Libyan Health Information System

Assessment and roadmap of priority actions

Final report July 2017 Contents

Acronyms 11 Executive Summary 12 1. Background 14 1.1 Overview of the health situation in Libya 14 1.2 Overview of the health information system 15 2. Purpose and objectives of assessment 16

3. Assessment methodology 17 3.1 Document reviews 17 3.2 Health information system assessment workshop and working groups 18 3.3 Synthesis of findings, recommendations, and report preparation 18

4. Key findings on health information system 19 4.1 M&E/HIS assessment and planning tool: scoring 19 4.2 M&E/HIS assessment and planning tool: qualitative inputs 22 4.2.1 Mainstreaming emergency information needs into the Libyan HIS 23 4.2.2 HIS in an emergency context: The 2017 Libya Humanitarian Response Plan 23 4.2.3 Information needs about vulnerable populations 24 4.2.4 Feedback from group discussions on emergency mainstreaming 25 4.3 M&E HIS assessment and planning tool: key performance metrics 25

5. DHIS-2 requirements for implementation 27 5.1 Demonstration of DHIS-2 technology 27 5.2 Requirements for implementation of DHIS-2 27

6. Roadmap of key priority actions 28 7. Discussion 32 7.1 Sound policy and institutional environment 32 7.2 Data sources 32 7.2.1 Health systems, health facility, and community information systems 33 7.2.2 Disease surveillance 33 7.2.3 CRVS, household surveys and census 33 7.3 Institutional capacity for data management and analysis 33 7.4 Mechanisms for data use, review and action 34 7.5 DHIS-2 implementation 34

8. Recommendations 35 9. Next steps 35 Annex 1. Ministry of Health organogram 36 Annex 2. Terms of Reference for the assessment 37 Annex 3. Team members for the assessment of health information system 40 Annex 4. List of participants 41 Annex 5. List of participants for the working groups 44 Annex 6. Summary of scores by working group 45 Annex 7. Results of the scoring exercise, by component and attribute 46 Annex 8. Qualitative aspects of the Libyan Health Information System 50 Annex 9. DHIS-2 requirements for implementation 57 Annex 10. Agenda for the assessment workshop 58

4 Foreword Health Information System (HIS) is a key component of any health system. All the pillars of the health systems depend on HIS to guide their activities of planning and decision making. Therefore, having sound HIS is the priority of the Ministry of Health in Libya.

Due to the current challenges facing Libya, there is interruption in the flow of information. The timely availability of health information is difficult because of delayed and inconsistent reporting from the facilities and programmes. Similarly, other data gathering mechanisms such as death registry are also facing challenges due to the current crisis.

We are grateful to the European Union (EU) and the World Health Organization (WHO) for their support in strengthening HIS. I am very pleased with recent comprehensive assessment of HIS which was attended by all HIS stakeholders in Libya.

I am confident that implementation of all the priority actions identified in the assessment workshop will strengthen the HIS in Libya and all the partners working in the health sector will have access to quality health information. The evidence based Information produced by Health Information Centre will guide all the political leadership and decision makers to plan effectively and will bring a real change in health system of Libya.

I would like to seize this opportunity to thank the organizers, participants of the workshop, stakeholders from different entities at national and sub national level and all experts of WHO for their technical support which resulted in a roadmap to improve HIS in Libya.

I am especially grateful to the EU for giving importance to HIS and for their financial support to the Libyan Ministry of Health to strengthen the Libyan health system.

Dr. Omar Bashir Altaher Minister of Health Libya

6 Acknowledgements

Excellency Dr Omar Bashir Altaher, senior colleagues, distinguished officials, ladies andgentlemen, I sincerely thank the governments of Libya and the Ministry of Health for the hard work and dedication in the intense HIS assessment and production of this important report. A special appreciation and gratitude to Mr. Mohamed Ibrahim Saleh Daganee, Director of Health Information Centre, and his team for the great efforts that made this happen. Surely without the Regional Office and support of the many experts who worked in this process, this report wouldn’t have been delivered. I also sincerely thank the EU Delegation for funding SHAMS Project that is strengthening health information system in Libya and the medicines supply chain management.

Having reliable data on the strengths, weaknesses and performance of different parts of the health system is the only way to devise, execute, and measure health interventions. Successful strengthening of health systems will require relevant, timely, and accurate information on the health system itself. The essence of a health information system is to collect, organize, analyze and safely store and protect that information.

HIS in Libya is strongly and adversely affected by the armed conflict in Libya. Health information is vital to providing planners and policy makers the evidence and insight for effective policies and decisions for quality patient care and optimal system performance. With the widespread computerization of health records, traditional (paper-based) records are being replaced with electronic health records. The tools of health information and technology are continually improving to bring greater efficiency to information management in the health care sector. Both HIS and health human resources information systems are common implementations of health information management.

Well-functioning health system that covers entire populations is now regarded as the first line of defence against the threat from emerging and re-emerging diseases. Apart from strengthened health security, Libya has much to gain from its commitment to strengthening HIS, effective medicines supply chain management and service delivery towards universal health coverage.

For decades, the biggest barriers to better health have been a weak health system and inadequate information, policies, medicines, and human resources. A commitment to universal health coverage (UHC) means a commitment to work together and address these barriers.

As a way of organizing health services based on reliable data and solid evidence promotes a comprehensive and coherent approach to health which emphasizes people-centred quality care throughout the life course, stresses prevention as well as curative care, and moves away from a focus on individual diseases to UHC.

Special thanks to Dr. Arash Rashidian, Director, EM/RGO/IER and his team for his continued support to HIS. Especially Dr. Henry Doctor has been instrumental in coordinating and consolidating this report. From headquarters, Dr. Eduardo Celades has been a major contributor and provided solid ideas and lessons learned. Thank you also to Dr. Ali Okhowat, Dr. Najeed Al Shornajee and Dr. Ardeshir Khosravi. Finally my team Dr. Atef El Maghraby and Dr. Haroon Ur Rashid have done a great job in anchoring the HIS assessment.

Dr Syed Jaffar Hussain representative and Head of Mission World Health organization, libya

7 8 Acknowledgements ACknowLeDgeMentS

The assessment team is grateful first and foremost to the Minister of Health (MoH), His Excellency Dr. Omar Bashir Altaher, the Senior Advisor to the Minister of Health, Dr Nureddin Hassan Araibi, the Director of Health Information Centre, Mr. Mohamed Ibrahim Saleh Daganee, managers of all the directorates and subdivisions at the MoH for all their help and their willingness to make themselves and their staff available.

We are also grateful to everyone from the MoH in Libya who made themselves available during meetings and working group sessions and answered the questions we asked. We also extend our heartfelt thanks to several individuals from the Bureau of Statistics and Census, the Vital Registration Authority, the Social Information Centre, General Information Authority and other stakeholders for providing information and insights into their information systems.

The following national experts were requested to facilitate the working group sessions which were the main source of information for this report: Dr Fatima Salem, Dr Huda K.S. Kutrani, Dr Ramadan Osman, Dr. Mohamed Hashem, Dr Ghassan Karem, and Dr Hajer Elkout.

We gratefully acknowledge financial support from the European Union without which we would not have been able to produce this report.

Finally the assessment team thanks Dr Syed Jaffar Hussain, Head of WHO Mission in Libya for his leadership and support; and the WHO Country Office as well as the MoH teams for their assistance with preparation and logistics. Lqirupdwlrq/HylghqfhdqgUhvhdufk/KhdowkLqirupdwlrqdqgVwdwlvwlfv I hope this report will guide all decision makers in the MoH and all partners to effectively plan and implement interventions to improve health information system in Libya. ZKROle|dFrxqwu|Riilfh=Gu1V|hgMdiiduKxvvdlq>UhsuhvhqwdwlyhdqgKhdgriPlvvlrq0 ZruogKhdowkRujdql}dwlrq/Ole|d/GuDwhiHopdjkude|/Gu1KdurrqUdvklg>dqgdooZKROle|d Frxqwu|Riilfhvwdii1

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9 10 Acron Executive Summary

Health information systems (HIS) including civil registration and vital statistics (CRVS) systems are ANACoD Analysis of Cause of Death indispensable sources of health information data for programme monitoring, performance monitoring, BSC Bureau of Statistics and Census quality of care, planning, and policy making, among others. HIS and CRVS systems provide continuous CRVS Civil Registration and Vital Statistics information on the coverage of services in the health sector, and on mortality statistics, including causes of death. The availability of HIS data at the sub-national level provides countries with an opportunity to DHIS District Health Information System assess equity in the provision of health services. DHS Demographic and Health Survey This assessment was commissioned by WHO in May 2017 as part of the inception phase for the EU European Union two year project “Strengthening Health Information System and Medical Supply Chain Management EWARN Early Warning Alert and Response Network (SHAMS)” funded by the European Union. With support from the MoH and an international consultant, a team from WHO reviewed the extent to which Libyan HIS adheres to sound policy and institutional HIC Health Information Centre environment; utilization of well-functioning data sources; availability of strong institutional capacity HIS Health Information System for data collection, management, analysis, use and dissemination; and implementation of effective HISP Health Information System Programme mechanisms for review, data use and action. The assessment methodology was based on the approach developed by the WHO Regional Office for the Eastern Mediterranean for comprehensive assessment HMIS Health Management Information System of health information systems. During the assessment of Libya HIS, discussions were guided by the HMSNA Household Multi Sector Needs Assessment WHO M&E Assessment and Planning tool which aims at getting an overview of the weaknesses and strengths of the country M&E systems and to identify priority actions based on those findings. HNO Humanitarian Needs Overview HRH Human Resources for Health In collaboration with the Health Information Systems Programme (HISP) India, the review team also HRP Humanitarian Response Plan assessed the interest and potential of the MoH to pilot the District Health Information System (DHIS-2) technology in selected facilities as part of efforts to enhance information gathering, analysis and use ICD International Classification of Diseases for decision making. ICT Information and Communications Technology In this review, a number of observations were made related to HIS in Libya. The main strengths of the HIS IER Information Evidence and Research includes the existence of a functional Health Information Centre (HIC) within the MoH that coordinates INDEPTH International Network for the Demographic Evaluation of Populations and Their Health HIS activities, the growing demand for health-related information from senior programme managers, policy makers, donors, NGOs and other key players in the health sector; and a well-defined system of IOM International Organization for Migration data collection and reporting from the facility up to the national level. The review team also documented LMIS Logistics Management Information Systems the existence of well-defined catchment areas, administrative boundaries and georeferenced health MoF Ministry of Finance facilities. Information from census and surveys conducted by the Bureau of Statistics and Census and other partners is regularly used. The National Centre for Disease Control is one of the key centres MoH Ministry of Health within the MoH with active information systems. The fully automated vital registration system is also M&E Monitoring and Evaluation one of the key HIS data sources. The availability of a master facility list, defined list of priority diseases under current national surveillance, including alert thresholds and a completed CRVS assessment are MICS Multiple Indicator Cluster Survey additional areas of strengths. NCDC National Centre for Disease Control Nevertheless, the HIS in Libya has a number of weaknesses; about one third of the attributes of a NGO Non-Governmental Organization functional HIS are not present, distributed across all components. Libya does not have a comprehensive NHA National Health Accounts costed M&E plan; there are no SOPs for data management, institutionalized data quality assessments PAPFAM Pan Arab Project for Family Health or even a functioning, integrated web-based HIS system. Effective mechanisms for review and action such as independent reviews of data, linkages between health sector reviews and disease and PRISM Performance of Routine Information System Management programme-specific reviews, and active engagement of civil society in country reviews, are also non- SARA Service Availability Readiness Assessment existent. In addition, the HIC lacks an M&E unit and a unit responsible for collecting and processing emergency information. While the detailed priority actions and their timeline are provided in the main SDG Sustainable Development Goals body of this report, the overarching recommendations for intervention emanating from the assessment SHAMS Strengthening Health information system And Medicines Supply chain management are presented below : SOP Standard Operating Procedures · Establish a functional national steering committee, with representation from all key national HIS STEPS WHO STEPwise approach to surveillance stakeholders, to coordinate HIS activities at the national level. ToR Terms of Reference · Create a sub-technical committee to develop the HIS/M&E plan. · Improve coordination among MoH, various programmes, and other HIS stakeholders. UNFPA United Nations Population Fund · Strengthen routine HIS by training MoH cadres at all levels and purchasing ICT equipment. UNHCR United Nations High Commissioner for Refugees · Pilot DHIS-2 to improve collection, processing, analysis of data for planning and evidence- based decision making. VRA Vital Registration Authority · Complete the human resources registry to improve decision making regarding human resources WFP World Food Programme for health. · WHO World Health Organization Expand the number of surveillance teams and surveillance sites, including expansion of mobile units to respond more efficiently and timely to outbreaks.

