
The CHIS is a component of the reformed Health Management Information System (HMIS) designed by the
FMOH according to the principles of standardization, integration and simplification to provide information
for decision making
Also, integrated Disease Surveillance Report (IDSR) is a part of Health Information Management System
which is one of the building blocks of a health system. Hence IDSR contributes to improving health service
delivery. Effective communicable disease control relies on effective response systems, which in turn depend
on effective disease surveillance. Surveillance has been defined as the process of systematic collection,
collation and analysis of data with prompt dissemination to those who need to know, for relevant action to
be taken.
This document reports on the assessment findings that serve as a basis for formulating interventions to
improve the HMIS performance and as a baseline for future monitoring of HMIS performance improvement
in the zones. Additionally, lessons learned from this assessment will further inform needed modifications
and/or adaptations of the HMIS performance assessment tools to be used for assessments in the remaining
woredas of zones.

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1.2 Statement of the Problem
A health system is the sum total of all the organizations, institutions, resources and all activities whose
primary purpose is to promote, restore or maintain health. A health system needs staff, funds, information,
supplies, transport, communications and overall guidance and direction. And a health system needs to
provide services that are responsive and financially fair(1). Health systems have a responsibility not just to
improve people’s health but to protect them against the financial cost of illness – and to treat them with
dignity.
HIS is one of the six building blocks of a health system. A well-functioning health information system
supports the delivery of health services by ensuring the production, analysis, dissemination and use of reliable
and timely information on health determinants, health system performance and health status. (Refer to figure
1 below). Reliable information is the foundation of evidence-based decision-making across all health system
building blocks. It is essential for health system policy development and implementation, governance and
regulation, health research, human resources development, service delivery and financing. HIS has four key
functions: data generation, compilation, analysis and synthesis, and communication & use. The HIS collects
data from the health sector and other relevant sectors, analyses the data and ensures.
Figure 1: Building blocks of Health system functioning

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Simplification, standardization and harmonization are the core principles of the new HMIS. However,
parallel recording and reporting instruments for different services at all levels are still in use. For instance,
outpatient therapeutic program (OTP) cards and community conversation (CC) record book are in use in the
health posts. Separate weekly, monthly and quarterly reports are submitted based on these records to higher
level. The use of these parallel recording and reporting instruments is mainly determined by the needs of
specific programs whose information needs may in turn be driven by donor reporting requirements(4).
Owing to the observed gap in the health sector, information use has been given substantial prominence in the
HSTP as part of information revolution which is one of the four transformation agendas in the current HSTP.
The Information Revolution is not only about changing the techniques of data and information management;
it is also about bringing fundamental cultural and attitudinal change regarding perceived value and practical
use of information. Revolutionizing the availability, accessibility, quality, and use of health information for
decision-making processes, through the appropriate use of information communication technology, can
ultimately impact the access, quality, and equity of healthcare delivery at all levels in Ethiopia.
Bringing cultural transformation in information use is the most challenging part of the information revolution
agenda as it requires addressing barriers that are linked to technical, organizational and behavioral factors.
The decision-making and problem-solving behavior of information users can heavily influence the ultimate
use of data for service delivery improvements. Both data producers and users function in an organizational
context that can support or hinder them to use information for action.
A country where IDSR is functional would use standard IDSR case definitions to identify and report priority
diseases; collect and use surveillance data to alert higher levels and trigger local action; investigate and
confirm suspected outbreaks or public health events using laboratory confirmation, when indicated; analyze
and interpret data collected in outbreak investigation and from routine monitoring of other priority diseases;
use information from the data analysis to implement an appropriate response; provide feedback within and
across levels of the health care system; and evaluate and improve the performance of surveillance and
response systems.
Integrated Disease Surveillance and Response (IDSR) involve carrying out disease surveillance activities
using an integrated approach. An integrated approach means that data on all important diseases will be
collected, analysed, interpreted and reported in the same way, by the same people who normally submit

