Zambia Health Management Information System (HMIS)

Author : Bwalya .C. Njelesani
Date added : 1999-11-01

Brief Project Background

The Zambian Government in its bid to enhance the delivery of Health Care to its people had put in place Health Reforms.

Results

THE HMIS
Design of the HMIS
Implementation of the HMIS
Automation
Information flow
Conclusion
Some Lessons learnt
The future of the project

BACKGROUND

The Zambian Government in its bid to enhance the delivery of Health Care to its people had put in place Health Reforms. Within the Health Reforms the need for improvement of the health management information system was recognised at an early stage. The aim of the health reforms was to "bring cost effective quality care as close to the family as possible" and this could only be reached if a proper system of monitoring and evaluation was put in place.

Thus, the Health Management Information System (HMIS) was formed to establish a self-sustaining monitoring and evaluation system which would improve decision making at all levels of the health care system with timely, valid and appropriate information required to increase the effective utilisation of quality health services.

The implementation of the HMIS required a great deal of financial and human resource commitment. The HMIS had the full backing of the Zambian Government and of Co-operating Partners. International Agencies (mostly referred to as Co-operating Partners) like the Danish International Development Assistance (DANIDA), Swedish International Development Agency (SIDA) and the United States Agency for International Development (USAID) were greatly involved in the implementation of the HMIS by providing human resource and financial support.

The Health Reforms saw the establishment of the Central Board of Health (CBoH) which became the administrative wing of the Ministry of Health. The CBoH was responsible for implementing policies formulated by the Government of Zambia through the Ministry of Health. The CBoH was thus poised with the task of implementing, among other programs, the HMIS.

The CBoH constitutes the Headquarters, Regional Offices, Hospitals, District Health Boards and Rural Health centers. Each District Health Board supervises rural health centers, Regional Offices supervise Districts and Hospitals, while Regional offices are supervised by the Headquarters.

Some of the factors which lead to the formation of the HMIS

The Ministry of Health had an archaic information system which over time was failing to deliver it's intended purpose, the advent of the Health Reforms was supposed to deal with this problem. Some of the problems that were in the old system are:

1. Fragmentation - Each department in the ministry concentrated on it's own interest. There was no overview that could be obtained. Issues like cost effectiveness and impact could not be monitored.

2. Duplication - Different programs or departments were interested in the same type of information and used forms and formats for reporting. The record holder was leprosy where each case was reported through 4 different information systems. The health institutions were overburdened with report forms (an estimated 36 distinct forms).

3. Centralisation - Health institutions, district health offices and provincial health offices had to report raw and aggregated data to the center. The system did not provide tools for analysis at periphery and were not geared towards the needs of the district and health centers.

4. Delay - Overburdened by reporting requirements, and completely demoralised because of lack of feed back, health institution staff delayed reporting. But even if the motivation was there, the absence of report forms severely limited communications in rural areas.

5. Unreliability - Reporting was incomplete (sometimes even fake), too late, contradictory and often not processed or analysed at national level. The system proved not to be useful at national level.
6. The implementation of the health reforms required a dynamic and efficient system of Monitoring and Evaluation. This same system was to be used in monitoring the impact of the health reforms as well.

7. Since there were a lot of orgnisations collecting information from districts directly, it was difficult for Government to control the quality and what information was disseminated externally.

THE HMIS

The first task was to put together a project team, which would oversee the implementation of the HMIS. In 1995, a team was put together comprising the following:

· Medical and Public health specialists,
· Project management staff,
· Statistical staff, and
· Computer specialists

The team comprised Zambian and Non Zambian staff. A development team was later formed from some of these people.

This team was to design the HMIS with a wide view of the Health Care system requirements of the country. The design and implementation of the HMIS was guided by the National Strategic Health Plan which had been under development as far back as 1990 but was actually being implemented with a time phase of 1995 to 1999. The design of the HMIS saw a great deal of consultation from international organisations, government ministries and health offices on what information they collected and used from the Health system. This was done so as to gain an understanding of the information collected by the various vertical programs and organisations and to eventually design a system that would meet the requirements of all the stakeholders. This process was done through questionnaires, interviews and by referring to various documentation.

Design of the HMIS

The HMIS was designed with the following characteristics:

Decentralisation - Who collects analyzes. Analysis and self-assessment was to be carried out at the level where data was collected and used for decision making at that level. Data was not merely collected for upward reporting.

