HISPAims of this lecture

See the big picture of HISP, all that surrounds the software

Introduction to DHIS

Johan Sb

Overview of lectureHISP overviewGoalsActivitiesInformation systems in the context of developing countriesHow data is collected and transformed into informationUse of informationDHIS and the key design principles

Johan Sb

What is HISP?Health Information Systems ProgrammeGlobal network of individuals and organisationsAcademic institutionsNon-governmental organisationsGovernmental organisations Members are orientated towards the HISP goalAn example of a South-South-North collaboration

Johan Sb

The HISP goalTo support local management of health care delivery and information flows

Design, implement and sustain HIS following a participatory approach

In health facilities, districts, and provinces

And its further spread within and across developing countries

Johan Sb

HISP is truly global

Johan Sb

Achieved throughHIS design, development and implementation (including, but not limited to software)

Organisational and human resources development

Theoretical and practical knowledge about challenges of implementing HIS in developing countries (action research)

Johan Sb

Short historyStarted in South Africa after ApartheidSoftware piloted in one province for two yearsPolitical climate allowed a total renovation of the health systemStrategy followed a bottom-up development and standardization

Johan Sb

Short historyMozambique first international nodeIndia, Malawi, Cuba, Ethiopia, Tanzania, Vietnam, Botswana, Nigeria, Mongolia etc.Considerable human capacity on HISP developed in India, Ethiopia, MozambiqueDifferent contexts call for different approaches

Johan Sb

HISP as a FOSS projectSoftware (District Health Information Software, DHIS), FOSS

Emphasis on Participatory developmentCreation of software that empowers the users

Increasingly open to use of and integration with other FOSS packages

Distributed development although major work done in South Africa

Customisation of packages done locally

Multilanguage enabled software

Johan Sb

Critique of Software development (last years slide)Too focused on SAIn fact too focused on a single individual in SAPossibly we have not harnessed opportunities in India strongly enoughIn some countries software development component has not been complemented with a strong enough project implementation focus

Johan Sb

Software development todaySouth AfricaMain engine of development of v1.3 and 1.4OsloTwo PhDs and numerous Masters students developing v.2.0IndiaMany programmers, working with 1.4 and 2.0VietnamSome programmers, working with 2.0Various other smaller projectsExtra modules often made locally

Johan Sb

The context of a developing countryOften severe problems related to:InfrastructuresHuman resourcesInequality (urban/rural)Hardware and spare partsPoliticsMigration, natural disasters, war etcsCentralistic, bloated, and fragmented legacy systems

Johan Sb

Johan Sb

Health Information use in developing countriesCurative vs. Preventive approach reflected in information systemLittle use of information at local levelsLittle use of indicators, focus on raw dataCentralistic approach, data collected for the top level, little or no feedbackFragmented, little communication between health managers

Johan Sb

Legacy systemsHard to change, reflects power relationshipsDonor agencies works around them by making their own systems, just increasing the original problem of fragmentation.Developer has left many years ago, took the code with himLegacy systems can be a force of resistance against new systems

Johan Sb

HISP strategyOften beginning with a strong association with grass roots organisations and servicesFocus on piloting and modifying system in a few districtsEmpower local health managers with information and train them how to use itCreation of alliances with ministry for recognition of grass-roots progress and further roll-out

Johan Sb

Health StatisticsDistrict -DHTFacility 1Facility 2Facility nIDSR NotifiableDiseasesPMTCTEPISTDHome Based CareNutritionMCHFamily PlanningHIV/AIDSTBSchool HealthMental HealthAnd more Facility 3IPMSARVCurrent Scenario, Botswana

Johan Sb

Future scenario, Botswana

Johan Sb

Part IIDHIS and design principles

Johan Sb

Basic Criteria for Health Information Software: 1. Data capture:Prevents the capture of duplicate datasets.Has mechanisms for data validation.Can be adapted by users to reflect the changing reality in the health sectorOrganisational unitsData elements (and indicators). Is able to calculate indicators that use population as a denominator.

Johan Sb

2. Reporting functions:Reporting must be readily available to provide managers with real time data. Can provide automatic reports to various organisational levels.Must allow the creation of customised reportsLinks to GIS functionality

Johan Sb

Johan Sb

Johan Sb

Johan Sb

3. Export/Import function:Can automatically export data from lower levels for import at higher levels. Can specify data export of different groups of data (for onward transmission to various stakeholders e.g. donors, programme managers, etc).Can export data for use with other applications and databases

Johan Sb

4. Maintenance:Can be locally (in country) supported, adapted, and developed.FOSS + Platform independent

Johan Sb

HISP activities are all about moving people from providing services, to also using information to manage services

Johan Sb

Johan Sb

Johan Sb

Johan Sb

Johan Sb

Record of patients seenSummary of key informationData entry into databaseData analysis and use

Johan Sb

DHISOriginally developed in Visual Basic for MS Access and ExcelDHIS 1.4 last version to be tied to MSDHIS 2.0 platform independent FLOSS, web-enabled. Same functions as 1.41.4 still used in most countries, some use of 2.0 in India and Ethiopia

Johan Sb

DHIS, the basic structureSame principle for all versions of DHISNeed to reflect the health hierarchyNeed to map data to each reporting unit

Need to be easy to useNeed to be flexible

Johan Sb

Reporting OrgUnitThe Organisational HierarchyDHIS 1.4 supports an infinite number of OrgUnit levels in the hierarchy, but standard setups would be between 3 and 7.The lowest level is in this case called the reporting OrgUnit.

