Question: Identify any information management activity in any organization of your choice and apply the processes of designing data and information management.

Developing Health Management Information Systems
The basic concepts
Some Definitions
System: A collection of components that work together to achieve a common objective.
Information System: A system that provides information support to the decision-making process at each level of an organization
Health Information System: A system that integrates data collection, processing, reporting, and use of the information necessary for improving health service effectiveness and efficiency through better management at all levels of health services
Health Management Information System: An information system specially designed to assist in the management and planning of health programs, as opposed to delivery of care
HMIS: Health management information system

Steps in Developing a Health Management Information System
(1) Review the existing system
(2) Define the data needs of relevant units within the health system
(3) Determine the most appropriate and effective data flow
(4) Design the data collection and reporting tools
(5) Develop the procedures and mechanisms for data processing
(6) Develop and implement a training program for data providers and data users
(7) Pre-test, and if necessary, redesign the system for data collection, data flow, data processing and data utilization
(8) Monitor and evaluate the system
(9) Develop effective data dissemination and feedback mechanisms
(10) Enhance the HMIS

1. REVIEWING THE EXISTING SYSTEM
PRINCIPLE
Do not destroy existing systems; build on the strengths and learn from the weaknesses of what already exists.

STEPS
(1) Make an inventory of the forms, log books and other tools used to record and summarize data at different levels.
(2) Assess the quality of the data being collected using the existing forms at different levels. Among the aspects to be included in the assessment are: ▪ Accuracy ▪ Completeness ▪ Adequacy ▪ Timeliness
(3) Determine the problems encountered with the current system of data collection at different levels, including the timing and flow of information.
(4) Determine the current status of the other components of the HMIS like: ▪ Data processing ▪ Data analysis ▪ Data dissemination ▪ Supply and logistics ▪ Staff development ▪ Coordination, cooperation and communication within and between different units in the Ministry of Health, as well as with related agencies outside of the ministry
(5) Identify the aspects of the system that need to be: ▪ Retained ▪ Modified ▪ Abolished
(6) Summarize the results of the assessment in a formal report.
(7) Discuss results of the assessment with proper authorities.

ISSUES
(1) Who has the authority to make the assessment?
(2) Availability of technical expertise and resources to do the assessment.
(3) Cooperation among the different units in the assessment process; involvement of end-users at all levels.
(4) Formation of a body (ideally an inter-departmental committee) tasked with planning, monitoring and managing all phases of the development of the HMIS, from the baseline assessment to the evaluation phase.

2. DEFINING DATA NEEDS
PRINCIPLES
Different administrative levels in the health system have different roles, and therefore have different data needs. Not all data needs should be generated through the routine system of data collection. Data that are not frequently needed or are required only for certain subsets of the population can be generated through special studies and sample surveys.

STEPS
(1) Define the different roles/functions of each level, for each of the major programs.
(2) Identify the indicators needed by each level to perform its functions. Note that some levels, especially at higher administrative levels, need data coming from other ministries or departments related to the health sector.
(3) Determine the formula and identify the variables or data elements needed in order to compute the indicators.
Administrative Level Function
Village Case finding; service delivery
District Monitoring and supervision
Province Program planning; evaluation
National Policy formulation
(4) Determine the source of the different data elements needed for both the numerator and denominator of each indicator. The major sources can be: ▪ Routine data generated from the health management information system of the Ministry of Health ▪ Special studies and surveys conducted by the Ministry of Health, as the need arises ▪ Other health-related information systems under the responsibility of other agencies or institutions (Examples of these are the vital registration system – usually under the Department of Justice or the National Statistics Office – and the nutrition data collected by the Ministry or Department of Agriculture)

ISSUES
(1) Roles and functions of different units with respect to data generation and utilization are not well defined.
(2) Defining minimum basic data needs.
(3) Differentiating data that should be included in the routine data collection system, from data that are best generated through the conduct of special studies and sample surveys.
(4) Inability of staff at different levels to identify their data needs; understanding of indicators often lacking.

3. DETERMINING THE DATA FLOW
PRINCIPLE
Not all the data collected at a certain level need to be submitted to higher levels. The most detailed data should be kept at the source, and reporting requirements to higher levels should be kept at a minimum.