Action oriented - data was supposed to be collected for decision making. Health Management Boards require operational information for day to day management and supervision.

Responsive - data should be reported in an appropriate timeframe according to its use, and flexible in terms of adaptation to local needs.

Transparent - Obtaining information should be easy and dissemination facilitated by the newly created Regional and National Resource Centers.

The HMIS was designed with the following subsystems:

Health Status - This measures the outputs of the health system (curative care, preventive activities, and health promotion) as well as new outcomes in health.

Finances - This focuses on financial inputs into the health system. It allows managers to measure costs involved in delivering the six priority thrusts for health services as well as providing basic accounting information. The six health thrusts includes the following:

· Safe motherhood (including antenatal and postnatal care, family planning)
· Child health (including immunisations and nutrition)
· Aids and Sexually transmitted diseases
· Malaria
· Tuberculosis
· Environmental sanitation

Human Resources - This subsystem allows for the understanding of staffing patterns, movements and training requirements.

Drugs and supplies - Information will be used to measure utilisation and stock management. The distribution system will change from a "push to a pull" system to allow districts to determine their own needs for drugs and supplies.

Assets - Information on the infrastructure and equipment inputs (including transport) allow the district and central levels to plan and budget for maintenance and rehabilitation/upgrades. Indicators help measure progress against minimum physical quality standards already developed for some health institutions (health centers).

A total of 70 indicators were proposed for the inclusion in the HMIS. Notifiable diseases like cholera and Measles that require immediate action from the regional and central levels were also included in the system.

Other issues that the HMIS needed to change was the attitude of health staff from "filling in forms to please the bosses" to an active attitude that was based on " we want to know things because we have to make decisions" principle. The system needed to change the information process from being donor driven, to be used for decision making.

Implementation of the HMIS

The implementation strategy for the HMIS was designed to insure that the manual HMIS became operational in January 1998 in all the 72 districts of Zambia. The implementation of the HMIS was to occur in three phases namely, Development, Pretest and Roll out.

The development phase involved testing and refining the systems in two districts of the western province of Zambia, these 2 districts were referred to as developmental districts. After revisions to the system were made and an operations manual updated, the system was tested in at least 12 districts with various levels of experience in data management, these 12 districts were referred to as pre-test districts while the remaining 58 districts were in the roll out phase.

The HMIS was first introduced in the districts as a manual system. Training was done for the manual HMIS that incorporated components of the HMIS, stores procedures, and the six main health thrusts. Training and reference manuals were developed for each level of training. District staff were divided in groups and trained in selected locations through out the country.

After a district had been trained and worked with the manual HMIS system for at least three months, an automated HMIS system was introduced. The automation was designed to be done at district, regional, hospital level and national level so as to enable a smooth platform of data storage and transfer.

Automation

14 districts out of 72 were picked as pre-test districts in which automation was to be done first. These districts were systematically picked following the varying criteria listed below:

· District(s) with staff who were computer literate
· District(s) with staff who were not computer literate
· District(s) which had electricity problems
· District(s) with telecommunication problems
· Districts (s), which had good telecommunications and skilled staff.

The automation team comprised of the following:

· A local IT specialist (the author)
· An American IT specialist who had undertaken the design of the HMIS software
· Some Danish IT consultants were also involved in the initial planning of the automation, and
· A steering committee comprising of the above, a Director and Manager from the Directorate of Monitoring and Evaluation of CBoH, some members of the HMIS development team and the Chief Advisor of the Danish Health Sector Support was always on hand to guide the automaton process.

The automation plan was drawn and agreed beforehand, the plan addressed the following items:

· Computer Hardware and software specifications
· Automation time frame
· Computer Training
· Funding of the automation costs and
· Transportation and logistics.

Automation involved travelling to each of the 14 districts with the computer equipment. Training was then conducted at the specific district for a maximum period of 3 days depending on the literacy level of the participants.

The HMIS software was developed from the manual system and was developed in Access 97. The system had the same screens as the manual HMIS input and output forms and reports. This greatly eased the understanding of the automated system. Automation software also included Microsoft Office 97 Professional edition, Windows 95 operating system, Eudora software for e-mail and Mcafee antivirus software.