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routine report forms on health-related data. In this study session, we will also consider the case definitions
of priority diseases in Ethiopia, and how priority diseases are reported. Proper understanding of IDSR, the
case definitions and reporting methods will enable you to identify, register, analyse and report priority
diseases quickly and accurately to the proper authorities. These activities are essential in order to ensure that
priority diseases in your community can be prevented and controlled.
Currently, there are 20 reportable priority diseases or conditions in Ethiopia, which are included in the IDSR
system. These 20 priority diseases are further classified into ‘immediately’ or ‘weekly’ reportable diseases.
Some of the priority diseases, such as avian influenza, pandemic influenza, cholera, measles, meningitis and
relapsing fever are likely to spread quickly and to affect a large number of people. Therefore, you should
always be alert for such diseases in your community, and report immediately to a health centre if you suspect,
or are unsure about, a case.
1.3 Significance of the Assessment
The findings of this assessment will be expected to identify major problems observed in health institutions
in implementing HMIS and IDSR in South West Shoa. It will provide relevant information for planning
M&E and show areas that needs special attention and further follow up for program improvement. Also it
will be used as crucial inputs for strengthening Planning, Monitoring and Evaluation, informed decision
making based on adequate and quality information.
Furthermore, Zonal Health Bureau, Woreda Health Offices, Health Center and Health Posts can use the
finding of this assessment as an input for informed decision making in resource allocation and identifying
areas those need special concern.

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OBJECTIVES OF THE ASSESMENT
3.1. Assessment questions
The assessment questions were answer the following:
1. Are resources available to sustain reform activities?
2. Are the HMIS/CHIS activities implemented according to the standard and guidelines?
3. Are IDSR report implemented according to the national standard and guidelines?
4. Is there a culture of information use for decision making at local level using DHIS2?
3.2. General Objective
• To create a baseline for HMIS/IDSR and generate evidence for formulating interventions for improving
health information system performance in South West Shoa, Oromia Regional State, Ethiopia 2019.
3.3. Specific objectives
• To estimate the level of HMIS/CHIS performance in woredas measured by data quality and use of
information.
• To assess implementation Community Health Information System (CHIS) at health post levels in the
study area.
• To assess Integrated Disease Surveillance Report (IDSR) implementation in selected woredas
• To assess the functionality of Performance Monitoring Team (PMT) with national standards
• To assess local use of HMIS/ IDSR information for decision making all levels using DHIS2 in the study
area.
• Develop recommendations for interventions to strengthen the identified areas needing improvement.

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METHODS AND MATERIALS
4.1. Study area and period of assessment
The study was conducted in Woreda, Health center and Health Posts of South West Shoa Zone, Oromia
Regional State. The Zone is 114 km far from Addis Ababa to the South West part of the country. There are
11 woredas and one town administration, 264 rural and 22 urban kebeles in the zone. According to
population projection of 2007, there were a total of 1,101,129 populations (Male 556,194,& Female 544,935)
,and urban 149,878 and rural 951,251 residents in the zone(5). There are 4 functional government hospitals,
1 Private not for profit hospital, 54 functional health centers, and 72 different levels of private clinics and
264 health posts that serve the population living around. The study was carried out in four woredas in the
Zone such as Wonchi, Waliso Town, Goro and Waliso Rural. The health centers and health posts are
currently implementing Health Management Information System and Community Health information system
reform. The study was conducted in health facility of South West Shoa Zone, Oromia Region, Ethiopia, from
January 17 to 25, 2019.
4.2. Study Design
• Cross sectional study design.
4.3. Population
4.3.1. Source population
• Source populations of the study were all health institutions found in south west shoa zone.
4.3.2. Study population
• The study populations of this assessment were selected health institutions and woredas
4.3.3. Study units
• The study units of this assessment were health post, health centers, and woreda health offices.
4.3.4. Exclusion criteria
• Health centers and Health posts that do not implementing HMIS was excluded from this assessment.
4.4. Sample Size and sampling Procedure
4.4.1. Sample size determination
Among 12 woredas (11 rural woredas and one city administration) found in the zone, 4(30%) of the woredas
were taken. This is according to the WHO guideline for sampling district health system for assessing its
functionality(6). Therefore, 22 HIs were included in this assessment i.e. 12 health centers, 10 health post and
5 household in each health post. In this assessment, all health facilities’ documents from October to
December 2018 were reviewed.