STEPS
(1) Determine what data will be submitted to whom. This involves the: ▪ Identification of variables/indicators that need to be submitted to higher levels ▪ Identification of most appropriate unit and position of person to whom summaries will be submitted
A major determining factor for this step is the function of the office and/or the person to whom the data is submitted in relation to the generation and utilization of information.
(2) Determine how frequently data should be submitted to each level, considering the following factors: ▪ Needs of each level ▪ How common phenomenon is observed
Reports on infrequent events, or ones that are not often needed (e.g., the number of immunization campaigns conducted in a village) can be submitted on a quarterly or on a semi-annual basis, instead of monthly.
(3) Determine in what form data will be submitted to each level. ▪ Raw data versus summaries ▪ Hard copies versus electronic files
(4) Make a flow chart that shows the flow of information from the peripheral to the highest level.

ISSUES
(1) Lack of understanding of use for which data is collected.
(2) Inability to distinguish which data are needed for service delivery and which data are needed for program management and monitoring.
(3) Inability of lower administrative levels to generate summaries of raw data collected due to: ▪ Lack of technical expertise of staff ▪ Lack of data processing facilities (calculators, computers, etc.) ▪ Lack of computer skills of staff
(4) Lack of storage facilities for raw data at lower administrative levels.
(5) Data retrieval issues; inability to generate any information because of computer breakdown.

4. DESIGNING THE DATA COLLECTION AND REPORTING TOOLS
PRINCIPLES
The capability of the staff that will be tasked with filling out the forms must be taken into consideration in designing them.
The most effective data collection and reporting tools are simple and short.

STEPS
(1) Develop the first draft of each form that is needed, using as a guide the list of indicators to be used for the program. This step entails either the modification of existing forms, or the development of new ones.
(2) Compare the first draft of the form that has been developed with the list of indicators to ensure that all the data needs can be generated from the form.
(3) Present the first draft of the form to relevant staff members and discuss with them the following aspects of the new form: ▪ How does it compare with the old forms? ▪ What are the advantages and disadvantages of the new form? ▪ What modifications need to be done to the new form to enhance its advantages and minimize the disadvantages? ▪ For countries that have a number of dialects, is it necessary to translate the forms into the major dialects used in the different regions of the country?
(4) Prepare a draft of the Instructions Manual on how to fill out the new forms.
(5) Pre-test the use of the new forms as well as the Instructions Manual.
(6) Assess the results of the pre-test.
(7) Modify the forms and the Instructions Manual based on the results of the pre-test.

ISSUES
(1) Technical expertise/capability of data providers at data source is not consistent with the level of complexity needed for data collection tools to meet the data needs of users.
(2) Designing the pre-testing activity, ensuring the comparability of conditions with actual implementation. ▪ Where? ▪ Who will be involved? ▪ How long?

5. DEVELOPING PROCEDURES FOR DATA PROCESSING
PRINCIPLE
The way the HMIS data is processed should be consistent with the objectives for data collection and the plans for data analysis and utilization.

STEPS
(1) Assess the advantages and disadvantages of manually processing the data compared to using computers, considering the following factors: ▪ Cost ▪ Availability of personnel with the proper background/level of technical expertise to run a computerized system; in particular the software skills of the staff at the lowest level where computers can be provided should be looked into ▪ Availability of technical support in case of hardware breakdown
(2) If a computerized system is to be implemented, decide the lowest level where computers will be used to process data. Among the important considerations in choosing this level is the presence of staff trained in system maintenance.
(3) Define the specifications for software development, in consultation with different levels of data users. Among the important aspects to be decided are: ▪ Summary Reports to be routinely generated ▪ Data quality control mechanisms/checks to be incorporated within the software ▪ Data analysis requirements of the data users
(4) Develop the software needed to process the data at each level where computers will be used, based on the required specifications. It may also be possible that the software designed to generate outputs similar to those of the HMIS have already been developed, requiring only minor modifications to customize it. In this situation, the resources needed to acquire and customize the software should be determined. A decision then needs to be made on whether to develop new software or acquire and modify an existing program.
(5) Pre-test the software, paying attention to: ▪ Identification of bugs ▪ Ability of software to generate the expected data ▪ Ability of staff to use it
(6) Develop and pre-test the User’s Manual for the software.
(7) Design a training program to train relevant staff on the use of the software.