Computer hardware included Compaq Deskpro 4000 computers, with the following minimum specs, 166mhz pentium processor, 32MB Ram, 1.2gig hard disk capacity, 28.8 kps external modem, 15 inch colour monitor, APC UPS and HP 690c Deskjet printers.

All the Hardware was purchased by DANIDA from Denmark, while some software was purchased locally. An automation-training program was designed. This training included:

· Computer literacy training;
· Windows 95 basic training;
· Automated HMIS software training
· MS Office basic training;
· E-mail training; and
· Trouble shooting

Training and automation of the 14 districts was undertaken by Mimi Church (the American IT consultant) and myself (author) and some support staff. Training and automation of the remaining 58 districts is being done now and has been done by out-sourcing IT companies. Automation of the 14 districts was completed in December 1998 while automation of the remaining districts commenced in July 1999.

Information flow

Each district has rural health centers, clinics and Hospitals from where people go to receive medical attention. Information on patient visits is collected and sent to the District Health Board, which does the overall assessment for the whole district. Each rural health center also does it's own assessment before forwarding the information to the district.

Each district has a computer on which the HMIS system is installed, each quarter, input forms are collected from rural health centers and hospitals, this information is then entered in the HMIS system. Trained HMIS staff are then able to print different reports and analyse the information to understand the different scenarios presented by the results. Cumulative and trend analysis information is also available. Staff are able to monitor and make decisions from this information.

If the information provided displays abnormal statistics, support staff at the district level are then able follow up any rural health center or hospital and investigate the abnormality in the information they have received. These visits are sometimes done even without having abnormal statistics.

Each District Health Board has an email account for sending e-mail and browsing the Internet. As soon the data input is complete, the database is e-mailed to the regional office, where it is integrated into the regional HMIS database system.

Information is then analysed at the regional level, authorities are then able to plan and mobilize resources for the regional districts with the help of the information from the database.

When the data input is complete at the regional level, the regional database is then sent to the National Level, were data can also be analysed at the National level. The Ministry of Health, Other Ministries, Donor and other International Agencies are then able to obtain their information from the National Database, without bothering the districts. National resource centers were established at CBoH and Regional Offices to deal with queries. The database is also used to provide operational information for the different Directorates of the CBoH.



Some of the information that is derived from the system includes:

· Disease cases per population
· Population statistics
· Qualified medical personnel per district/population
· Pregnancies and child delivery
· Drug kit supplies
· Medical institutions

Some of the major Problems encountered in the implementation of the HMIS and how they were overcome.

Funding - It was difficult to mobilize funds, which would meet the expenses of the complete implementation of the HMIS. This was overcome by lobbying for support from the Government and Donor Agencies and was done by way of holding presentations, workshops and making publications about the HMIS and how it would function if completed. These presentations were open debates in which people were able to ask the HMIS team different questions.

Lack of political continuity - The Central Board of Health, which was implementing the HMIS, is under the Ministry of Health and thus directly under the Minister of Health. When the Minister who had been part of the HMIS planning process was moved to a different ministry, the new Minister who was appointed had little knowledge of the HMIS and maybe did not want to continue with old plans. As a result the HMIS implementation was suspended until only after extensive lobbying and explanation of the advantages of the HMIS and how much had been invested in it to date. This lobbying and explanation was done by doing presentations by the HMIS team and with the support of co-operating partners.

Transportation Problems - Transport for the HMIS team to the different parts of the country was a problem, especially when top political support was not there. However, this was solved by having properly planned travel dates and by outsourcing transport from Co-operating partners and other international organisations and by hiring from private transport operators.

Procurement of IT equipment - The purchase of IT equipment was a problem because it was coming in form of Donor Aid. This meant that computers of a preferred choice could not be bought locally and thus not carry any warranty and after sales maintenance. It was difficult to convince the Donors to purchase IT equipment locally, this was only resolved by pressing for the purchase of a reputable brand of computers for which there was abundant local skill and spares for maintenance. An additional budget of maintenance was also added in the funding to cover maintenance costs.