11 12 · Develop a national guidebook for notifiable diseases. 1. Background · Establish a department/unit for encoding in every hospital as one of the means to improve the system of death notification and certification. 1.1 overview of the health situation in Libya · Strengthen capacities to conduct household surveys and censuses, including capacities to The health sector in Libya has been facing the worst humanitarian crisis in its recent history. improve analysis and report writing. Historically, the less capacitated health system of Libya has further been deteriorated due to · Implement a system of joint periodic progress and performance reviews and independent fragmented governance, limited financial resources, inadequate human resources, acute shortage reviews of data to promote evidence-based decision-making. of basic lifesaving medicines and equipment. Repeatedly, results from surveys have shown that The priority actions presented in this report will support the MoH, in collaboration with other improved health care delivery is the greatest need for Libya; yet prioritizing this has been a challenge. stakeholders, to develop short-term, mid-term, and long-term plans for HIS strengthening. While the As a result, Libya has experienced poor health outcomes largely due to the deterioration of health process of strengthening HIS entirely can take at least 4-5 years to see the effects, the immediate services. focus for Libya should be designing interventions that can strengthen existing HIS operations without much change (“quick-wins”) and be able to meet the target indicators for the EU-funded SHAMS In order to assess the readiness of Libya’s health sector to deliver health care to the population, a Project. This can be developed through involvement of stakeholders and HIS specialists. Service Availability and Readiness Assessment (SARA) was conducted in 2016. Among other things, results from SARA showed that 17% of the hospitals and 20% of PHCs (polyclinics, health centres and An important step will be for the MoH and other stakeholders to vet the findings and priority actions units) were closed. The availability and readiness of services in PHCs and hospitals was significantly or recommendations of this assessment and align them with their analysis and final direction to low. Lack of readiness was due to acute shortage of life saving medicines, medical supplies and make them part of a single agreed set of recommendations. Identifying interventions is the first equipment along with critical shortages of human resources, particularly specialized physicians, stage in the improvement process. What remains critical though is to cost the interventions, their nurses, midwives and technicians. These shortages were critical at the primary care level. As a estimated person-days, and where necessary, individuals to be trained or materials/equipment to be result, referral and tertiary hospitals were overloaded with patients presenting with common illnesses purchased and proposed time frame which are consistent with the roadmap of key priority actions and were unable to meet the demand. Provision of primary health care, especially for communicable presented in Section 6 of the report. The costing and development of an HIS improvement plan diseases among migrants in detention centres, is a major challenge. can be done by a small group of technical and programme HIS experts (i.e. a technical committee). The proposed time frames can be adjusted based on the actual time period for commencement or Another challenge with the Libya health system is the limited health screening mechanisms at the implementation of the HIS improvement plan. borders/ports of entry which increases the likelihood of importation of viruses and bacteria from other countries including Polio, Ebola, and the Zika virus.

Despite Libya’s complex political framework which negatively affected the health structure, WHO and other national /international health partners united their efforts to provide the maximum needed assistance to reduce avoidable morbidities and mortalities and prevent the occurrence of major outbreaks. A robust early warning alert and response system (EWARS) was established in February 2016 and as at May 2017 it was reporting on 8 immediate notification and 18 weekly communicable diseases. In 2015-2016, WHO also supported Libya by providing life-saving medical supplies and procurement of essentials drugs ehqhilwlqj approximately 2 million people.

In collaboration with Johns Hopkins University, WHO prepared 35 different priority actions which will strengthen accident and emergency care of hospitals. WHO Libya has recently recruited an expert to support the MoH to establish an Emergency Management Department (EMD). The EMD includes an Emergency Operations Centre (EOC), an intra and inter-sectoral coordination platform, and several support units such as human resource, capacity building, communication, and partnership. WHO will also support the EMD in areas related to capacity building and development of a strategic framework, policy, operational plan and protocols. The national EMD and EOC will be established in Tripoli following establishment of similar structures and programs in the East and the Southern parts of the country. To sum, the following remains major challenges currently facing the Libyan health system:

· Access to health care particularly in all conflict affected areas, including, Ubari, Sebha, Aljafara, Sirt, Derna, Benghazi, Azzawya, and Tripoli. The most vulnerable include the injured; the elderly; children; people with disabilities; hard-to-reach people; women (pregnant, lactating mothers and those within the reproductive age group); 241 000 internally displaced people; 356 000 returnees; 599 000 migrants; and 437 000 non-displaced individuals. · Availability of essential medicines in public facilities due to reduced accessibility and private health facilities due to increasing costs of medicines. · Access to health professionals, including specialized nurses, midwives and technicians, particularly in hard-to-reach areas, both in terms of availability, accessibility, acceptability and quality. · Robust disease control programs to detect and combat infectious diseases and life-threatening diseases such as polio, measles and HIV/AIDS. Maintenance of immunization against childhood infectious diseases at primary health care level as well as support to referral systems. · Sustainable electricity and solar energy backup for public health services provide to enable critical medical operations.

13 14 2. Purpose and objectives of assessment 1.2 Overview of the health information system Theoretically, Libyan HIS is managed at the central level by the Ministry of Health (MoH; see In Libya, the MoH Health Information Centre (HIC) was established in 2006 under Law No. 4 of organogram in Annex 1) in Tripoli with 23 information offices located across the country (see Figure 1990. Since then the centre has its own annual budget, collects routine data from the health facilities, 1 on the schematic representation of routine HIS in Libya). Before the conflict, these 23 sub-centres conducts health surveys, trains human resources for the statistical units and issues various statistical were responsible to collect, collate and transmit data to the central level to the MoH through electronic reports. Currently the HIC is headed by a director general who oversees 26 staff, consisting of reporting. Although there were major gaps in the information collection and reporting, still data on statisticians, information technologists, data entry and documentation clerks and a health information disease burden, service usage and outcome were available to some extent. The central level consultant. The HIC has five offices for statistics and research, data analysis, information technology, would use all the data received to publish an annual report. Since 2018, however, no such report documentation, and office for administration and financial matters. has been published because of some challenges. Out of 1,656 primary health care facilities only a limited number of facilities were reporting the data. Some of the reasons for non-reporting Historically health information is received directly from the statistical offices of all the hospitals and include closure of some of the hospitals and primary health care centres, closure of most of the sub- from the statistical units from the directorate of health at the district level. Reports were generated centres due to lack of training, non-availability of human resources, limited access to internet, and accordingly and all the annual reports from 2004 to 2014 are available and can be accessed from the using older versions of data recording tools and formats. HIC website1. However, due to current political challenges the flow of information has been interrupted and substantially decreased from hospitals and PHCs. MOH The National Centre for Disease Control (NCDC) is the main entity responsible for disease surveillance and response. All the disease-specific programmes have disease notification system and they report annually to the HIC. National center for Bureau of Statistic diseases Control and census

Information on vital registration for birth is available in almost 100% of the cases and information Central on death in around 60% of the cases. The Vital Registration Authority (VRA) has extended its birth Level Health information center and death registry services to seven branches and 380 service offices covering the whole country Specialized medical including the establishment of civil registry offices in all major hospitals and medical centres. With centers & Hospitals technical support from WHO, the VRA conducted civil registration and vital statistics (CRVS) rapid and Yearly comprehensive assessments in 2013 and 2015, respectively and are adapting the regional strategy for strengthening CRVS especially in areas related to death certification and the use of ICD-10 for Municipality mortality coding. Vital statistics are issued by the Bureau of Statistics and Census (BSC), which carries Level Directorates of Health Monthly out the general population census every 10 years. The last census, however, was conducted in 2006 (Information offices) and the next census is planned in 2018. Private sector clinics hospitals, labs The HIC in collaboration with the NCDC and the Libyan Cardiac Society conducted the STEPS Survey Public hospitals in 2009 and conducted independently the Global Youth Tobacco Survey in 2003, 2007 and 2010, the Global School Personnel Survey in 2003 and 2010 and the Global School-based Student Health Survey in 2007. The Global Health Professional Student survey was conducted in 2006. The HIC is also NCD centers PHC facilities a custodian of two cancer registries (Benghazi and Sabratha). The PAPFAM survey was conducted in cooperation with NCDC and BSC in 2007 and 2014. Another challenge with Libyan HIS is lack of training for resource persons who were positioned in the Even in very difficult circumstances, the HIC in collaboration with WHO conducted the Service information offices, hospitals and district health administration. Any existing data are seldom used Availability and Readiness Assessment (SARA) in 2012 and 2016. Health-related information is also for decision making purposes, because the system and the Libyan MoH have limited capacity in this available from school health services, the Libyan Nursing Board and the Libyan Board for Medical respect. Although WHO supported the MoH in the strengthening of a comprehensive CRVS system, Specialities. there is still a need for more capacity building. Libya has adopted the WHO Regional Framework for health information systems and the 68 core indicators2 for monitoring health situation and health system performance. Additional indicators will With funding from the European Union through the SHAMS Project, the government has started be added to the list to cover the Sustainable Development Goal (SDG) 3 on health. An assessment efforts to strengthen the national HIS, supported by WHO. Strengthening HIS in Libya will help conducted by WHO in 2016 on country capacity to report on the core indicators3 showed that Libya the country to monitor its health development agenda as well as enhance its reporting capacity was reporting 53% of the population-based indicators and 65% of the institutional-based indicators. on the 100 core health indicators5 including 68 regional core indicators. To achieve this, a review of the HIS was planned aimed at improved regularity and reliability of information produced by the In order to strengthen the HIS, WHO and the HIC conducted an assessment of the Libyan HIS from existing HIC; boosted outreach of information gathering; health information analysis, intended as an 9 to12 May 2017 to commence the main activities of a two-year European Union funded project essential part of public health planning and decision making. The Terms of Reference (ToR) for the “Strengthening Health Information System and Medical Supply Chain Management (SHAMS)”4. assessment (Annex 2) specified that the report provide a description of the HIS, including overall HIS structure within the country, information flow, governance and quality assurance; infrastructure; data management and standards; dissemination and use of data for policy and planning; analysis of its strengths and weaknesses; and recommendations on how to further develop the system to respond to requirements of reporting on national and international priorities and commitments such as the

1. http://www.seha.ly/ SDGs. The results of the review will help the government develop a prioritized and detailed roadmap 2. http://applications.emro.who.int/dsaf/EMROPUB_2016_EN_19169.pdf?ua=1 for HIS improvement and reporting of core indicators at the national, regional, and international level. 3. Summary report on the Intercountry workshop on country capacity to report on core indicators, WHO, Regional Office for the Eastern Mediterranean, Cairo, Egypt, 15-17 August 2016. 4. The overall objective of the Strengthening Health information system And Medicines Supply chain management (SHAMS) Project is to improve the health care provision efficiency in Libya by focusing on two components: i) the supply chain; and ii) health information system management. 5. http://www.who.int/healthinfo/indicators/2015/100CoreHealthIndicators_2015_infographic.pdf?ua=1

15 16 3. Assessment methodology 3.2 Health information system assessment workshop and working Consistent with the priority areas outlined in the ToR, the review team (Annex 3) focused on an groups approach that aimed at developing common understanding of available information systems and A four day workshop was conducted in Tunis, Tunisia from 9 to12 May 2017 to learn about specific databases; assessing the strengths and weaknesses of these components and operations within information systems focusing on information systems directly relevant to the MoH interests. HIS; and providing recommendations consistent with WHO and HIS standards, indicator frameworks Presentations on information systems were made by the HIC, the NCDC, the BSC, the VRA, and and guidelines. The assessment methodology was based on the approach developed by the WHO the Social Information Centre. Six working groups sessions9 were held focusing on key issues of Regional Office for the Eastern Mediterranean (EMRO) for comprehensive assessment ofHIS a functioning HIS: policy and governance; CRVS; routine HIS; disease surveillance; institutional (Figure 2). During the assessment, discussions were guided by the WHO M&E Assessment and capacities; and review, data use and decision making (see Figure 3). Presentations from the MoH and Planning tool6 which aims at getting an overview of the weaknesses and strengths of the country other stakeholders as well as discussions and working group sessions revolved around the type of M&E systems and to identify priority actions based on those findings. In collaboration with the Health systems used, problems related to data collection and flow, limited capacity of staff, to use information Information Systems Programme (HISP) India, the review team also assessed the interest and for decision-making, difficulty of assembling information from different sources at all levels, and the potential of the MoH to pilot the District Health Information System (DHIS-2) technology7 in selected importance of mainstreaming emergency information needs into the Libyan HIS. Availability of ICT facilities as part of efforts to enhance information gathering, analysis and use for decision making. support and plans for future systems development were also discussed. Discussions were guided The demonstration was followed by discussion on its feasibility for use in Libya. by the quantitative WHO M&E Assessment and Planning tool. In addition to the M&E Assessment and Planning tool, additional qualitative questions were adapted from the Performance of Routine Information System Management (PRISM) framework.10 The qualitative questions focused on other Governance critical HIS issues not captured in the attributes of the M&E Assessment and Planning tool. framework