ISSUES
(1) Capability of existing hardware, especially at the lower levels, to accommodate the software, as well as its ability to store all the data.
(2) Compatibility of the developed software with other existing software (both within and outside the Ministry of Health) that it might need to interface with in the future.
(3) Basic system maintenance procedures.
(4) Security system.

6. DEVELOPING THE TRAINING PROGRAM
PRINCIPLE
Training programs should be designed according to the needs and level of the target groups.

STEPS
(1) Conduct a training needs assessment for data providers and data users. Four types of training are usually conducted. These are: ▪ Training of trainers ▪ Training of data providers at the peripheral levels on how to fill out forms ▪ Training of computer operators on the use of the software and hardware ▪ Training of staff at different levels on data utilization
A separate training-needs assessment should be conducted for each type of training.
Among the variables to be collected for the training-needs assessment are as follows: ▪ Basic functions of each staff related to HMIS ▪ Extent of previous training received on the performance of such functions ▪ When training was received ▪ Adequacy of previous training to enable staff to perform expected functions ▪ Desired training areas
2) Develop the curriculum for each type of training, based on the results of the training needs assessment. The following aspects should be covered: ▪ Target group (For Whom?) ▪ Content (What?) ▪ Strategies (How?) ▪ Duration (How long?) – This refers to the total duration of the training program, as well as the time allocated for each topic included in the training
(4) Reproduce the training materials. Since there is a chance that some modifications in the format, structure and content of the training materials will be made based on the evaluation results, the number of copies to be reproduced at this point should be limited.
(5) Formulate the evaluation design for the training program. It is important to determine this prior to the conduct of the training activities, since most evaluation designs require the collection of a baseline or a pre-training level of knowledge among the participants.
(6) Identify the most appropriate participants for each type of training, based on their duties and responsibilities related to data generation, management and utilization.
An efficient strategy to use is to identify and train a core set of staff who can act as trainers for the neighbouring areas. If this strategy is adopted, it is important to consider the geographic distribution of participants for the Training of Trainers.
(7) Conduct the training of data providers.
(8) Conduct the training of data users. This is usually conducted after sufficient data from the HMIS has been collected for use as examples during the training.
(9) Evaluate the training program, including the training materials used.
(10) Modify the training materials and the training program itself based on the results of the evaluation. This should be done prior to the conduct of another series of training activities.

ISSUES
(1) Selection of the appropriate participants for the different training programs to be conducted.
(2) Backgrounds of staff identified to enter data and generate reports using the software developed for the HMIS. Are they very different?
(3) Language/dialects to be used for the training materials.
(4) Extent of dissemination of training materials and manuals.
(5) Preparation of adequate facilities to conduct training.

7. PRE-TESTING THE SYSTEM
PRINCIPLE
The system should be pre-tested in conditions that reflect as much as possible the actual conditions prevailing during its implementation.

STEPS
(1) Prepare the guidelines for pre-testing the system. This involves addressing the following questions: (1.1) Where? Selection of the place(s) where the pre-testing will be conducted. There is a need to develop criteria for selecting the pre-testing sites. These can include technical factors like the level of expertise or qualifications of the staff in the area, or practical considerations like the proximity of the area, the provision/availability of infrastructure support, or how cooperative the staff are. (1.2) Who? Who will participate in the pre-testing? It is important for the different types of data providers and data users to participate in the pre-testing. (1.3) What? What are the specific objectives of the pre-testing? Specifically, what aspects of the HMIS will be pre-tested? What are the different activities to be undertaken to achieve these objectives? (1.4) How? What modes and tools for data collection will be utilized to systematically collect the data required for an efficient pre-testing of the forms? (1.5) How long? For how long will the pre-testing be conducted? (1) Orient the staff involved in the pre-testing. (2) Inform them on the objectives of and procedures for the pre-testing. (3) Train the data users and data providers in the pre-test areas on the new system. (4) Implement the pre-testing activities. (5) Write a report on the results of the pre-testing. (6) Formulate recommendations, based on the results of the pre-testing.

ISSUES
(1) Implementation of a systematic and proactive monitoring mechanism during the pre-testing phase.
(2) Systematic updating of the software in all units where it has been installed.
(3) Ensuring that all elements and staff are ready for the pre-testing phase.

8. MONITORING AND EVALUATING THE SYSTEM
PRINCIPLE
The goal of monitoring and evaluation is not to focus on what is wrong and condemn it; rather, it is to highlight the positive aspects of the system that make it work, as well as to identify what went wrong as a basis for improving the system.