E-mail connections - All the districts that had been automated, had an e-mail account to be used for information exchange. However, most districts do not have good telecommunication facilities, which made it difficult for them to connect to Zamnet, the main Internet Service Provider (ISP) in Zmabia which was always long distance dialing. The problem of having bad telecommunication facilities was resolved by lobbying the Telecommunications Authority of Zambia to improve Telecommunications infrastructure in rural areas. This saw some districts become equipped with satellite links which enabled people to be able to dial Lusaka numbers (capital city of Zambia) just as if they were dialing their local numbers, users were then able to dial to the ISP on local charges. The Telecommunications Authority also introduced reduced tariffs and easier approvals for Companies and individuals wishing to set up telecommunication infrastructure in rural areas.

Other efforts that helped with Telecommunication problems was expansion of the ISP dial in points to two other main towns. This meant that some districts around these towns are able to dial with fewer difficulties. Efforts were also extended to international Organisations like USAID Leland initiative to provide financial and technical support to improving the telecommunication infrastructure in rural areas.
The best effort was to source funds from Danida, separate from the HMIS costs to foot the connection and subscription charges to the ISP by districts. After that districts were advised to include these subscription costs as part of their communication budgets.

Conclusion

The implementation of the manual HMIS was completed with a lot of problems and what was left was the automation of the remaining 58 districts. All the 14 pre-test districts were automated. Automation of the remaining districts is currently going on now.

Three quarters of the objectives of the project have been met with the manual HMIS implemented in all the districts, this means that information flow is being done from the districts to the Regions and National level and most of all being utilised by the districts. The only difference is that, from the 14 districts, information is sent in softcopy format while the other districts send copies of hardcopy reports which would other wise be used to enter data into the computer if they had one. This still means that the regional and national levels have updated databases of the HMIS.

Some Lessons learnt

Some of the lessons learnt from the project include:

· Team Work - it is important to have a team that knows where it wants to go and is united. Team members should be committed and should have the project at heart. It was easy to give up the project when problems increased, but a committed team soldiered ahead.

· Support - It is very important to have support from the people at the top and at the bottom, if a project that affects both is to be successful. There was tremendous support from the Co-operating partners, Senior Medical specialists and from the users in the District and rural health centers. This is because they were all involved in the planning and implementation of the HMIS.

· Develop a system for the people - When designing a system, let the users tell you want they want and how they do it. Then you can now show them how using ICT can do it faster, better and cheaply.

· When a project affects the country greatly and funding involves the government and donor countries, it is important to have an independent team so that the government cannot intimidate team members and that donor counties cannot hijack the project for their own benefit. If possible payment of salaries and allowances should done by some other organisation that is not funding the actual project budget.

· It is important to press for the procurement of equipment from or through a local supplier, as this will allow for warranty on the equipment. If the donor country insists on bringing in equipment from their country, then it should be done through a local supplier.

· When software has been developed for an organisation for a national scale by individual consultants or an external company, a local company should be contracted to maintain and upgrade the software. This is important because professional staff may not be retained after the completion of the project. Handing over of source codes (sometimes training) should be part of terms of reference for the people developing the software.
The future of the project

When all the districts are using the automated HMIS, the National level will host the HMIS database on the Internet from which people can have restricted access. This will be important for districts, as they will be able to look at how other districts are performing and relate to their performance.

The HMIS will also be followed by the design and implementation of the Hospital Information System, which will be used in the major hospitals in Zambia and the Financial and administration management system (FAMS), The initial stage of this project has already commenced. The Hospital MIS will integrate with the HMIS to provide an online and active information system for the health sector.

Units have been created within the Directorate of Monitoring and Evaluation to monitor and maintain the HMIS system.

Team players

The following are people who formed the core HMIS team.

Development Team - Charles Mundale (Project Manager), Dr J A Koot (Dutch Medical consultant), Ms Mary Church (American IT Consultant), Ms Anne Young (American Public Health consultant) and Ms Tabo Mubonda (Training co-ordinator).

Automation Team - Bwalya Njelesani (IT Specialist) and Ms Mary Church (American IT Consultant). However input at was derived from the two teams and from the steering committee mentioned in the main story.

The teams were guided by Dr E Limbambala, who was the Director of Monitoring and Evaluation.


Extracts have been taken from the Zambia National Strategic Health Plan 1995-1999 and the Design and Implementation Plan manual for the HMIS 1996.

Project Information

Total budget in US$ : -
Country of activity: Zambia [ZM]

Contact Information

Bwalya .C. Njelesani

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