Data management and Infrastructure standards and support

Effective

Quality National Health Dissemination assurance Information and data use System

The review team included an international consultant on CRVS systems who contributed to One of the tasks of the review team was to identify selected institutions and departments to be visited review the status of the implementation of the CRVS improvement plan that emanated from by a consultant after the assessment workshop in order to review the status of the systems currently the CRVS comprehensive assessment workshop and the implementation progress workshop being utilized to collect health and health-related data. Findings from the site visits were expected conducted in April 2015 and September 2016, respectively. A debriefing meeting was held with to complement those from the assessment workshop. During the workshop, however, an agreement the MoH and other stakeholders on the last day of the mission to present the observations was reached with the MoH that there would be no added value for a consultant to conduct field made in this review and to discuss next steps. Representatives from WHO country office also visits as part of the assessment since the implementation of SARA in 2016 had identified a number of successes and challenges related to information systems.8 Thus, the resources meant for the participated in the meetings.Annex 4 lists all the participants of the HIS assessment workshop. planned consultancy for the field visits would be used to support the overall HIS improvement plan for Libya. 3.3 Synthesis of findings, recommendations, and report preparation In addition to the documents that were reviewed and the information gathered during the discussion and 3.1 Document reviews working groups with MoH officials and other stakeholders, the team also used technical judgements and Before the mission, the team reviewed documents provided by the MoH, documents available in the carefully organized the findings according to the thematic areas of the M&E Assessment and Planning tool. public domain, and some documents from previous WHO missions related to HIS in Libya. Some The team used this as a basis to formulate priority actions or recommendations and finalize the road map for documents were also received during the meetings. HIS improvement in Libya. Each team member contributed to each of the sections of the report which were then compiled and shared with working group session facilitators for review and feedback. After incorporating feedback from the facilitators, the final report was shared with the MoH and all stakeholders.

6. M&E assessment and planning tool. WHO, February 2017 (in press). 7. A detailed description of DHIS-2 is available at https://www.dhis2.org/ 9. Each of the six working group sessions was facilitated by one participant with experience in the key HIS issues for discussion. The facilitators were 8. The key objective of SARA is to assess the readiness of a country’s health sector to deliver health care to the population. The first SARA in Libya was assisted by the review team members. conducted in 2012; and the second in 2016, which was a collaborative effort between WHO and MoH, supported by the European Civil Protection and 10. The PRISM framework consists of tools to assess Routine HIS performance, identify technical, behavioural and organizational factors that affect Humanitarian Aid Operations. The 2016 SARA was conducted as a census covering all 1,656 public health facilities in Libya. Routine HIS and identify priority interventions to improve performance, quality and use of routine health data.

17 18 4. Key findings on health information system According to the assessment conducted by the workshop participants, about one third of the attributes of a functioning platform are not present, distributed across all components. Libya Enhanced management of health information is a key step to achieve better health outcomes in does not have a comprehensive costed M&E plan; there are no SOPs for data management, Libya. Evidence-based decision making can only be achieved in the presence of a functional HIS. institutionalized data quality assessments or even a functioning, integrated web-based HIS system. The growing demand for health-related information by policy makers, program managers, donors, Effective mechanisms for review and action such as independent reviews of data, linkages between NGOs, the public at large and other stakeholders demands a unified well defined system of data health sector reviews and disease and programme-specific reviews, and active engagement of civil collection and reporting from the health facility to the national level that will suit all the users of the society in country reviews, are also non-existent. data. More than half of the attributes (63%) need some or a lot of strengthening, meaning that although Libya, as in the case with most countries, uses HIS to serve multiple users and a wide range of key attributes of a good functioning HIS are in place, there is still significant room for improvement. purposes. This discussion of the key findings on HIS focuses on three key components: (1)a This includes key strategic areas such as improving coordination mechanisms; strengthening data quantitative scoring on the availability of key attributes of a functional HIS; (2) a qualitative assessment sources (certification in causes of death, adequate infrastructure and staffing for a functional RHIS, of selected HIS functionality issues that were not covered in detail using the scoring approach; and coordination and implementation of surveys; and improving health systems monitoring); and building (3) assessment of key performance metrics, their status and means of verification. Then the key analytical institutional capacities on data dissemination and use. priorities for improvement are identified in later sections based on findings reported in this section. Finally, only few attributes are already present and don’t require further action. That is, a master 4.1 M&E/HIS assessment and planning tool: scoring facility list is in place; defined list of priority diseases under current national surveillance, including alert thresholds, have been defined; and a CRVS assessment has been conducted.

The M&E/HIS assessment and planning tool was used to get an overview of the current status of the Table 1 summarizes some of the key issues discussed by component in each of the working groups, different components of the M&E platform of the health sector, and to identify a set of priority actions aggregated in two main domains: Substantial support is needed (which includes attributes scored as that require further strengthening or development. The tool includes a check-list of attributes of the 1 and 2); and some support is needed (score 3). four main components of a functioning M&E platform: sound policy and institutional environment; well-functioning data sources; strong analytical capacities; and mechanisms for review and action. Table 1: Key areas requiring improvement in HIS identified in working groups The tool was presented to the participants in a plenary session. Previously, it was translated to Arabic. Key HIS component Substantial support is needed Some support is needed

Participants in the workshop were divided into six groups to score 71 attributes of the check-list, There is a weak coordination falling under the following categories: of HIS and M&E activities, due to unstable institutional The lack of an agreed national health strategic administrative structures, 1. Sound policy and institutional environment; plan poses a crucial challenge to the HIS, resulting continuous institutional 2. Well-functioning data sources: Health facility and community information systems; health in unclear definition of indicators to be monitored, changes, and non-periodicity of systems information (e.g. LMIS, NHAs, human resources); 1. Sound policy lack of HIS plan, and no clear SOPs for monitoring meetings. 3. Well-functioning data sources: Disease surveillance and institutional progress. 4. Well-functioning data sources: Household surveys; censuses; CRVS; environment Better coordination among 5. Strong institutional capacity for data collection, management, analysis, use and dissemination; A key priority to address it should be to create a MoH and programmes is and committee to develop the HIS/M&E plan. 6. Effective country mechanisms for review and action. needed. This should run in parallel with the establishment Annex 5 includes the composition of participants in each group. Figure 5 displays results of the of a committee to develop the scoring of the attributes. Complete scoring results (by working group) are presented in Annex 6. HIS plan. Current infrastructure, staffing and analytical Data on availability of HR 2. Health facility capacities to ensure a functional RHIS in place is available, but not used to and community are insufficient. Health resources are also inform decisions. Data on 60, information inadequately tracked, as other health systems 000 health workers has been Not present, needs to 6% be developed systems; monitoring systems entered by the Information and health systems Documentation Center. Work information Key activities to strengthen RHIS include training is underway to enter remaining 31% Needs a lot of (LMIS, NHAs, of MoH cadres at all levels; and purchasing ICT data. 22% strengthening Human equipment. DHIS-2 will be rolled-out nationally. Resources). A comprehensive hospital management system The Human Resources registry should be developed. should be completed. Needs some strengthening

41% Already present, no action needed

Figure 5: Summary of scores from the M&E assessment and planning tool

19 20 Key HIS component Substantial support is needed Some support is needed 4.2 M&E/HIS assessment and planning tool: qualitative inputs

There are still significant gaps in disease In addition to scoring the attributes of a functioning HIS, a series of questions to address some surveillance: Public health laboratories do not have Currently there is no unified qualitative aspects of the national HIS were developed to help in identifying priorities. This section the capacity to diagnose and confirm diseases national guide for standardized describes the main findings; detailed results are presented in Annex 8. that have to be reported; private sector is not definitions for diseases under routinely involved in case detection; surveillance surveillance. Outbreaks · Existing information systems were mapped, and equity stratifiers identified. The country has programmes are not integrated, and some verification is delayed a several information sub-systems responding to the different needs of the MoH. The routine HIS 3. Disease essential equipment such as ICT and vehicles are sometimes, and weekly reports collects aggregated information from facility level, and is paper based. The laboratory information surveillance not available. are not submitted timely. system is also paper-based, but some sub-systems such as disease-specific sub-systems (TB A key priority for the MoH is to expand the number and HIV) or the disease surveillance system are mixed (collection of data is paper-based, but the of surveillance teams and surveillance sites, A key priority to address this information is later on introduced into an electronic database). including expansion of mobile units to respond will be to develop a national more efficiently and timely to outbreaks. guidebook for notifiable · Equity dimensions disaggregated by the routine systems were analyzed. All relevant Additional disease registry must be developed diseases information sub-systems provide information disaggregated by sex. Education and occupational such as cancer registry. status is also provided by the Human Resources registry. However, routine information systems don’t provide information on wealth/income status, race, ethnicity, or migrations status. Disease- Although there is a system of death notification specific information systems provide disaggregated data on nationality (Libyans/no-Libyans). and certification, a huge gap in cause of death certification according to ICD code was identified. There are coordination · Data collection tools (forms and registers) were listed. The list included medical records, mechanisms for CRVS, although nurses records, admission and discharge forms, ICU records, death certificate records, The system for death certification and data entry the implementation plan needs investigation records, pharmacy store records, outpatient department records, discharge forms, should be improved. A department/Unit for encoding to be accelerated. The national and other online/electronic forms which are filled at the hospital level for special services such as should be created in every hospital. Options such 4. Household health plan should include a noncommunicable diseases. The forms/registers need further analysis, especially if the routine as payment for performance could be explored to surveys; harmonised health survey plan. HIS is going to be migrated to DHIS-2. Some forms such as the death certificate records will need improve death certification. censuses; CRVS to be revised (i.e. to add enough space to write in English and Arabic). All stakeholders should be Capacities for analysis of data from surveys actively engaged through · are limited. To strengthen capacities to conduct Tools for data collection, reporting and management of surveillance information were the Ministry of Planning to household surveys and censuses, training and described. Two tools were described: EWARN (Early Warning, Alert and Response), which is an implement surveys and census. recruitment of statistician and data collectors is electronic tool used for immediate and weekly reporting, which is not fully functional yet; and the needed. Capacity building of NSOs, public health notification tool, which is paper-based at peripheral (health facility) level, being data introduced national institutes is also needed. into an electronic database at central level. Data, methods and analyses · Composition and capacities of rapid response teams were described. Libya’s response are publically available, but still 5. Strong Analysis of data can be substantially improved. to outbreaks is provided by rapid response teams at two levels: central teams, which can be there is room for improvement. institutional Strengthen organizational communication deployed within 24 hours; and by 36 governorate-level teams, which need additional time to Although inter-sectoral capacity for mechanism between relevant sectors was investigate and respond to outbreaks. Last formal training was provided in 2007. coordination has started to data collection, identified as a priority, jointly with other actions define levels of and rights management, such as recruitment of staff, provide training and · A list of surveys that have been conducted in Libya during the past 5 years was generated. to data access, intersectoral analysis, use and build specialized capacity in data analysis (e.g. Two health facility assessments were conducted (SARA, in 2012 and 2016) and at least three cooperation in presenting and dissemination. statistical packages such as SPSS). household surveys (PAPFAM, HMSNA, workforce survey). A more detailed analysis of the discussing annual data needs indicators generated, comparability and/or evolution of indicators over time would be needed. further strengthening. Also, as pointed out during the scoring and planning exercise, a survey plan would be needed to identify key information needs and inform and coordinate the upcoming surveys. A system of joint periodic progress and performance reviews needs to be created/substantially improved, · Finally, the main information products of the Libyan HIS were listed, and the approach to including independent reviews of data, active improve them was discussed. Main actions to improve the quality and ensure periodicity of engagement of civil society and incorporating 6. Effective reporting were trainings in statistical software for statistical officers; assess the information needs results from reviews into decision-making. country to develop information guidelines; increase awareness on the information products; and ensure N/A mechanisms for that adequate human resources to analyze and disseminate the information are in place. Suggested activities include to raise awareness on review and action importance of data; to conduct Training of Trainers on data use and analysis; and to conduct a budget analysis in relation with health data, to inform further budget allocations.