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4.4.2. Sampling technique
For this assessment, at zonal level, woredas was purposively selected. After selection of woredas, health
centers randomly selected using lottery method depending on the number of health centers found in each
woreda and one accessible for transportation health post was included in each health center. Also, in each
health post five households are included to assess health extension program status. All health professionals
and supporting staffs working on HMIS/IDSR and those are available at the time of data collection was
interviewed in the study. All selected health institutions were physically observed.
Figure 2 :-Schematic presentation of sampling procedure for HMIS/CHIS and IDSR assessment in South
West Shoa, Oromia Regional State, Ethiopia, 2019.
4.6. Data collection
4.6.1 Data collection Instrument
The data was collected using HMIS structured questionnaires to answer the objective of this assessment.
Also, data was collected from registers, tally sheet and reports.
4.6.2. Data Collectors
Ten BSc health professionals who know local language and trained on HMIS were recruited for data
collection. Half a day orientation was given to the data collectors on the data collection tools and procedures
by the principal investigators.
12 woredas in South West Shoa Zone
Wonchi
HC=6
HP=23
HC=3
HP=3
12_HC ,and 10-HP included in the study
Goro
HC=4
HP=19
HC=2
HP=2
Waliso Town
HC=2
HC=2
Waliso Rural
HC=10
HP=36
HC=5
HP=5
4 woredas included purposively
Selected by lottery
method

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4.6.3. Data collection Field Work
Quantitative data were collected from health professionals and supporting staffs working on HMIS, IDSR
and service delivery unit was interviewed using structured questionnaire. Prior to start the interview, data
collectors were communicated with HIs head to obtain information about the staffs and whom to interview.
Thereafter, 30 minutes interview per respondent in each HIs was conducted. Data was checked for
completeness and accuracy by data collectors though out the data collection period.
4.9. Data Analysis
After cleaning and checking for illegal codes, missing values and completeness, quantitative data was
analyzed by SPSS version 23 using descriptive statistics and summary of frequencies was presented by tables
and charts.
4.10. OPERATIONAL DEFINITIONS
Data quality is an assessment of data's fitness to serve its purpose in each context in terms of timeliness,
accuracy and completeness.
Completeness refers 90% of required data are present on registration and reported format.
Accuracy refers the consistency and actual presence of data on service registration books and interpreted by
national range of accuracy level (Verification Factor=0.9-1.1).
Timeliness refers data are recorded and reported on time as per the national standard.
HMIS data utilization refers to use of health information/data in decision making, i.e., for planning,
monitoring, evaluation, budget allocation or writing feedback and other purposes.
4.11. Data Quality management
Data cleaning and checking was done at field level and repeated after entry to check for coding error and
missing values by principal committees and errors were removed and completeness was checked.
4.12. Ethical consideration
Prior to initiation of data collection, permission was obtained from South West Shoa Zonal health department
and woreda health offices. Informed verbal consent was obtained from each study health institutions after
clear explanation about the purpose of the study. Confidentiality was assured during data collection and the
collected information was utilized for the purpose of the assessment only.

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4.12. Dissemination plan
The final assessment findings were presented to Zonal Health Department and CUAMM project. The result
of an assessment was disseminated to Zonal Health Department, Woreda Health Offices and to health centers.
All of them was provide with clear, simple and summarized soft copy of the report while ZHD and CUAMM
project was provided with both softcopy & hard copy of the report.