Johan Sb

Parent OrgUnit

Reporting OrgUnitParent OrgUnitCountryHealth districtFacilityThe Organisational HierarchyReporting OrgUnits belong to parent OrgUnits, which are either physical health facilities (clinics, hospitals) or administrative OrgUnits arranged in a hierarchical structure. Parent OrgUnits can also be reporting OrgUnits, but the norm is to collect as much data as possible at the lowest level.

Johan Sb

An example of an organisational hierarchy in the DHIS14

1. Central Ministry2. Health districts3. Health facilities

Johan Sb

Johan Sb

Parent OrgUnits

Parent OrgUnits

Reporting OrgUnitSemi-permanent dataRoutine data set (monthly, weekly, quarterly, annually, daily, etc)Data element 1Data element 2Data element nAdding data to the org unitsData that is collected is attached or linked to reporting units.

Johan Sb

Johan Sb

Parent OrgUnit

Parent OrgUnit

Reporting OrgUnitSemi-permanent dataRoutine data setData element 1Data element 2Data element nData can also be added to higher level OrgUnits (i.e. data can be captured at multiple levels)Adding data to the org units

Johan Sb

Org unit 5Org unit 4Org unit 3Org unit 2Org unit 6Org unit 1Group 1Group 3cGroup 3bGroup 2 Group set 1Group set 2Group 3a ExclusiveCompulsoryAn example: Org unit types Location OwnershipUnderstanding org units, org unit groups, and org unit group sets

Johan Sb

Org unit 5Org unit 4Org unit 3Org unit 2Org unit 6Org unit 1Group 1Group 3cGroup 3bGroup 2 Group set 1Group set 2Group 3a ExclusiveCompulsoryExamples: Accreditation Inclusion in Training programmes Inclusion in research projectsUnderstanding org units, org unit groups, and org unit group sets

Johan Sb

Importance of this functionHealth services are often in a state of fluxHard-coding various types of classification (e.g. groupings might thus block specific useEnabling the user to determine these options increases functionality in an environment that is constantly changing (and with large variations between DHIS-using countries)Main purpose of these groupings is to allow analysis to be performed on certain groupsLimits on groupings in version 1.3 have been a significant impediment, with a lot of tinkering and ad-hoc modifications necessary to make it work

Johan Sb

Routine data setData element 1Data element 2Data element nData element groupsIndicatorsUnderstanding data elements, and data element groups(which are also used as indicator groups)

Johan Sb

Routine/semi-permanent/survey data sets:Data element 1Data element 2Data element nData element groupsIndicatorsRaw dataProcessed informationUnderstanding the data elements, and data element groups

Johan Sb

Data elementData elementData elementData elementData elementData elementData Element & Indicator Groups are defined in the lookup tables.

The grouped data elements / indicators have some characteristic in common (a data entry form, a programme/service, whether they are gender sensitive or not)Understanding data elements, and data element groupsPeople are interested in a grouping in one way or another this is what we analyseData elementData elementData elementData elementData elementData elementData elementData elementData elementData elementData elementData element

Johan Sb

Data element 1Data element 6Data element 5Data element 4Data element 3Data element 2Data set 1Data set 2The DHIS back-end data file uses One table to store all data elements. Each data element can be assigned to one or more data sets.Each data set can be used to capture or import data for a number of OrgUnits but it may not be necessary for all org units to complete all data sets.Typically, a data set reflect either one paper form, a collection of data that belong together (e.g. Census data), or a collection of data elements traditionally updated in a similar manner (e.g. semi-permanent data)Understanding data elements, and data sets

Johan Sb

Data element 1Data element 6Data element 5Data element 4Data element 3Data element 2Data set 1Data set 2Data entry form 1Data entry form 3A data entry form can be created to address the specific needs of:A dataset, orAn org unit.

Understanding data elements, and data sets

Johan Sb

Johan Sb

Data element 1Data element 6Data element 5Data element 4Data element 3Data element 2Data set 1Data set 2Data entry form 1Org unit 5Org unit 4Org unit 3Org unit 2Org unit 6Org unit 1Data entry form 3Understanding data elements, and data sets

Johan Sb

Useful ArticlesBraa, J., O. Hanseth, et al. (2005). "Standardisation of Health Information Systems in Developing Countries - flexible standards the "third way"."Braa, J. and C. Hedberg (2000). Developing District-based Health Care Information Systems: The South African Experience. IRIS 23.Braa, J. and C. Hedberg (2002). "The Struggle for District Based Health Information Systems in South Africa." 18: 113-127.Braa, J., E. Monteiro, et al. (2004). "Networks of Action: Sustainable Health Information Systems Across Developing Countries." MIS Quarterly 28(3): 337-362.Wilson, R., C. Hedberg, et al. (2003). South Africa's District Health Information System: Case Study, EQUITY Project: 17.HISP Websites (follow links from confluence)Manual on DHIS 1.4 (early, limited draft only!!)Manual on DHIS 1.3 (comprehensive but occasionally complicated)GIS User Manual

Johan Sb

A register using an old diary note the format for data collectionRegister a printed version that makes totalling up the data easierMonthly summary report: Note the different time period (daily through to monthly, some data on a monthly basis only, some both)An example of an organisational hierarchy in the DHIS14