A full table summariting the scores by attribute and component of the M&E platform can be found in Annex 7. The priorities emerged from the discussion and captured in Table 1 have also been included into the roadmap, Section 6.

21 22 4.2.1 Mainstreaming emergency information needs into the Libyan HIS 3. Health objective 3 (HO3): Reduce communicable disease transmission and outbreak through detection and mitigation measures. “It is not the case that countries with insufficient resources [and/or acute and protracted emergencies] should forgo good health information. Indeed, they are the ones that can least afford to be without it.”11 Each SO and HSO has its respective objectives, indicators and targets as presented in Table 2.

In contexts of fragility, conflict, or infectious outbreaks, health needs and capacities may differ Table 2: Strategic and health strategic objectives for the Libyan Human Response Plan markedly from routine conditions. Just as health system and public health essential functions must continue during emergencies, so too must the knowledge of health stakeholders about their Objective Indicator In Need Baseline Target drivers, capacities and gaps. Rather than being a reactive action undertaken during the response TOTAL: 88,606 TOTAL: 45,035 TOTAL: 60,000 Number of people in need Male: 32,880 Male: 16,712 Male: 22,265 and recovery phases of the emergency management cycle, planning for reliable and timely health reached with life-saving Female: 25,156 Female: 12,786 Female: 17,035 information during emergencies is ideally rooted in health decision-makers’ policies and procedures assistance through mobile Boys: 15,498 Boys: 7,877 Boys: 10,494 undertaken during the prevention and preparedness phases. medical support. Conceptually, this means that a national emergency preparedness and response plan must interface SO1 Girls: 15,072 Girls: 7,660 Girls: 10,206 with national health policies, strategies and plans in a way that fulfills this need across the four Number of health workers TOTAL: 25 TOTAL: 8 TOTAL: 22 components of the M&E platform. As a starting point, participants in working group discussions (medical doctors, nurses, Male: 10 Male: 3 Male: 7 were asked to consider the most recent (2017) Libya Humanitarian Needs Overview (HNO) and midwifes) per 10,000 population. Female: 15 Female: 5 Female: 15 Humanitarian Response Plan (HRP) and to elaborate upon how routine capacities across M&E TOTAL: 8,500 TOTAL: 2,658 TOTAL: 8,000 components could both contribute to and benefit from information collected through the programmes Number of outpatient department Male: 56% Male: 56% Male: 56% of various humanitarian stakeholders. visits per 10,000 population per Female: 44% Female: 44% Female: 44% year. Boys: 56% Boys: 56% Boys: 56% National Emergency Girls 44% Girls 44% Girls 44% National health policies, strategies and plans preparedness and HO1 TOTAL: 88,606 TOTAL: 45,035 TOTAL: 60,000 response plan Number of people in need Male: 56%, Male: 56% Male: 56% reached with life-saving Female: 44% Female: 44% Female:44% M&E Platform assistance through mobile Boys: 56% Boys: 56% Boys: 56% medical support. Effective country mechanisms fo review and action (6) Girls 44% Girls 44% Girls 44% Strong institutional capacity for data collection, analysis and use(5) Emergency Risk Number of health workers Well functioning data sources Management for health : HO2 (medical doctors, nurses, Same as SO1 Hazards, midwifes) per 10,000 population Health Health Other non- Population- Civil Vulnerabilities and facility and systems health Surveillance based Registration Percentage of children receiving TOTAL: 235,262 TOTAL: 214,088 TOTAL: 223,499 community monitoring sector (3) surveys and and Vital capacities measles vaccination (6 Boys: 131,747 Boys: 119,890 Boys: 125,159 information sources (2) sources (2) census (4) Statistics (4) months–15 years) Girls: 103,515 Girls: 94,198 Girls: 98,340 systems (2) HO3 TOTAL: 6,330 TOTAL: 4,088 TOTAL: 5,000 Number of HIV patients receiving Male: 4,178 Male: 2,698 Male: 3,300 ARV Sound policy, governance and institutional environment (1) Female: 2,152 Female: 1,390 Female: 1,700 Figure 6: Conceptual model of integrating the National Emergency Preparedness and Response Plan across the M&E platform components. 4.2.3 Information needs about vulnerable populations 4.2.2 HIS in an emergency context: The 2017 Libya Humanitarian Response Plan Vulnerable populations are those that are exposed to greater health risks and who have heightened The HNO and HRP are documents that are jointly drafted by emergency organizations. The HNO vulnerabilities or decreased capacities to respond to the hazards they encounter. In Libya, this outlines the evidence base, magnitude of the crisis and prioritized humanitarian needs. The HRP includes the more than 1.3 million people who require urgent humanitarian assistance.13 uses these needs to inform the development of high-level strategic objectives, which are then supported by more detailed Cluster/Sector plans (e.g. health, food security or education plans). This population may be disaggregated into three general groups: (1) migrants, Internally Displaced Persons (IDPs), asylum seekers, returnees, and detained populations; (2) non-displaced Libyans The 2017 Libya HRP outlines three strategic objectives (SO), the first (SO1) of which is to, “Save living in areas affected by conflict or with reduced humanitarian access; and (3) persons having lives through safe and dignified access to essential healthcare and essential medicines.”12 The conditions that, in the absence of timely and adequate health care, will suffer severe health Health Sector portion of this plan has, in turn, three Health Objectives (HO), which support this first consequences. strategic objective and are as follows: Data regarding these vulnerable groups must be mainstreamed into each phase of the five 1. Health objective 1 (HO1): Improve access to basic life-saving primary and emergency elements of an effective national health system (see Figure 2). To achieve this, humanitarian and secondary healthcare services through the provision of essential medicine, medical supplies development-related health stakeholders must proactively dialogue with decision-makers to ensure and technical support for primary healthcare, disability care and life- saving emergency care. that the minimum dataset relevant to the provision of effective, efficient and equitable care for these 2. Health objective 2 (HO2): Strengthen the existing health structure and avoid collapse of the populations is monitored, evaluated and reviewed in a periodic fashion. health system by ensuring deployment of essential health staff, functional referral system. 440Framework and standards for country health information systems / Health MetricsNetwork, World Health Organization. – 2nd ed. 2008. p. 6. Accessed 08 March 2017. http://apps.who.int/iris/lwvwuhdp243998276;:5242<:;<5748<8<73bhqj1sgi1 b 460UN Office for the Coordination of Humanitarian Affairs (OCHA), 2016, Humanitarian Response Plan 2017: Libya. 450UN Office for the Coordination of Humanitarian Affairs (OCHA), 2016, Humanitarian Response Plan 2017: Libya. 23 24 4.2.4 Feedback from group discussions on emergency mainstreaming Means of verification In group discussions, participants were instructed to consider how the specific indicators above – as Metrics Country data source(s) Status (Libya ) (actual country data well as the more general strategic and health objectives – could be informed through and contribute source) to existing HIS data tools or their modification (e.g., expanding their scope, increasing data collection Outbreak, events frequency, or creating new, fit-for-purpose tools). To this end, groups provided input related to each % of outbreaks/events Routine reporting systems, investigated and EWARNs of the four M&E components: sound policy and institutional environment; well-functioning data reported and investigated including surveillance response in one Routine Surveillance sources; strong institutional capacity for data collection, analysis and use; and effective country in less than 48h mechanisms for review and action. The key priority actions related to these components – within the week context of emergency settings - are presented in Section 6 (Table 4). No health Health expenditures National health accounts; Public expenditures updated at least once in N/A Expenditure Tracking Survey publicly for 4 4.3 M&E HIS assessment and planning tool: key performance metrics past 2 years Table 3 summarizes some key metrics of a functioning HIS based on input from the group discussions years and plenary sessions. Human resources for HRH database/registry/ HRH database health data updated observatory; exists: 60,000 HRH database Table 3: Assessment of key metrics of a functioning HIS identified in working groups within past 2 years and National HRH Accounts records included Means of verification publicly available Metrics Country data source(s) Status (Libya ) (actual country data Annual statistical reports source) with disaggregation Ministry of Health Available EVF M&E plan has not published One M&E plan used by Ministry of Health (MoH) been developed N/A government and partners Health sector yet Health sector progress progress and National plan for and performance performance report Ministry of Telecommunication; Ministry of Health No integrated digital N/A N/A analysis carried out has not been MoH architecture within the past 5 years published recently due to instability Country has 10 year Comprehensive National Statistics Office; Bureau Training , upgrading, comprehensive survey survey plan does N/A National institution(s) with Ministry of Health; National of Census; MoH Yes improve and support plan not exist capacity in data analysis Statistics Office application tools ≥2 key data-points DHS or MICS, STEPS , LSMS, Policy reports/ available for following Data-driven policy 1 other surveys briefs have not health SDGs reports/briefs publically Ministry of Health; National been published N/A Birth registration Libya: Health Systems available on national Statistics Office CRVS, SRS, DHS or MICS 98% recently due to coverage (%) Profile (WHO, 2016) priorities and targets political instability Death registration Libya: Health Systems CRVS, SRS No systematic coverage (%) 60% Profile (WHO, 2016) Health data available to availability of subnational decision- Ministry of Health N/A % of registered deaths CRVS, SRS, facility reporting 66% of the total data for sub- CRVS and MOH makers with cause of death systems; deaths national level No statistics No publically Annual statistics on N/A all deaths to be INDEPTH Network or SRS on community Health statistics with Ministry of Health available data community deaths certified by physicians deaths latest reports and repository. The data available to the MoH website N/A Data is not % timely and complete public (data repository/ has some key Routine reporting system routinely N/A reporting observatory) information analysed available Annual data quality No regular reviews Ministry of Health quality reviews N/A conducted Facility surveys in past SARA conducted SARA report (May Ministry of Health 2 years in 2016 2017) Annual data on Routine reporting systems, facility SARA conducted SARA report (May availability of essential surveys in 2016 2017) medicines Last assessment No feedback on total IHR compliance (index) conducted in Ministry of Health score received by the 2015 by self- country assessment

25 26 5. DHIS-2 requirements for implementation 6. Roadmap of key priority actions

As briefly discussed in Section 3, the review team discussed the DHIS-2 technology andits Priority actions were identified during working group sessions, based on the score of the attributes and the qualitative information gathered during Day 2 of the workshop. The priorities were discussed potential to enhance information gathering, analysis and use for decision making. To achieve this, extensively in a plenary session, with substantial input from the MoH and other key stakeholders. a demonstration of the technology was made by HISP India followed by discussions of the various Tentative timeframe, responsible of the actions, and other key actors needed for implementation attributes of DHIS-2 and the possibility of its pilot in Libya. were identified. Table 4 presents the key priorities identified.