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RESULTS OF THE ASSESMENT
5.1 Overview of Health Center and Health posts
Total numbers of study health facility were 22 with 100% response rate. Health staffs such as HMIS, IDSR
focal person, and heads /deputy of the selected health institutions and Health extension workers are
interviewed during this assessment.
Table 1: Overview of Health Facility Assessment, 2018
Health Facilities Goro Wonchi Waliso Rural Waliso Town Total
Health Center 2 3 5 2 12
Health post 2 3 5 0 10
Total 4 6 10 2 22
5.2. Resources available for HMIS/CHIS at Woreda and health facility level
Among the 12 health centers only 7 (58%) had HMIS unit. Fifty (50%) of the health posts and (8%) health
centers had no electric power access. In all Woredas HMIS/CHIS focal person was assigned and trained on
DHIS2 and data quality & information use.
Table 2: Resources available for HMIS/CHIS at Woreda and health facility level,2018
Facility Infrastructure
Health Post
(N=10)
Health Center
(N=12)
Woreda Health Offices
(N=4)
YES NO YES NO YES NO
HMIS Unit NA NA 7(58%) 5(42%) 4(100%) 0
Have DHIS2 Computer NA NA 9(75%) 3(25%) 4(100%) 0
DHIS2 cloned computer NA NA 7(58%) 5(42%) 4(100%) 0
MPI/Tickler Box 8(80%) 2(20%) 5(41%) 7(59%) NA NA
Standard Shelves 9(90%) 1(10% 7(58%) 5(42%) NA NA
VPN/ADSL line in place NA NA 3(25% 9(75%) 4(100%) 0
Active/functional VPN/ADSL line NA NA 3(25% 9(75%) 3(75%) 1(25%)
LAN in place (Network expansion done) NA NA 5(42%) 7(58%) 0 4(100%)
Trained Focal person on HMIS/CHIS 0 10(100%) 7(58%) 5(42%) 4(100%) 0
HIT/HMIS Professionals assigned NA NA 11(92%) 1(8%) 4(100%) 0
Electric power 5(50%) 5(50%) 11(92%) 1(8%) 4(100%) 0

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5.3. Performance Monitoring Team (PMT)
From this assessment health Center and woreda health offices 75 % and 100% of Performance Monitoring
Team (PMT) was formally established as national standards respectively. At health post level all HEWs send
the report to the next level and she doesn’t identify performance gaps, set priority to solve performance gaps,
identify root causes and developed action plan using problem investigation and action plan form. Most of the
PMT does not know how to prioritize the problem and know the root cause and needs refreshment training
on information use.
Table 3: Establishment and Functionality of Performance Monitoring Team (PMT), 2018
Performance Monitoring Team (PMT) Health Post (N=10) Health Center
(N=12)
Woreda Health
Offices
(N=4)
YES NO YES NO YES NO
Formally established PMT as National Standard NA NA 9(75%) 3(25%) 4(100%) 0
PMT members participated in data quality
check (Completeness)
NA NA 10(84%) 2(16%) 4(100%) 0
PMT meeting conducted in the last month NA NA 7(58%) 5(42%) 4(100%) 0
PMT meeting minutes documented NA NA 8(67%) 4(33%) 4(100%) 0
PMT minutes book clearly shows date, time,
and attendees, meeting agenda, summary of
discussion & conclusions
NA NA 9(75%) 3(25%) 2(50%) 2(50%)
Institution head or deputy head was chaired
PMT meeting
NA NA 10(83%) 2(17%) 4(100%) 0
PMT/HEWs identified performance gaps 0 10(100%) 5(42%) 7(58%) 3(75%) 1(25%)
PMT set priority to solve performance gaps 0 10(100%) 4(33%) 8(67%) 2(50%) 2(50%)
PMT/HEWs identified root causes and
developed action plan using problem
investigation and action plan form
0 10(100%) 4(33%) 8(67%) 2(50%) 2(50%)
PMT/HEWs conducted resource mapping using
stakeholder analysis
0 10(100%) 3(25%) 9(75%) 0 4(100%)
PMT/HEWs ensure and/or implement proposed
interventions and started result monitoring 0 10(100%) 3(25%) 9(75%) 1(25%) 3(75%)
Conducting Lot Quality Assurance
Sampling(LQAS) monthly
5(50%) 5(50%) 7(58%) 5(42%) NA NA