STEPS

1) Develop a plan for the systematic monitoring and evaluation of the system

▪ What will be monitored and evaluated? ▪ How will it be done? ▪ Who will do it? ▪ How frequently will it be conducted? ▪ How will the results be systematically disseminated? ▪ How will action resulting from the evaluation results be generated?
(2) Identify the resources needed to implement the monitoring and evaluation plan.
(3) Prioritize the activities, based on availability of resources and need.
(4) Implement the monitoring and evaluation plan.
(5) Document and disseminate the results of monitoring and evaluation activities.
(6) Make recommendations based on the results of monitoring and evaluation activities.

ISSUES
(1) Institutionalization of monitoring and evaluation to ensure that it becomes a regular activity and will be allocated the corresponding resources.
(2) Availability of technical expertise and other resources for monitoring and evaluation.

9. DEVELOPING DATA DISSEMINATION AND FEEDBACK MECHANISMS
PRINCIPLE
An effective way of motivating data producers is to constantly provide them with both positive and negative feedback on the status of the data they produce.

STEPS
(1) Determine the most effective and efficient way of disseminating the data generated from the HMIS by considering the following factors:
(1.1) To whom should the data be disseminated? The needs of target groups have to be considered.
(1.2) What should be disseminated? This should include not only the outputs of the HMIS, but also feedback on who is using the information and what/how they are using it.
(1.3) How often should data be disseminated to the different target groups?
(1.4) In what form should the data be disseminated to each of the different target groups? The whole range of forms and venues for data dissemination should be considered.
(2) Identify the human, financial and other resources needed to implement the data dissemination plan.
(3) Prioritize the different modes of data dissemination to be adopted, based on need and availability of resources.
(4) Implement the data dissemination activities.
(5) Develop and implement a system for monitoring and evaluating the data dissemination and feedback activities conducted. Among the factors to be considered are: ▪ Coverage — to what extent is the material reaching the target audience? ▪ Effect of the feedback system on the staff ▪ Degree of utilization by the target audience — are they actually using the data presented in the different materials prepared?

ISSUES

(1) Preparation of a Management Report.
(2) Limited financial resources for dissemination.
(3) Ensuring that dissemination activities reach the ‘correct’ audience.
(4) Consistency between the data disseminated by the HMIS, and similar data published and disseminated by other units within the ministry, especially those of the vertical programs.

10. ENHANCING THE HMIS
PRINCIPLE

The development of the HMIS is always a work in progress. It is a dynamic endeavor where managers and workers strive for constant improvement.

STEPS
(1) Review the results of monitoring and evaluation activities conducted on the HMIS in recent years.
(2) Identify aspects of the HMIS that need to be developed further to facilitate the functioning of the core system. The basic question to be answered is, “Where do we go next?”. Among the possible aspects that need looking into: ▪ Enhancement and institutionalization of procedures to assure data quality control ▪ Developing capacity to conduct special studies and sample surveys ▪ Defining coordinating mechanisms for the horizontal use of data generated ▪ from vertical programs ▪ Developing strategies to create and/or sustain the interest of staff at different levels to use the data for program planning, management and evaluation ▪ Establishing inter- and intra-sectoral linkages among units involved in different aspects of the HMIS ▪ Unifying and coordinating initiatives of sectors and funding agencies involved in activities related to the HMIS
(3) Identify resources needed to implement the different options for the enhancement of the HMIS. This should include specific types of resources for each planned expansion activity; the budgetary requirements (if any); and the desired source of support for each type of resource needed.
(4) Prioritize the different options according to degree and urgency of need, and availability of resources for its proper implementation.
(5) Prepare a timetable for the implementation of the different activities for the expansion of the HMIS.
(6) Conduct the different activities needed to implement the desired enhancement of the HMIS.
(7) Monitor and evaluate the effect of newly implemented aspect of the HMIS.
ISSUES

(1) Sustaining interest among different stakeholders for the continuous development of the HMIS.

(2) Generation of resources to support the different activities for system enhancement.
(3) Coordinating the activities of the different donor agencies so as to minimize the proliferation of data collection forms and the duplication of efforts in areas related to HMIS development.
(4) Ensuring the continued existence of a body/committee to oversee the HMIS after the pilot-testing phase.