5.1 Demonstration of DHIS-2 technology Table 4: Key priority interventions to enhance Libya health information system The demonstration of DHIS-2 focused on its components and use as an open-source medical system Roadmap of key priority actions Chronogram Strategic Responsible/ which also functions as a data collection, aggregation, and reporting tool. Workshop participants Key priority actions 2017 2018 2019 2020 2021 were informed that DHIS was implemented by HISP – a global network established to strengthen dimensions other actors HIS in low and middle income countries.14 The DHIS-2 runs on HTML5 and Java, which allows for the 1. Policy, 1.1 Hold a national workshop to define MoH - HIC governance customization of HIS. Participants were informed that DHIS-2 is primarily used for aggregated data M&E coordination mechanisms, including Other ministries X and programmes, partners Partners based systems, though it also has a module for patient tracking. It provides a platform on which an institutional environment 1.2 Create a technical committee HIS can be built on and is designed as a data warehouse – to serve as repository of different data in MoH - HIC to develop the national M&E and X Other ministries a health systems context. In particular, notable attributes of DHIS-2 include data entry at the health surveillance plan facility level, pre-defined analysis tools, user-defined dashboards, and Geographical Information 1.3 Assess the structure and functionality HIC - (MoH) XX System interface. DHIS-2 can also be used to collect and share essential clinical health data records of HIC (MoH) for effectiveness across multiple health facilities as well as collecting detailed ICD-10 codes for inpatient admissions MoH - HIC, WHO and deaths to enhance data analysis of morbidity and mortality. 1.4 Develop HIS Strategy Other ministries & XX Partners

MoH, HIC, GIA, MoT 5.2 Requirements for implementation of DHIS-2 1.5 Develop the e-health strategy XX The HISP India team shared and discussed with the participants the three building blocks for DHIS-2 WHO 1.6 Establish an M&E unit and implementation: “What”, “Where”, and “When”. That is, it is important to know the type of information HIC Emergency HIS unit within HIC to collect Other ministries XX needed to be generated by DHIS-2 (i.e. “What”); deciding on the location, reporting structure, and data on emergency including refugees/ Partners flow of information to be collected (i.e. “Where”); and deciding on the reporting frequencies (i.e. asylum seekers “When”; e.g., weekly, monthly or quarterly). 1.7 Discuss and adopt the SDGs across MoH - HIC state sectors through information and X Other ministries Discussions on the implementation also focused on the four main phases of implementation, as planning management centres follows: 1.8 Designate HIC as focal point for SDGs and built the capacity of HIC on MOH collection and reporting of health related o Phase 1: Gathering required information (i.e. achieved through the workshop); SDG data o Phase 2: Systems design and development (i.e. release of prototypes with focus on 1.9 Support development of the national MoH, WHO. All health XXX routine HIS); health strategic plan actors o Phase 3: Capacity building and pilot implementation in selected facilities across the 1.10 Standardize type, collection intervals and flow of data so that information country and various levels of service delivery; and MoH HIC , WHO. All systems may interface between XXX health actors o Phase 4: Large scale implementation (i.e. addition of vertical programs and integrating humanitarian health providers and de with existing systems). facto health authorities 1.11 Standardized data sources that MoH HIC , WHO. All capture migration status-related XX In separate meetings, the DHIS-2 team from India discussed with the MoH and WHO detailed health actors requirements for implementing DHIS-2 as part of the SHAMS Project. In broad terms, these information or inequity stratifiers discussions focused on ensuring timely submission by the MoH of the required documentation or 1.12 Strengthen HIC (MoH) to be potential candidate for WHO collaborating MoH XXX information to design the DHIS-2 system for Libya (Annex 9), selection of a “DHIS-2 team” by the centre MoH to be the focal point for the system design and piloting, visit by the HISP India team to Libya for capacity building workshop, and planning for three levels of training within the project cycle. The trainings will be (1) master trainers on end user training, (2) a DHIS-2 design and configuration training, and (3) DHIS-2 information use training.

27 http://www.dhis2.org/ 14 28 Roadmap of key priority actions Chronogram Roadmap of key priority actions Chronogram

Strategic Responsible/ Strategic Responsible/ Key priority actions 2017 2018 2019 2020 2021 Key priority actions 2017 2018 2019 2020 2021 dimensions other actors dimensions other actors Surveillance 4.1 Develop national standard case NCDC Routine Health 2.1 Train and develop the skills of the key MoH - HIC XXXXX definition for all diseases under Medical universities. XX Information staff at the central level . EU/WHO systems surveillance WHO 4.2 Expand notification system to 2.2 Assign and recruit specialists to NCDC. MoH MoH - HIC hospitals, public health facilities , private work in the field of health statistics and XX Private sector XXX . EU/WHO sector, immigration retention centres and informatics administration others 2.3 Recruitment and training of data MoH - HIC 4.3 Capacity building for public health clerks at national and facility levels as per XX . EU/WHO laboratories and surveillance sites: NCDC, WHO XXXX accredited health facility equipment, ICT and training 2.4 Build specialized capacity in effective 4.4 Training for surveillance officers on MoH - HIC NCDC - HIC XX supervision at health facility level and XXXXX data collection and analysis . EU/WHO health sector-reporting entities 4.5 Expand EWARN sites and rapid NCDC - HIC XX response teams with HIC WHO 2.5 Develop guidelines for data collection, MoH - HIC 4.6 Collect non-camp vulnerable XXX NCDC processing and dissemination . EU/WHO populations (especially migrant and WHO detained populations) to gain more insight XX 2.6 Provide incentives to data collectors MoH - HIC IOM XX into their health status and threats they (thank you messages, awards,…) . EU/WHO UNHCR face 2.7 Conduct key trainings to the relevant HIC staff on: 4.7 Establish disease specific registries XXX MoH - HIC WHO -workshops in the importance of feedback XX Household 5.1 Develop the household surveys plan, MoH, WHO, HIC – . EU/WHO XX - bookkeeping, reporting and use of surveys and as part of the M&E plan/health sector plan NCDC other sectors health-related information censuses 5.2 Involvement of all related stakeholders MoP, MoH, BSC, CRA, 2.8 Develop an unified data architecture MoH - HIC to implement the surveys and census XXXXX XX GIA, MOC, in the context of DHIS-2 roll-out WHO according the survey plan and SDGs 5.3 Capacity building of BSC, VRA, NCDC, 2.9 Roll-out DHIS-2 nationwide (training, MoH - HIC HIC and other public health institutes, integration of programmes, procurement X BSC, WHO, MoH X X X X X . EU/WHO including recruitment of statisticians and of equipment) data collectors 5.4 Conduct survey on burden of disease, 2.10 Develop and implement a hospital MoH - HIC MoH XX maternal and infant mortality survey, and XXX management information system . EU/WHO Other UN agencies health and nutrition examination survey 2.11 Implement quality of care (QoC) MoH - HIC 5.5 Build the capacity of in sampling HIC BSC, WHO and patient safety standards, including XX XXXXX . EU/WHO techniques and survey implementation NCDC systematic QoC assessment report 5.6 Update the census form by adding MoH HIC XX 2.12 Interface humanitarian actors’ relevant health-related questions WHO MoH - HIC facility-based data collection tools with XX Civil 6.1 Reactivate the multi-sectoral CRVS BSC, CRA, HIC (MoH), , WHO, NGOs XX local or district-level HIS Registration committee WHO and Vital 6.2 Enhance the awareness of CRA on Health systems 3.1 Support information and MoH - HIC Statistics importance of CRVS data for public health CRA, MoH, HIC WHO X X X monitoring documentation centre to complete the XX . EU/WHO through awareness/advocacy workshops health workforce registry 6.3 Update the current birth and death MoH, HIC, WHO XX 3.2 Train financial and technical staff notification forms as per standards of WHO in NHA, and adopt NHA, and develop MoH. EU/WHO XX 6.4 Capacity building for physicians and BSC, HIC, CRA. financial skills, including private sector CRA personnel, including use of incentives XXX WHO for proper completion of death registration 3.3 Establish mechanisms to use the 6.5 Create and train Units for ICD coding BSC, HIC (MoH), CRA. results of health accounts to inform MoH. EU/WHO XX XXX at every hospital WHO planning 6.6 Implement automated tools for data 3.4 Procure and install the inventory quality assessment such as ANACoD and MoH, WHO XXXXX monitoring system and provide training MoH. EU/WHO XX IRIS for automated causes of death coding to staff 6.7 Integrate the existing databases in BSC, HIC(MoH), CRA. HIC and CRA, and improve the system for XX 3.5 Adopt a complementary ministerial MoH WHO X death certificate collection/data entry. decree on information sources Other ministries 6.8 Integrate death certification and birth HIC (MoH), WHO X X registration into DHIS-2

29 30 Roadmap of key priority actions Chronogram 7. Discussion

Strategic Responsible/ Key priority actions 2017 2018 2019 2020 2021 The recommendations provided here are aimed at streamlining and strengthening the entire HIS; and dimensions other actors the improvement plan can be achieved through a well-coordinated approach by the MoH, its Health Analysis, Information Centre (HIC), and all key stakeholders. Implementing effective coordination mechanisms 7.1 Cross-sectoral coordination to define will lead to an effective HIS with increased access, data quality, and optimal efficiency. use and levels and rights of access to and utilization MoH, HIC (MoH) X X dissemination of data, and data flows of data, Addressing the recommendations should be made with reference to the detailed roadmap of key including 7.2 Capacity building (ToT) in statistical priority actions (Section 6). That is, the roadmap of priority actions should be considered as an analysis of data, including awareness mechanisms MoH, HIC. WHO X X X X X “implementation plan” of the recommendations. A coordination committee should oversee the for review and workshops, report writing and how do develop dissemination materials progress in implementing the recommendations whereas a technical sub-committee should support action the operationalization of the priority actions. 7.3 Developing a manual to analyse data MoH, HIC. WHO X X 7.4 Strengthen national data repositories and develop open data access MoH, HIC (MoH), GIA 7.1 Sound policy and institutional environment XX mechanisms; with a focus of human WHO, EU. resources management data 7.5 Support monitoring teams and develop Recommendations and suggested activities in this component are aimed at improving management, NCDC, MoH HIC X training programs to improve efficiency coordination, and efficiency for all HIS stakeholders. The recommendations for the sound policy and 7.6 Strengthen intersectoral cooperation in institutional environment include: presenting and discussing annual data on NCDC, GIA, BSC, HIC XXXXX the population and select subgroups (e.g. (MoH) & MoH · Enhance the HIS by ensuring that all stakeholders, with the leadership of the HIC (MoH), migrants) agree on a national health strategic plan with clearly defined indicators to be monitored, 7.7 Conduct a situation analysis of health develop an HIS plan, and clear SOPs for monitoring progress. This can be achieved through private sector and civil societies related to HIC . Relevant partners X X a functional national steering committee. health. · Create a committee to develop the HIS/M&E plan and assist in monitoring progress with 7.8 Conduct a budget management implementation of the key priority actions. analysis to assess efficient use of MoH. Relevant partners X X · The HIC (MoH) should continue its custodian role as a lead actor in HIS through advocacy, resources. strengthening coordination of HIS and M&E activities, and holding regular meetings with 7.9 Enhance mechanisms for predictable financing at the national and sub-national MoH, MoF, Relevant stakeholders to update them on the progress with HIS functionalities. This should run in XXXXX levels for HIS strengthening in emergency partners parallel with the establishment of a committee to develop the HIS plan. contexts · Strengthen the leadership of the HIC (MoH) as the lead actor in HIS by establishing an M&E 7.10 Prepare regular information products unit and an emergency HIS unit within the HIC. (at least six months) to supportive Libya · Standardize the type of data, periodicity of information collection and flow of data so that HRP’s HO3 (reducing transmission MoH, HIC WHO XXXXX information systems may interface between humanitarian health providers and de facto of infectious diseases and enhancing health authorities. outbreak detection). · Reduce gaps in sources of data for equity stratifiers by standardizing data sources that 7.11 Compilation of previous four years capture migration status-related information. report from all the facilities as short term MoH, WHO XX strategy 7.2 Data sources 7.12 Collect data on the nature and extent of conflict-related injuries and 7.2.1 Health systems, health facility, and community information systems death and the effect of their deleterious MoH, WHO XXXXX Health systems, health facility and community information systems are core data building blocks consequences on health system needs and capacities. for any HIS and need to be managed effectively and valued by all parties to the HIS. This section 7.13 Update HIC website regularly and provides key recommendations that are inevitable for a HIS that is required to share data from health HIC , EU, WHO XXX include an option for English language systems, health facility, and community information systems. Key recommendations include: 7.14 Equip HIC (MoH) with ArcGIS software for collection and analysis of WHO, EU XX · Improve current infrastructure, staffing and analytical capacities to ensure a functional routine georeferenced data HIS is in place. This can be achieved by training of MoH cadres at all levels; purchasing ICT 7.15 Equip the HIC with printing facilities HIC , EU XXX equipment to enhance collection, processing, and dissemination of data; and piloting the 7.16 Develop a plan on use of information DHIS-2 technology for effective data collection, processing and reporting. and dissemination through advocacy HIC MoH, WHO XX · Develop a comprehensive hospital management system to enhance access, retrieval and workshops at district and municipality level utilization of evidence-based decision making. 7.17 Establish libraries and learning · Complete the development of the human resources registry to enhance informed decision resource centers in HIC and have access HIC , WHO XXXX making. While data on 60,000 health workers have been entered by the HIC, there is a need to scientific health information for the to complete entering the remaining data and ensure that the registry is complete and up-to- hospitals date, with regular updates. 7.18 Encourage learning and knowledge · Systematically interface humanitarian actors’ facility-based data collection tools with local or sharing of HIS experts through participation MoH, EU,WHO XXXXX district-level health authorities’ information systems. in regional and international conferences/ · seminars. Data transmission and reporting is primarily paper-based for the majority of local and district- 7.19 Orgnaize study tours for HIC, CRA, level information systems. While many external agencies implement various electronic BSC and other stakeholders identified by BSC , WHO XXXXX information systems, they do not regularly aggregate this data with wider health authority HIC. networks.