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5.4. Status of Birth and Death Notification in health facility
Event of birth registration is considered for all live births occurred either at the facility or outside health
facility. The health facility it means the hospitals, the health centers and the health posts found in the country
either owned by government or privately-owned facilities. Like births, death also occurs either at the health
facility or outside health facility. With the same with the event of birth, the health facility is expected to
notify for the death events occurred within the health facility for the caregivers of the deceased person
immediately. During this assessment health post level birth notification and death notification not started and
at health center level 42% start birth and 33% death notification. Al the interviewed Health extension
Workers does not trained on vital registration and she didn’t know the importance of vital registration.
Table 4: Status of Birth and Death notification in health Center and Health posts, 2018
Vital Registration
Health Post Health Center
YES NO YES NO
Start to notify birth (compare copies of birth
notified against live births reported) 0 10(100%) 5(42%) 7(58%)
Start to notify death (compare copies of death
notified against institutional death reported) 0 10(100%) 4(33%) 8(67%)
5.5. Presence of manuals for implementation of HMIS and CHIS
At least four manuals which facilitate the implementation of HIS are in place within the Woreda Health
Office and Health center level. During this assessment at woreda level all manuals are available. At health
center level HMIS recording and reporting, indicator reference, NCoD and Data quality and information use
manuals are 25%, 33%, 17% and 58% respectively.
Table 5: Presence of Manuals/Guidelines for implementation of HMIS and CHIS, 2018
HMIS Manuals
Woreda Health
office
Health Center Health Post
YES NO YES NO YES NO
HMIS Recording and reporting manual 4(100%) 0 3(25%) 9(75%) NA NA
HMIS Indicator reference manual 4(100%) 0 4(33%) 8(67%) NA NA
HMIS NCoD manual 4(100%) 0 10(83% 2(17%) NA NA
HMIS Data Quality and Information use manual 4(100%) 0 5(42%) 7(58%) NA NA
CHIS Users Manual- Afan Oromo Version 4(100%) 0 NA NA 6(60%) 4(40%)
Master Family Index(MFI) NA NA NA NA 8(80%) 2(20%)
Field Book NA NA NA NA 8(80%) 2(20%)

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5.6. Levels of HMIS Performance: Data quality and information use
5.6.1 Data Accuracy
In the revised HMIS the definition of Repeat Contraceptive Acceptors was modified to those clients who are
ever users of any contraception and in a given year are coming for the first time for contraception (either for
re-supply, or restarting or starting a different method of contraception). Thus, ever-user clients who come for
second and subsequent visits are not counted. Previously, however, all the repeat visits were counted as
continuous users. Thus, there were chances that the health staff might confuse the definition of Repeat
Contraceptive Acceptors. During this assessment interviewed midwives on the service delivery unit only
75% of health center define and record new and repeat acceptor according to the national standard. Also the
data elements of different registers was did not filled
properly according to the national guidelines and
manuals for instance Antenatal care, PNC, Delivery
registration the column box of reportable data element at
the end of the registration page also no filled.
On the other hand, in case of OPD attendance, the patients’ data is recorded in the OPD Abstract Register
and also in OPD Tally sheet. In the register, one row is used for one visit and the main diagnosis is recorded
even if the patient comes for more than one illness. On the
other hand, in the Tally sheet, every diagnosis is tallied;
moreover, the tally sheet allows tallying by age and sex
groups. This arrangement encourages the health staff to rely
on the tally sheet for reporting and there are chances that the
records in the register and tally sheet might not match. From
this assessment 67% of Staffs define new
and repeat, and filled in the register
properly and some of them didn’t use
NCoD to classify HMIS disease
classification. So, from this assessment for
OPD and other service delivery unit refreshment training and conducting continuous mentorship to health
facility will be needed to address this gap.

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5.6.2. Data Completeness
5.6.2.1 Monthly Health Facility Reporting Completeness
The completeness of the monthly report is measured by number of HF reports with over 90% of the data
elements filled against the total number of data elements that the facility was supposed to fill. The result
showed less than 7% of the facilities did not complete the monthly form before reporting.
Completeness of the report at woreda level is assessed by how many facilities in the whole woreda were
supposed to report are actually reporting to the respective WorHO. In the four woredas, all of the facilities
were observed to be reporting
Table 6: Monthly health facility reporting completeness of Service Delivery report from October to
December, 2018
Completeness of Service Delivery report from October to December 2018
Name of
PHCU/WorHO
October November December
Actual
Reports
Expected
Reports Percent
Actual
Reports
Expected
Reports Percent
Actual
Reports
Expected
Reports Percent
Wayu 1 1 100 1 1 100 1 1 100
Gurura 1 1 100 1 1 100 1 1 100
Goro WorHO 4 4 100 4 4 100 4 4 100
Korke 1 1 100 1 1 100 1 1 100
Karu Simala 1 1 100 1 1 100 1 1 100
Gerbo 1 1 100 1 1 100 1 1 100
Obi 1 1 100 1 1 100 1 1 100
Kora 1 1 100 1 1 100 1 1 100
Woliso WorHO 8 8 100 8 8 100 8 8 100
Waliso 1 1 100 1 1 100 1 1 100
Waliso 03 1 1 100 1 1 100 1 1 100
Woliso Town 2 2 100 2 2 100 2 2 100
Lemen 1 1 100 1 1 100 1 1 100
Darian 1 1 100 1 1 100 1 1 100
Gatiro 1 1 100 1 1 100 1 1 100
Wonchi WorHO 6 6 100 6 6 100 6 6 100

