Presented by Theo Lippeveld at the November 2013 American Public Health Association Annual Meeting.

1. Strengthening routine health information
systems (RHIS) in LMICs:
Towards a sustainable data source for
measuring evidence based service delivery
Presentation by Theo Lippeveld, MD, MPH
tlippeveld@jsi.com
APHA 143nd
Annual Conference
Boston, November 5, 2013

2. Presenter Disclosures
Presenter: Theo Lippeveld
I have no relationships to disclose

3. Presentation Outline
 Routine Health Information Systems:
 Why are they so important?
 Why are they not functioning well?
 PRISM framework and tools
 PRISM interventions
 Use of PRISM in various countries
 Conclusion and next steps

4. The role and importance of decentralized
Routine Health Information System (RHIS)
 Facility-based and ideally also community-based
 AKA = Health Management Information System (HMIS)
 Main source of information for (daily) planning and
management of health services at district level and below
 Coverage and quality of health interventions
 Disease surveillance
 Commodity security
 Financial information systems
 Commission for Information and Accountability on
Women’s and Child Health: essential role of RHIS in
accelerating progress on MDGs

5. Unfortunately...
Routine health information systems in most
developing countries are woefully
inadequate to provide the needed
information support ...

6. The burden of data

7. Where HMIS data often end their
journey…

8. What is wrong with existing routine
health information systems?
• Plethora, irrelevance and poor quality of the data
collected
• Centralization of information management
without feedback to district and service delivery
levels
• Fragmentation into “program- oriented”
information systems: duplication and waste
• Poor and inadequately used health information
system infrastructure and resources

9. As a result…
• Poor use of information by users at all
levels: care providers as well as managers
• Reliance on more expensive survey data
collection methods but the findings are
relevant only to national and global levels

10. So, the question is not ….
Where can we find other data sources (since
RHIS cannot provide the information)?
but rather…
How can we improve the RHIS performance in
support of planning and management of
quality district health systems?

11. Examples of RHIS reform efforts in
the past twenty years

12. Some of the lessons learned
 Need for well defined RHIS performance criteria:
 Production of relevant and quality information
 Continued use of information for DM at all levels
 Empirical evidence shows that availability of quality
information does NOT NECESSARILY mean that is it used
for decision making
Need for broader “system” thinking
Need for better understanding of factors influencing RHIS
performance
PRISM framework:
Performance of Routine Information System Management

13. Behavioral
Determinants
Knowledge/ skills, attitudes,
values, motivation
PRISM framework for understanding
Routine Health Information System (RHIS) performance
Improved Health System
Performance
Improved Health
Outcomes
Technical
Determinants
Data generation architecture
Information/communication
technology
Desired Outputs
= RHIS performance
•good quality
information•appropriate use of information
Inputs
RHIS assessment,
RHIS strategies
RHIS interventions
Organizational
Determinants
Information culture, health system
structure, roles & responsibilities,
resources

14. PRISM tools
A) RHIS Performance Diagnostic Tool
B) RHIS Overview
Facility/ Office Checklist
Quality of data Use of information
C) Organizational & Behavioral
Questionnaire
D) RHIS Process Assessment
Tool

15. Application of PRISM tools

16. Measuring RHIS Performance:
Findings of PRISM assessment in different
countries at different health system levels
Availability of quality data
does not necessarily mean that
information is used for making
decisions

17. Measuring RHIS Performance:
Competency in problem solving
Inter-
ventions

18. What can we do to improve RHIS
performance?
 Technical interventions (classic)
 Organizational and behavioral
interventions (new approach)

19. 1. Technical interventions
 Defining set of essential indicators
 Standardize data generation architecture based on best
practices (data recording – reporting – processing)
 Improving integration of data sources: establishment
of data warehouse
 Development of computerized data analysis/
presentation application: DSS

20. 2. Organizational interventions
 Self-assessment
 Problem solving approach
 Advocacy
 Promotion Of Culture Of Information

21. How does self-assessment
work?
 Facility staff along with district staff set their own
service coverage targets and monitor them
periodically.
 Example (Pakistan): increasing facility utilization
rate from 30% to 50% in one year (1.6%
increase/month)
 Facility staff develop action plan to motivate the
community to visit their facility
 Facility staff monitors progress through line or control
chart and measures whether target is achieved
 Self-assessment assumes knowledge and skills
of using problem solving approach – next topic

22. Problem solving approach towards
performance improvement
Track and create institutional memoryTrack and create institutional memory

23. How does advocacy work?
 Ensure that all relevant information for supporting
the position is based on objective assessment
 Establish credibility based on previous good work
 Network within the organization (other health
centers, other counties)
 Create alliances with outside forces to get support:
 community, NGOs, private sector, local
politicians

24. How to promote culture of information?
 Role modeling by senior management on
using collected information
 Emphasis on HMIS performance during
meetings
 Dissemination of success stories of use of
info for service improvement and advocacy
 Institutionalizing use of HMIS information

25. 3. Behavioral Interventions
 Improve confidence level by asking people to do
simple HMIS tasks and then add complexity in
tasks
 Capacity building to improve data analysis,
problem solving and advocacy skills of district
and facility staff
 Organization of in-service training courses (Pakistan,
Uganda, South Africa, Mexico)
 On-the-job training through supportive supervision
 Include module in pre-service training programs

26. PRISM assessment results in Ivory
Coast
RHIS
Performance
Health Facilities Districts
2008 2012 Status 2008 2012 Status
Data quality 43% 60% 40% 81%
Data use 38% 38% 44% 70%

27. Examples of RHIS strengthening
interventions in Ivory Coast
 Integration of HIS/AIDS indicators into the
overall RHIS (T)
 Organized training in use of information
including problem solving techniques at
district and health facility levels (B)
 Developed feedback bulletins for health
offices at all levels (O)

28. Conclusions
 The unique role of HMIS is to produce quality
information that is used to improve health system
management functions at all levels
 PRISM tools allow countries (for the first time) to
measure RHIS performance
 RHIS performance improvement interventions should
focus on district level and below and include a mix of
technical, organizational, and behavioral interventions
 Senior management needs to role model use of
information and promote information culture for
improving service delivery performance

29. MEASURE Evaluation is a MEASURE project funded by the
U.S. Agency for International Development and implemented by
the Carolina Population Center at the University of North Carolina
at Chapel Hill in partnership with Futures Group International,
ICF Macro, John Snow, Inc., Management Sciences for Health,
and Tulane University. Views expressed in this presentation do not
necessarily reflect the views of USAID or the U.S. Government.
MEASURE Evaluation is the USAID Global Health Bureau's
primary vehicle for supporting improvements in monitoring and
evaluation in population, health and nutrition worldwide.