31 32 7.2.2 Disease surveillance 7.4 Mechanisms for data use, review and action A fundamental function of public health is surveillance. Rapid informed response can save lives, protect the public and mitigate the impact of disease. While Libya has an active disease surveillance system, there is still room for improvement. Key recommendations include: Data collection and processing can only yield desired outcomes if there are mechanisms to use the data, regularly review them, and implement evidence-based interventions. Key areas to strengthen · Improve the capacity of public health laboratories to diagnose and confirm diseases that have these mechanisms include: to be reported. This can also be strengthened by routinely involving the private sector in case detection. · Develop an integrated web-based HIS system to address fragmentation challenges. · Expand the number of surveillance teams, surveillance sites including mobile units to respond · Improve significantly the system of joint periodic progress and performance reviews, costed more efficiently and timely to outbreaks. M&E plan, independent reviews of data, active engagement of civil society and incorporating · Capture the non-camp vulnerable populations (especially migrant and detained populations) results from reviews into decision-making. as there is little insight into their health status and threats they face. · Develop inter-ministerial mechanisms to promote health information sharing related to · Integrate surveillance programmes and purchase essential ICT equipment and vehicles to migrant populations. improve operations of surveillance staff. · Raise awareness on importance of data and conducting Training of Trainers on data use and · Develop unified guidelines and standardized definitions for notifiable diseases to minimize analysis. delays in outbreaks verification and production of weekly reports. · Conduct a budget management analysis of health data to inform further budget allocations. · Develop modalities and methods to collect data onthe nature and extent of conflict-related 7.2.3 CRVS, household surveys and census injuries and the effect of their deleterious consequences on health system needs and Data from the different HIS sources support different decision-making processes in health policy capacities. formulation, planning and implementation. CRVS, population-based surveys and census provide data for the entire population – its overall health status, access to health services and other needs. Population-based data sources are comprehensive in Libya and have been collected for a considerable time. However, there are opportunities to improve population-based data sources as follows: 7.5 DHIS-2 implementation The growing interest in DHIS-2 worldwide has been remarkable. While DHIS-2 allows countries to · Improve systems for death certification and data entry by establishing a department or unit customize their HIS for data collection, aggregation, and reporting, preparations for roll-out need to responsible for coding in every hospital. This can be enhanced by considering options such be carefully planned. For a successful roll-out of DHIS-2 pilot in Libya, the key requirements outlined as payment for performance to improve death certification. by HISP India (Section 5.2 and Annex 9) should be met. These include: · Provide a clear mandate across all the systems in terms of minimum standards for data quality related to death notification and certification. These can be achieved by implementing · The MoH should provide key DHIS-2 customization information such as formats for data automated tools for data quality assessment such as ANACoD and also IRIS for automated inputs, type of data (aggregate or patient), type of reports to be generated, reporting format causes of death coding to ensure reliable data quality. with formulae. · Develop an on job training system for physicians on issuing medical death certificate based · Ensure availability of adequate infrastructure related to server hosting and management on ICD and also including this in the training curriculum for medical students. including internet access in all health facilities. · Ensure availability of M&E mechanisms for the CRVS improvement. · Select of a ‘DHIS-2 team’ with technical capacities in areas related to application development · Strengthen capacities to conduct household surveys and censuses including analysis of data and maintenance. through training and recruitment of statisticians and data collectors. These efforts can be · Identify pilot facilities for all the different levels of health service delivery. strengthened through capacity building of the Bureau of Statistics and Census and national public health institutes. · Develop a national household survey plan to harmonize efforts to collect population-based surveys and generation of national, regional, and international core health indicators. · Through the Ministry of Planning and the HIC, strengthen coordination mechanisms for HIS stakeholders and CRVS stakeholders in particular to enhance monitoring of the CRVS improvement plan and collection, processing and use of population-based data. 7.3 Institutional capacity for data management and analysis Health information systems should be enhanced to produce high quality data to support evidence- based planning, policy formulation, decision making, and action. In order to improve health outcomes in Libya, the HIS stakeholders should address the following key areas:

· Strengthen organizational communication mechanism between relevant sectors in areas related to staff recruitment, training and building specialized capacity in data analysis (e.g. statistical packages such as SPSS). · Although data, methods, and analytical results are publically available, there is a need to enhance inter-sectoral coordination to define levels of and rights to data access. In addition, inter-sectoral cooperation should be promoted by the MoH in discussing annual data needs. · Promote predictable financing at the national and sub-national levels for HIS strengthening in emergency contexts. · Produce institutional products with regular periodicity of at least six months to support the Libya HRP’s Health Objective 3 (reducing the transmission of infectious diseases and enhancing outbreak detection). Nevertheless, surveillance of specific vulnerable populations needs to be significantly strengthened to achieve appropriate coverage.

33 34 8. Recommendations Annex 1. Ministry of Health organogram

From the preceding discussion, the overarching recommendations emanating from this assessment Ministry of Health - LIBYA are:

· Establish a functional national steering committee, with representation from all key national Health Information Center The Ministry Libyan board for medical specialties HIS stakeholders, to coordinate HIS activities at the national level. · Create a sub-technical committee to develop the HIS/M&E plan. National center for diseases control Medical Human Resources Development Center · Improve coordination among MoH, various programmes, and other HIS stakeholders. National Council for Medical responsibilities Authority for Drugs & Medical Supplies · Strengthen routine HIS by training MoH cadres at all levels and purchasing ICT equipment. · Pilot DHIS-2 with potential for rolling out nationally depending on the outcome of the pilot. Central hospitals & Medical Centers Ambulance Services Authority · Complete the human resources registry to improve decision making regarding human Under Secretary Directorates of Health Services at district level resources for health. · Develop a comprehensive hospital management system. · Expand the number of surveillance teams and surveillance sites, including expansion of mobile units to respond more efficiently and timely to outbreaks. Under Secretary Directorates · Develop a national guidebook for notifiable diseases. · Establish a department/unit for encoding in every hospital as one of the means to improve the Health Labs & Primary Humain Health Health Private Drugs & system of death notification and certification. Health Construction Blood Medical Nursing Minister’s Office Resources Planning Education Health Sector · Strengthen capacities to conduct household surveys and censuses, including capacities to Care Projects Hanks Equipement improve analysis and report writing. International Cooperation Health Financing District’s · Implement a system of joint periodic progress and performance reviews and independent Hospital Administrative Quality Assurance Health affairs reviews of data to promote evidence-based decision-making. Internal auditing Affairs affairs & services & Patient safety Services The affairs of Treatment abroad Inspection & Health 9. Next steps Legal Affairs Follow up Expenditure Enhancing HIS requires plans and schedule that outline the components of the system to be developed/enhanced/reformed/used as is; the expected output; costs; responsible parties; and any other recommended areas for strengthening. In Libya, developing an HIS improvement plan will require coordination among all stakeholders at the national and sub-national level and also guided by a strategic plan that takes into account the strengths and opportunities of the current HIS.

The HIS implementation plan should be based on the information provided in Section 4. Key findings on health information systems (including the priority actions in Section 6) and focus on building an integrated system along the key components of a functional HIS: policy and governance; infrastructure and support; data management and standards; quality assurance; and dissemination and data use. The efforts and investments to improve HIS can be implemented and coordinated within the context of the European Union SHAMS Project funding as well as other potential sources of funding in Libya and elsewhere, over the HIS planning period 2017-2021. The MoH, guided by the National Health Strategy, should mobilize support for consensus building in defining the primary goals and interventions to improve HIS.

The roadmap of priority actions and responsible actors presented in this report will support the MoH, in collaboration with other stakeholders, to develop detailed short-term, mid-term, and long-term plans for HIS strengthening. While the process of strengthening HIS entirely can take a considerable time (e.g. 4-5 years) to see the effects, the immediate focus for Libya should be designing interventions that can strengthen the existing HIS operations without much change (“quick-wins”). This can be developed through involvement of stakeholders and HIS specialists.

Identifying interventions is the first stage in the improvement process. What remains critical though is to cost the interventions, their estimated person-days, and where necessary, individuals to be trained or materials/equipment to be purchased and proposed time frame which are consistent with the roadmap of key priority actions in Section 6. The costing can be done by small group of technical and programme HIS experts. The proposed time frames can be adjusted based on the actual time period for commencement or implementation of the HIS improvement plan.

35 36 Annex 2. Terms of Reference for the assessment Purpose of the assignment Purpose: Technical assistance – Health Information System Assessment in Libya The key objectives of the mission are to: Organization Section/Unit: WHO EMRO/Information, Evidence and Research (IER)/Health Systems 1. Develop a common understanding of information systems and databases currently available and Innovation cluster in Libya in order to identify areas for improvement particularly on information flow across the Duty Station: Tunis, Tunisia country. Proposed Period: 9 – 12 May 2017 2. Provide documentation of the different sources of data for HIS (i.e. population‑based, Actual work time: 4 days (excluding travel days) institution‑based, service records and individual records, and surveillance or community system). Background 3. Provide an understanding of their content, data elements, associated reporting burden, and Health information systems (HIS) including civil registration and vital statistics (CRVS) systems how these information systems are used and by whom. are indispensable sources of health information data for programme monitoring, performance 4. Assess the strengths and weaknesses of these components and operations within HIS, monitoring, quality of care, planning, and policy making, among others. HIS and CRVS systems including aspects of governance; data sources; institutional capacities; and review and action. 5. Provide recommendations for an over-arching HIS agenda in Libya that is consistent with provide continuous information on the coverage of services in the health sector, and on mortality WHO and EMRO HIS standards, indicator frameworks and guidelines. statistics, including causes of death. The availability of HIS data at the sub-national level provides 6. Recommend strategies that build capacity of the information management system enabling countries with an opportunity to assess equity in the provision of health services. it to produce core indicators on disease burden, health access and utilization, mortality, disease- and injury-specific early warning, HIV surveillance, and human resources, including HIS data offer many opportunities to assess various aspects of the health system. In Libya, HIS has responding to the information requirements of the SDGs. experienced challenges even before the conflict. Theoretically, HIS is managed at the central level 7. Develop a roadmap to strengthen Libya HIS based on the findings of the assessment, by the Libyan Ministry of Health (MoH) in Tripoli with 23 sub-centres/branches located across the including priority actions, responsible and timeline. country. Before the conflict, these 23 sub-centres were responsible to collect, collate and transmit data to the central level to the MoH through electronic reporting. Although there were major gaps in The results of the review will help the government develop a prioritized and detailed roadmap for HIS the information collection and reporting, still data on disease burden, service usage and outcome improvement and reporting of core indicators at the national, regional, and international level. were available to some extent. The central level would use all the data received to publish an annual report. Since 2013, however, no such report has been published because limited data Specific tasks to be performed by the review team have been received from the peripheral hospitals and primary healthcare centres. Out of 1,589 The review team will be led by WHO with support of a HIS consultant. The team will provide an Primary Health Care Units, for example, only olplwhg qxpehu are now reporting data (much independent review of the existing HIS and is expected to: deficient than what it used to report). Similarly, out of 96 hospitals (including specialized hospitals), only 19 hospitals are currently reporting data (again much deficient). Some of the 1. Review relevant background documents reports, publications and materials related to HIS in reasons for non-reporting include closure of some of the hospitals and primary health care Libya. 2. Conduct a workshop with key stakeholders to identify key issues related to HIS and formulate centres, closure of most of the sub-centres due to lack of training, non-availability of human recommendations for their mitigation, including identifying priorities. resources, limited access to internet, and using older versions of data recording tools and 3. Identify selected institutions and departments to be visited by a consultant after the workshop formats. in order to review the status of the systems currently being utilized to collect health and health-related data. Findings from the site visits will complement those from the workshop. Currently, there is no practice in place for imparting training to resource persons who 4. Critically evaluate existing governance structures and capacities, in order to translate stated were positioned in the sub-centres, to the health information focal points, and/or to the government policy and international obligations into practice to standardize reporting of clinicians and doctors in the primary health care centres. Any existing data are seldom used for health situation and trends in Libya and at the regional and international level (e.g. regional decision making purposes, because the system and the Libyan MoH have limited capacity in this core indicators, the global reference list of 100 core health indicators, and the health-related respect. Although WHO supported the MoH in the introduction of a CRVS system in 2015, SDGs). CRVS is not functioning properly due to limited capacities in the HIS system. With funding from 5. Present results of the review to the MoH and other national stakeholders to ensure the European Union, the government has started efforts to strengthen the national HIS, understanding and agreement on the findings. supported by WHO. Strengthening HIS in Libya will help the country to monitor its health development agenda as well as enhance its reporting capacity on the 100 core health indicators The review mission for Libya HIS will be conducted in Tunis, Tunisia for 4 days. as well as the 68 regional core indicators. To achieve this, a review of the HIS is planned aimed at improved regularity and reliability of information produced by the existing Health Expected outputs Information Centre; boosted outreach of information gathering; health information analysis, The following are the key outputs of the technical assistance: intended as an essential part of public health planning and decision making. The review report 1. Workshop facilitated. will describe the HIS, including overall HIS structure within the country, information flow, 2. Final report with clear recommendations approved and validated by the MoH. governance and quality assurance; infrastructure; data management and standards; 3. A roadmap which will include priority actions, responsible actors, and a timeline. dissemination and use of data for policy and planning; analysis of its strengths and weaknesses; and recommendations on how to further develop the system to respond to (Note: Ideally, the roadmap should include costing but this may not be feasible during the workshop requirements of reporting on national and international priorities and commitments such as and will be planned as a separate activity). the Sustainable Development Goals (SDGs).