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5.6.3. Monthly Report Timeliness
Another dimension of data quality is timeliness. Timeliness is measured by the PHCUs and WoHOs receiving
facilities’ reports by the predetermined deadlines. One out of four PHCUs in Goro WoHOs did not have
records to measure timeliness December month and four out of eight PHCUs in Waliso Rural did not meet
the pre-determined timelines in October month.
Table 7: Monthly report timelines of Service delivery report from October to December, 2018
Expected
Reports
October November December
Name of
PHCU/WorHO
Reports
On Time
Percent On
Time
Reports
On Time
Percent On
Time
Reports
On Time
Percent
On Time
Wayu 1 1 100 1 100 1 100
Gurura 1 1 100 1 100 0 0
Goro WorHO 4 4 100 4 100 3 75
Korke 1 1 100 1 100 1 100
Karu Simala 1 0 0 1 100 1 100
Gerbo 1 1 100 1 100 0 0
Obi 1 1 100 1 100 1 100
Kora 1 0 0 1 100 1 100
Woliso WorHO 8 4 50 8 100 7 87.5
Waliso 1 0 0 1 100 1 100
Waliso 03 1 1 100 1 100 1 100
Woliso Town
ZHD 2 1 50 2 100 2 100
Lemen 1 1 100 1 100 1 100
Darian 1 1 100 1 100 1 100
Gatiro 1 1 100 1 100 1 100
Wonchi WorHO 6 4 66.7 5 83.3 6 100

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Generally timelines of data quality varies from woreda to woredas. For instance in Goro woreda one out of
four PHCUs did not have records to measure timeliness December month and in Waliso Rural woreda four
out of eight PHCUs did not meet the pre-determined timelines in October month.
Figure 3: Woreda report timelines of Service delivery report from October to December, 2018
5.6.4. Data quality check
Table 8 shows that in over 75% of Health Centers, the supervisors visited the health facility for supervision
and 58% of the supervised HFs received feedback on the supervisory visits.
Table 8: Supportive Supervisions on data quality check, 2018
Supportive Supervision
Health Center
(N=12)
Woreda Health Offices
(N=4)
Woreda/PHCU has a supportive supervision plan to HCs/ and
HPs 9(75%) 4(100%)
Woreda/PHCU conducted supportive supervision to HCs and
HPs in the quarter 2 9(75%) 4(100%)
Checklist used in supportive supervision 9(75%) 4(100%)
Zone/Woreda kept copies of filled supportive supervision
checklist in the health facility 7(58%) 4(100%)
Copies of supportive supervision feedback was documented 7(58%) 4(100%)
HMIS/CHIS action plan was developed 8(67%) 1(75%)
Evidence of HMIS/CHIS action plan implementation
observed 8(67%) 0
Ways to monitor and follow the implementation of the
proposed intervention were identified 8(67%) 0
100%
50% 50%
66%
100% 100% 100%
83%
75%
87%
100% 100%
0%
20%
40%
60%
80%
100%
120%
Goro Waliso R Waliso T Wonchi
October November December