37 38 Qualifications/expertise sought WHO/EMRO/IER Health Systems &Innovation will lead the mission, with support from WHO/HQ/ IER Global Partnership for Measurement and Accountability; WHO/EMRO Emergency Programme; and WHO/EMRO Department of Health Protection and Promotion. An international consultant with experience in HIS will be recruited, to support the core mission members. The consultant will have master’s or higher degree in health information systems, public health or related field, be familiar with HIS assessment processes (e.g. the WHO Health Metrics Network) and developing an integrated and linked HIS. Extensive experience with using a variety of HIS beyond epidemiological and utilization data (e.g., other management-related information, such as financial information systems, human resources information systems) is preferred.

Relationships and responsibilites WHO/EMRO/IER/HIS will have the overall responsibility to implement the project and interact with MoH and other national stakeholders. WHO EMRO IER/HIS will provide leadership during all phases of the project; facilitate the co-ordination of team members’ roles and responsibilities during the mission, and be responsible for writing of the final report with key conclusions, recommendations and next steps. rganization O WHO Headquarters, Department of Information, Evidence and Research, Global Partnership for Measurement Accountability WHO Regional Office for the Eastern Mediterranean, Department of Information, Evidence and Research, Health Information and Statistics WHO Regional Office for the Eastern Mediterranean, Emergency Programme Islamic Republic of Iran Tehran, Ministry of Health and Medical Education, Health Information Systems Programme (HISP) - India Health Information Systems Programme (HISP) - India WHO Country Office, Libya Public Health Officer, WHO Country Office, Libya EU SHAMS Project Manager, hosravi K ripathi ame eam members for the assessment of health information system T N lmaghraby T khowat E O duardo Celades E . Haroon Rashid Dr. Ali Dr. Dr. Henry Doctor Dr. Dr. Dr. Ardeshir Dr. Saurabh Leekha Mr. Sumit Mr. Dr Atef Dr. Annex 3.

39 40 BSC, Vital Statistics Department BSC, Vital Department BSC, IT Statistics Department BSC, Vital MoH, Planning Director, Directorate of Hospitals, MoH Directorate of Nursing DG Central Hospital Tripoli Head, Statistics Department, Medical Centre Tobruqi Head, Statistics Department, Designation/Department/Unit Health Systems Expert Designation/Department/Unit H.E. Minister of Health, Libya Tunis WHO Representative and Head of Mission for Libya EU Health Coordinator MoH, HIC, Documentation Department Department (IT) Technology MoH, HIC, Information MoH, HIC, Statistic Department Analysis Department MoH, HIC, Data MoH, HIC, Hospital Statistics Council of Economic Development MoH Advisor, NCDC, International Cooperation Office Programme NCDC, Tuberculosis NCDC, Communicable Disease Department NCDC, Noncommunicable Diease Department NCDC, Public Health Laboratory Benghazi Medical Centre Head, Statistics Department, Sebha Medical Centre Health Statistics Expert Medical Centre Tobruq Head, Statistics Department, Sebha Health District Derna Health District Musrata Health District Health District Ben Waled Institute for Human Resources Development Centre Authority General Information Director, Authority Department, General Information Head, IT Directorate of Health Expenditure Blood Bank Tripoli ame Anwer M.M. Abodia Munir M.A. Aladl Nizar A.S. Alforjani Hesham S.S. ElharhuniElsdieg A.I. Elsaeeh M. Hateb Yousef Dr. Statistics BSC, Vital Director, Amal A.A. Dao A. Elfiturri Zuhra Fatma S. Alrgaeg Dr. Ibrahim A. Jabeal Ibrahim Dr. Araibi Nureddin H. Dr. Mr. Mohamed I.S. DaganeeMr. Ms. Costarelli Edda MoH, Health Information Centre (HIC) Director, N Omar A.S. Abdurahman Zaed A.M. Zaed Khloud A. S. Albeggar Ali S.A. Tunsi Fatma I.M. Rahab Hajer M.M. ElkoutDr. Salaheddin M.A. Blaaou MoH, HIC, ICD - Cancer Registry Ministry of Social affairs Nagia N.M. Ben NwejiMuhasen M.S. Alhawat Libyan Midwifery Society Al Najjar Badruddin Dr. Abdulhakim Aitawa Dr. Furjani Mohamed F.A. National Center for Disease Control (NCDC) Director, Hussin M.M. BenothmanRamadhan M.M. OsmanAbdulbassit S.M. Smeu NCDC, HIV/AIDS Programme A. Shaibi Taher NCDC, Disease Surveillance Mohamed M.J. Aghilla NCDC, Expanded Programme on Immunization R.A. Elahmer Omar. Huda K.S. KutraniDr. Fatima M. Salem Dr. Abdulhafith Almadhdi M.A. College of Public Health, Benghazi Mohamed H.M. Alashkham Atia M.S.H. Gaballa Amhimmid M.M. Aboulqassim Miftah A.O. Alkareemi Ali M.A. Ehmida Khalid A.M. Alhammali Mohamed M.S.H. ElbuzidiSalem M.M. Alhabroosh Libyan Board for Medical Specialty Abdurraouf A.M. Albibas Mahmud A.M. Ekhuja Adel J.A. AbdulrahmanAhmad M.A.A. Alawal Nagi M.G. Abdalla General Information Authority name Altaher Dr. Omer B. Dr. Syed J. Hussain Annex 4. List of participants

41 42 Annex 5. List of participants for the working groups

Group 1: Sound policy and institutional Group 2: Data Sources: Routine health environment information systems Adel I. Atajory Dr. Ibrahim A. Jabeal Mohamed I. S. Daganee Khuloud A.S. Albeggar Salaheddin M. A. Blaaou Dr. Yousef M. Habeb Nizar A.S. Alforjani Khaled A.E. Rabya Khalied M.E. Oedate Sayfulnasr M.A. Albrnawi Nagi M.G. Abdalla Zuhra A. Elfiturri Hussin M.M. Benothman Mohamed F.A. Furjani Dr. Abdalmonam Biala Dr. Ridha Shoutah Dr. Siraj Al-Souri Almahdi M.A. Abdulhafith Adel J.A. Altoumi Atia M.S. Gaballa Dr. Abdurraouf A.M. Elbibas Fatma S. Alrgaeg Dr. Nurredin Arebi Fatima M. salem Ghassan Karem Group 3: Disease surveillance Group 4: CRVS, census, surveys Abdulhakim Atiwa Munir M. Aladl FatmaI M. Rahab Omar A.S. Abdurahman Mustafa M. Omer Miftah A.O. Alkareemi Mohammed H. Alashkham Hesham S.S. Eltarhuni Amhimmid M.M. Aboulqassim Nagia N.M. Ben Nweji Khalid A.M. Alhammali Mohamed M.J. Aghilla Najla A.O. Altweil Dr. Nureddin Abuhelfaia

Dr. Mohamed Ahmed Waleed S.A. Masoud Dr. Badereddin Annajar Abdulhakim M.M. Bayoud Rmadhan M. M. Osman Sami R.F. Ben Muftah Hajer M.M. Elkout Group 6: Effective mechanisms for review Group 5: Institutional analytical capacities and action Omar R.A. Elahmer Abdurahman M.A. Furarah CRVS, Civil Registration Officer CRVS, Ministry of Education, Information Department Administration MoH, International Cooperation Office (ICO) MoH, ICO Administration Group MoH, Primary Health Care (PHC) Work group, MoH Work Administration, MoH Supervision and Inspection MoH, ICO Administration Administration Health Service, Tripoli National Expert on Health Ex-Director HIS, WHO EU Support to Strengthening HIS/SCM WHO, Libya Project Manager, WHO Libya Supply Officer, WHO Libya Information Management Officer, Consultant Designation/Department/Unit Kljkfrpplw|rigldoo|vlv Ali S.A. Tunsi Zaed A.M. Zaed Ashraf K. Z. Aburukba Anwer M.M. Abodia Muhasen M.S. Alhawat Khalid B. Atia Ali M.A. Ehmida Amal A.A. Dao Mahmud A.M. Ekhuja Taher A. Shaibi Dr. Haider El Saeh Mohamed M.SH. Elbuzidi Dr. Adel Laswed Ahmad M.A. Abdullah Alawal Dr. Mohamed Elhenshiri Elsdieg A.I. Elsaeeh Dr. Mohamed Hashem Huda K.S. Kutrani ame Sami R.F. Ben MuftahSami R.F. Abdulhakim A. Khadr Statistics Department Vital CRVS, Najla A.O. Altwell Abdalmonam Dr. Biala Mohamed Hashem Dr. Adel Dr. Laswed Dr. Nureddin Abuhelfaia Haider El Saeh Dr. Mohamed ElhenshiriDr. MoH, PHC Administration Dr. Siraj Al-Souri Mr. Mohamed Ahmed group, MoH Work Mrs. Nelufer Elbadri Ridha Shoutah Dr. Dr. Mohamed Awn Pharmaceutical Administration, MoH Dr. Najeeb Al-Shorbaji Atef Dr. Elmaghraby Haroon Ur RashidDr. Khirea Heshaishi Dr. Mashhour Halwani Mr. WHO Libya, Epidemiologist Moncef Bouslama Abdulhakim M.M. Bayoud Civil Registry CRVS, Sayfulnasr M.A. Albrnawi N S.A. MasoudWaleed Albyda Hospital Head, Statistics Department,

43 44 Annex 6. Summary of scores by working group

Group 1. Institutional environment roup 4. Household surveys; censuses; CRVS needed 18% 7% 28%

29% Already present, no action 55% 27%

36%

Group 2. Health facility information systems/health group 5. Strong institutional capacities sources. systems information data collection standards. eeds some strengthening information including all data N health data architecture & 1.4.3 There is an overall unifying 1.4.3

5% and detailed regulations for health

11% There is up-to-date legislation 1.3.2 9%

38%

56% 33%

48% e-heath. and other actors.

Group 3. Surveillance roup 6. Effective country mechanisms for enterprise architecture; eeds a lot of strengthening strategy for e-health and ICT partner and domestic support. 1.3.1 Existence of an effective 1.3.1 Existence of an effective N for M&E and review with active 1.4.1 There is a national policy/ 1.4.1 and research evaluation on development and use, including review and action framework used as the basis for development partners, civil society governance and legal frameworks; standardization and interoperability; involvement and support of relevant country-led coordination mechanism 1.2.2 There is a common investment 1.2.2

20%

50% 50% 50% 30% SDGs strategy. M&E Plan. confidentiality. current M & E /HIS. There is a comprehensive costed 1.1.3 The M & E Plan includes a 1.1.3 measurement and data sources. monitoring, evaluation mechanisms, 1.4.2 Standard operating procedures by a recent (< 2 years) assessment of limited set of core indicators with well- Colour code: Not present, needs to be developed 1.1.1 have been written that define roles and M&E plan for the national health sector responsibilities for collecting, managing 1.2.1 Disease- and programme-specific defined baselines, targets, frequency of including indicators, are aligned with the of measurement and targets (developed and disseminating health data, including framework that specifies a balanced and 1.1.2 The M & E Plan has been informed 1.1.2 1.2.3 There are agreed indicators, means 1.2.3 in collaboration) for M&E of health-related

Needs some strengthening Not present, needs to be developed

Already present, no action needed Needs a lot of strengthening Policy & Component institutional environment Annex 7. Results of the scoring exercise, by component and attribute The table below captures the results of scoring exercise, by working group and attribute