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5.6.5. Use of HMIS/IDSR Information
The use of information was assessed by observing feedback provided on facility performance and through
records of performance review meetings to collect documentary evidences of whether or not HMIS findings
were discussed and decisions were eventually made based on those discussions.
5.6.5.1. Data Display
Availability of tables, charts and/or maps on maternal health indicators, child health indicators, facility
utilization, and /or disease surveillance indicators were assessed for understanding the level of data display
in the health facilities, and woreda health offices. Table 9 shows that 8 (67%) health centers and 2(50%) of
woreda health offices were displaying data; of them 5 (42%) Health Centers and 2(50%) had updated over
the last 3 months period. From this figure most of the health center does not display required information on wall
and DHIS2 analysis due to skill gap of training.
Table 9: Displaying Information at Health facility and woreda health office level, 2018
Display Information
Health Post
(N=10)
Health Center
(N=12)
Woreda Health
Offices (N=4)
HP/PHCU/Woreda has displayed any charts or
table of performance monitoring in HMIS unit
and/or Office of institution head 7(58%) 8(67%) 2(50%)
Charts/Tables have been updated for the last
month 7(58%) 5(42%) 2(50%)
Charts/Tables have clear title, axes naming, plot
area & legends 5(50%) 8(67%) 2(50%)
Worksheets/data sources for the charts/table
were documented 0 5(42%) 2(50%)

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5.7. Integrated Disease Surveillance and Response (IDSR) implementation
Among health Extension workers interviewed only 70% know Integrated Disease Surveillance and Response
(IDSR) program. Among those who express to know what IDSR was, about 60% of know the meaning of
IDSR and its importance. At health center and woreda health office level health professionals know this
program and clearly know the meaning of the program. Also, IDSR focal person assigned in all Woredas and
trained.
At all levels of hierarchy the last day of reporting from the institutions to the next level was Monday. A
measles disease was frequently reported from the Integrated Disease Surveillance and Response and means
of communication for report was hard copy. Functional and active emergency preparedness committee was
established 33% and 50% at health center and woreda level respectively.
Health
Post
(N=10)
Health
Center
(N=12)
Woreda
health office
(N=4)
Could you show us the receipt of the last six months
PHEM report?
YES 1(8%) 1(8%) 4(100%)
NO 11(92%) 11(92%) 0
What is the last day of reporting from your
institution to the next level
YES Monday Monday Monday
Is there any case of reports for disease under
surveillance from your institution during the last six
months?
YES 10(100%) 1(8%) 3(75%)
NO 0 11(92%) 1(25%)
If Yes what case Measles Measles
Means of communication for weekly report
Hardcopy 10(100%) 12(100%) 4(100%)
Mobile 0 0 0
Is there Functional and active emergency
preparedness committee
YES NA 4(33%) 2(50%)
NO NA 8(67%) 2(50%)
Has the committee an emergency preparedness plan?
YES NA 2(17%) 1(25%)
NO NA 10(83%) 3(75%)

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5.8. Health Extension Program (HEP) implementation at household level
The Health Extension Program (HEP) is designed to achieve significant basic health care coverage in
Ethiopia over five years through the provision of a staffed health post to serve every 5000 people served.
This new community-based health care delivery system will improve access and equity in health care through
a focus on sustained preventive health actions and increased health awareness.
Every health post (current or to be built) will be staffed by two Health Extension Workers (HEW), who will
have undergone a one year training course. The training program for the Health Extension Workers includes
16 major packages under four components. However, from this assessment only 73% of households know
the health extension workers name and some service offered from health posts are EPI, ANC and FP. Among
households interviewed 38% and 16 % know their “Gare” and one to five (1:5) network leaders respectively.
Table 10: Health Extension Program (HEP) implementation at household level, 2019
Health Extension Program(HEP) implementation YES NO
Do you know your ‘Gare” 21(38%) 34(62%)
Do you know your 1 to 5 network leader 9(16%) 46(84%)
Do you know the name of your health extension workers 40(73%) 15(73%)
How frequent your health post open
Always 24(44%) 31(56%)
1day/Week 2(4%) 53(96%)
2days/Week 6(11%) 49(89%)
3days/Week 18(33%) 37(67%)
Never opened 5(9%) 50(91%)

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6. DISCUSSION AND RECOMMENDATIONS
6.1. Discussions
This baseline assessment highlighted very low level of data accuracy in health facilities across all the three
study areas. Data accuracy is affected by lack of data quality check process, absence of HMIS procedural
manual and minimum use of data quality checklist during supervision. Poor understanding of definition of
indicators such as OPD visits and low capacity to calculate data were also contributing to the low level of
data accuracy. Despite the fact that reports are scanned and entered into the database automatically a similar
low level of data accuracy was observed for health posts while comparing the paper report against the
computer DHIS2.
Unlike data accuracy, exceptionally high level of completeness of reports was observed at all levels of the
health system. At facility level all woreda met the acceptable completeness standard (90%) set in HSDP IV.
Another encouraging pattern revealed was timeliness of reports. Although records of report receipt are not
kept properly, from the available records more than 75% of the facilities were found to be reporting within
the deadline. In Ethiopia context, this is high level of reporting even though the HSDP IV target for timeliness
by facilities is 90%.
The use of information, another dimension of HMIS performance, was found limited in the assessed woreda.
The revised HMIS in 2017 is geared towards supporting and strengthening local action-oriented performance
monitoring. HMIS information use guideline helps identify gaps, to develop plans of action to address them,
and review progress, thereby continually improving service coverage over time. In the assessed health
facilities absence of such guideline may be one of the contributing factors for the observed minimum use of
HMIS information in the annual plans. This finding is consistent with the limited competence in data analysis,
interpretation and problem solving at the health facilities. It shows data are being collected primarily for
reporting, and use of data for evidence based decision making is low at peripheral level.

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6.2. Recommendations
The findings of assessment are expected to inform South West Shoa Zonal Health department for taking
necessary actions to improve HMIS data quality and information use. The assessment identified strengths
and weaknesses of the HMIH/IDSR performance in terms of data quality and information use in the woredas.
Based on the findings, the following general recommendations are provided based on the findings of the
assessment for further discussion in the planned action planning workshop.
Short term
• Standardize supervision practices – develop supervisory checklists. Supervision should be conducted on a
regular schedule with feedback provided to the facilities. Performance data (data quality and use indicators)
should be collected, monitored and reviewed regularly.
• Conduct refreshment training for WoHOs and HCs on revised HMIS and Information use
• Conduct refreshment training for HEWS on Community Health Information System and Vital Registration
• Link HMIS/IDSR data with program monitoring – integrate HMIS quality controls activities into integrated
supervisory visits. That is, if an EPI supervisor visits a facility they should be able to conduct the supervision
for HMIS/IDSR at the same time.
• Expand remote access to the processed data set to woreda health offices to facilitate timely use of
information for decision making at local level. Roll out the DHIS2 to the woreda level.
• Establish a standardized feedback mechanism between levels. DHIS2 provides an opportunity for
generating automated report from the HMIS software that should be forwarded to reporting sites at regular
intervals.
• Create linkages with service delivery managers – i.e. the facility in-charge should be integrated into the
monitoring of HMIS performance.
• Conduct on the job training or Mentorship on data analysis, interpretation and continuous use of information
at all levels using DHIS2.
Long term
• Establish systematic periodic assessments of HMIS/IDSR performance in terms of data quality, data use
and management functions on a periodic basis.
• Promote transparency and accountability of HMIS/IDSR data. For example - institutionalize the use HMIS
information to make everyone accountable for health system performance.
• Identify local partners (NGOs within zones) to support HMIS/IDSR – find a mechanism to generate budget
for HMIS supplies locally to ensure sustainability of the system.

30. 30
References
1. Indicators AHOF, Strategies TM. MONITORING THE BUILDING BLOCKS OF HEALTH
SYSTEMS : A HANDBOOK OF INDICATORS AND. 2010;
2. FMOH. Manual, HMIS Information Use and Data Quality manual. FMOH. 2014;
3. Manual P. FEDERAL MINISTRY OF HEALTH POLICY , PLANNING AND Monitoring &
EVALUATION DIRECTORATE ( PPMED ) November 2018. 2018;(November).
4. Belay H, Azim T, Kassahun H. Assessment of Health Management Information System ( HMIS )
Performance in SNNPR , Ethiopia.
5. “The 2007 Population and Housing Census of Ethiopia: Statistical Report for Oromiya Region; “The
2007 Population and Housing Census of Ethiopia. Addis Abeba; 2007. 518 p.
6. Sambo LG, Chatora RR. Tools for Assessing the Operationality of District Health Systems. 2003;10.