45 46 needed needed needed and syndromes. CRVS performance. CRVS surveillance is defined. Already present, no action Already present, no action Already present, no action facility identifier and geocodes. 2.2.6 There is a comprehensive 2.2.6 has been conducted of current list of health facilities, with unique 2.4.1 List of priority diseases and been defined for priority diseases 2.4.7 Alert/action thresholds have 2.4.7 syndromes under current national 2.1.1 A comprehensive assessment A 2.1.1 etc…). death. surveys. strategic plan. the aggregate availability eeds some strengthening 2.5.2 There is an electronic 2.5.2 sex, contact, place of work, of human resources. These of human resources. registry (“HRIS”) with up-to- 2.5.1 There is a reliable and 2.5.1 date data on each individual N by cadre and by health facility, by cadre and health facility, particular time and place. eeds some strengthening transparent system for tracking eeds some strengthening identifier, qualifications and key identifier, of assessing equity productivity. of assessing equity productivity. health worker including a unique characteristics (name, birth date, are widely available for purposes resources to strengthen the aggregate data on HR availability, aggregate data on HR availability, data are defined at all levels. 2.3.3 Household surveys are N N conducted every 2-3 years to above expected levels for the 2.1.3 There are an up-to-date 2.1.3 registration and vital statistics. 2.1.9 There are strategies and 2.1.9 syndromes under surveillance. 2.4.2 Standard case definitions monitor progress on key health indicators of the national health 2.3.1 A coordination mechanism A 2.3.1 and to report weekly aggregated the national census and events involving cases or deaths medical certification of causes are available for all diseases and is in-place to coordinate plans for legislation and regulations for civil 2.4.5 Timeframe to verify an event Timeframe 2.4.5 2.4.6 Data is analysed on a regular notification of births and deaths basis at the different levels to detect basis at the different district). central level). delivery/QoC. dissemination. case detection. information system. individual record. (NSOs, MoH, …). to all sub-reporting units. integrated, into the HMIS. certification using ICD. eeds a lot of strengthening staffing for a functional RHIS. facilities, laboratories and management system, tracking N eeds a lot of strengthening eeds a lot of strengthening cases of notifiable diseases. data elements and indicators are system for tracking commodities, N women of reproductive age by N system financing policy specifically. 2.4.4 The country has adequate 2.4.4 capacity to diagnose and record 2.1.2 A functional multi-sectorial A 2.1.2 population estimates for various 2.5.4 There is strong public financial 2.5.4 There is a logistics information 2.5.7 including the causes of death by medicines, equipment, and supplies. 2.5.8 There is a functional laboratory 2.5.8 (e.g. live births, surviving infants, 2.2.10 There is a harmonized system 2.2.10 2.1.5 There is IT infrastructure for There is IT 2.1.5 communities contribute to routine coordination committee is in place 2.4.3 Public and private healthcare 2.3.4 The National Statistics Office 2.3.4 overall health system policies to of facility assessments to verify service for policy planning and evaluation, from 2.5.9 “Health systems” information sub- 2.2.8 Disease- and programme-specific publishes timely and reliable annual 2.5.6 Health accounts results are used capacity for census and survey data expenditures at all levels (from facility to 2.2.12 Data on community-based health 2.1.4 Hospitals are reporting deaths, systems are interoperable, or have been with cause of death, through medical demographic and geographic groups 2.3.5 There is adequate country level 2.3.5 entering information on the deceased collection, analysis, report writing and programs are available in formats easy to integrated in the common data repository. government budgets, disbursements, and 2.2.4 Feedback is systematically provided 2.2.1 There is adequate infrastructure and 2.2.1 access/ linked to facility-based databases. access/ linked to RHIS. feasible. resources). point of service. institutionalized. and response. accounts annual surveys. surveillance activities. service delivery strategies surveillance programs. Accounts 2011 (SHA 2011). (SHA Accounts 2011 routine recording systems for data quality assessments are conduct verbal autopsies in place (up-to-date checklist, 2.5.3 Health expenditures are 2.2.2 Effective supervisions are 2.2.2 Effective 2.5.5 There are country-specific 2.5.5 2.2.11 Regular and independent 2.2.11 capacity building for a functional 2.2.3 Local level decision-makers use facility and community-based information to develop appropriate of patient management data at the insurances, etc.), to replace health 2.2.7 Facility reporting systems use (e.g., by NGOs, enterprises, private tracking private health expenditures global standard of System Health 2.2.5 There is adequate training and 2.2.5 2.2.9 There is a system for collection 2.2.9 communication including internet tracked on an annual basis, using the and the National Health Strategy. web-based systems (e.g. DHIS) when Not present, needs to be developed and community members analyse 2.1.8 Use of verbal autopsy is being 2.1.7 There are trained resources to 2.1.7 2.4.9 Equipment and logistics (forms 2.4.10 Enough staff is available at all 2.4.10 Enough staff and registers, computers, telephones, connectivity, cars and motorbikes) are connectivity, in the country to conduct public health Not present, needs to be developed Not present, needs to be developed and funding, aligned with the M&E plan 2.4.8 There is integration of all diseases 2.4.8 representative cause of death statistics. research agenda for household surveys causes of death are progressively used. sufficient and appropriately disseminated 2.3.2 There is a national survey plan and 2.3.2 detailing content, sequencing, periodicity, detailing content, sequencing, periodicity, gradually expanded to generate nationally levels to conduct public health surveillance 2.1.6 Systems for the automated coding of systems/ CRVS information information Component surveys; Health facility censuses; health systems Household Component Component Surveillance

47 48 Annex 8. Qualitative aspects of the Libyan Health Information System

Background The main objective of the Libyan Health Information System (HIS) assessment is to provide an overview of the current status of the different components of the national HIS, and to and to identify action needed action needed a set of priority actions that require further strengthening and/or development. Already present, no Already present, no

In order to complement the quantitative scoring provided by the Rapid HIS/M&E assessment and planning tool, a series of questions to address some qualitative aspects of the health information’s system have been developed to help to identify priorities.

Structure of the rapid assessment (group work) Participants were divided into six working groups, based on the components of the M&E platform. The groups were organized based on skills and experience of the participants:

GROUP 1: Sound policy and institutional environment.t eeds some strengthening eeds some strengthening GROUP 2: Well-functioning data sources: Health facility and community information systems; health N N systems information (e.g. LMIS, NHAs, Human Resources). GROUP 3: Well-functioning data sources: Disease surveillance.

3.1.4 Synthesis and analysis of national data is conducted using a collaborative approach involving health ministries, national statistics offices, experts and public private sector. 3.1.5 International standards are followed for analysis and presentation of key indicators in order to ensure comparability of results between populations and over time. range of dissemination strategies A 3.2.1 exist for health information, censuses and vital statistics, including reports, policy-briefs and web-based dissemination. 3.2.2 Health data are transparent and accessible. 3.2.3 National public health and academic institutions, advocacy groups, and the media are engaged by MoH and NSO to disseminate key health information. GROUP 4: Well-functioning data sources: Household surveys; censuses; CRVS/Civil Registration and Vital Statistics. GROUP 5: Strong institutional capacity for data collection, management, analysis, use and dissemination. GROUP 6: Effective country mechanisms for review and action.

locally Additional qualitative questions will be addressed to each group.

The questions have been adapted from the PRISM15 tools and/or tried to address other critical HIS eeds a lot of strengthening eeds a lot of strengthening including resource allocation key stakeholders are in place. N 4.1.5 Results from reviews are N issues not captured into the “attributes” section. regular feedback and use of data incorporated into decision-making, 4.1.1 Regular/ transparent reviews priorities with broad involvement of of progress against national defined 4.1.6 Health information flows include 3.1.1 Strong analytical institutional capacity for supporting synthesis of data is in place. At national level, there are 3.1.2 periodic Performance Reviews / Analytic Reviews based upon robust analysis of health data from all sources including contextual and qualitative information. processes There are effective 3.1.6 to support analysis and use at sub- national level. . . at all levels. conducted regularly between health sector reviews and 4.1.3 There are systematic linkages 4.1.3 4.1.2 Independent reviews of data in Not present, needs to be developed 4.1.4 CSOs meaningfully participate in Not present, needs to be developed maternal, child and perinatal deaths, are strategically important programs, such as disease and programme-specific reviews. country reviews of progress/ performance 3.1.3There is a regular (annual) report of progress and performance that covers progress against the objectives and targets, equity and efficiency ffective action country E Component Component mechanisms for review and Strong institutional capacities PRISM Tools for Assessing, Monitoring, and Evaluating RHIS Performance 15

49 50 N AR no no no no no No No EW IDPs, status HIS HIS HIS S/ MoF MoF MOH None None None Migration migrants, NCDC NCDC returnees) System (Refugees, applicable EW Database (if eD National Notifiable Disease Surveillance no no no

same None Race/

Libyan-

Libyan – Libyan – ethnicity non Libyan non Libyan Non Libyan None None None paper paper paper Paper Paper Paper Paper based lectronic electronic electronic Electronic Electronic E yes yes yes yes yes Yes

None /region Province Paper/electronic- no no no no no s No

None CDC +/- NGO

N None None None to NCDC yes yes yes yes yes Yes Sex Urban/rural

Private to ? None NCDC to HIS Health facility to Equity stratifier Hospitals to HIS / Hospitals to HIS / respective Hospital to NCDC / Reference lab to HIS / Health facilities to MoF Health facility -> NCDC Health Facilities to MoF campaign -> Dialysis centres to MOH PHC to NCDC branches of collectionà final use) Field-based vaccination NCDC branches to NCDC/ s District health authority to HIS / Flow of information (first point District health authorities to HIS / Health facility to NCDC branches no NCDC branches to HIS /

yes yes yes yes Ye None ccupation O

no no no no yes

eekly

Yes

, monthly,…) None None None None Annual Annual Annual Weekly Dialysis Monthly Monthly weeks) Irregular W Monthly ducation Immediate TB monthly E feedback relevant to the Libya Humanitarian Response Plan’s (HRP’s) Strategic Objectives. Strategic (HRP’s) Plan’s Response Humanitarian Libya the to relevant feedback d HIV 3months (epidemiological (e.g. annually, bi- (e.g. annually, annually Periodicity of reporting underline no no no no no None Income/ xpenditure/ asset index Chapter one E consumption/ None None Data) Individual Individual Individual / Individual / Aggregated Aggregated Aggregated Aggregated Aggregated Aggregated Aggregated aggregated data) Individual (line list) Individual ype of data (individual/ T (specific programmes have their HMIS

Chapter 1 Chapter 2 Finance… LMIS (logistics)

Human resources

Programme-specific information systems Disease surveillance

HMIS Laboratory information system system

For example: Fill the table below, remembering to record in record to remembering below, table the Fill Chapter 1 Chapter 2 Finance… Laboratory UP 1: Sound policy and institutional environment UP Surveillance Based on the table filled in previous exercise, kindly fill below which collects information equity stratifies LMIS (logistics) O 1. Human resources o Unique data source 2. Programme-specific information systems 7 Community information system 8 6 5 4 3 2 1 information system R Information system N Disease surveillance Community information G

51 52 GROUP 2: Well-functioning data sources: Health facility and community information GROUP 3: Disease Surveillance systems; health systems information systems 1. Review of electronic tools for data collection, reporting, management and analysis Data collection and transmission Is there an electronic tool for surveillance (data collection, reporting, management and analysis)? Provide details in the table below : Please list ALL data collection tools/forms that are used at the community/facility level. Facility-based data collection tools, Comments on tools. Is the form easy to use? Programme Which type such as patient registers Enough space to record data? Takes too much Name of tool Type of tool using the of data is Functionalities of the time? tool managed? tool Medical records EWARN Electronic EWARN Immediately Partially tool & weekly Response part isn’t fully Nurses records report functional yet Admission and discharge form Mix of paper Routine Weekly and ICU records Notification (peripheral ) Surveillance monthly and electronic reports Death certificate records add enough space to write by English and Arabic (Central) Investigation records 2. Describe the sources of information and mechanisms of reporting for EBS (Event-based Pharmacy store records surveillance)

Outpatient department records 3. Review of availability of rapid response team at different levels Discharge form Number Can be deployed Last training Online / electronic forms There are special form which are filled monthly and Level of teams within 24 hours Team composition received annually available y/n Special services as NCDC -Surveillance Officer Data transmission/reporting forms Comments on forms. Is the form easy to use? -Epidemiologist Enough space to record data? Takes too much Central -Lab. Personnel 1 Yes 2007 time? -Infectious disease Form of Ministry of Health specialist -Logistician

Forms designed from each hospital / Intermediate Surveillance Officer (Governorate) -Lab. Personnel some new hospitals 36 No 2007 -Physician Online form from ministry of health -Logistician District N/A N/A N/A N/A

53 54 GROUP 4: Well-functioning data sources: Household surveys, CRVS, census GROUPS 5 & 6: Strong institutional capacity for data collection, management, analysis, use and dissemination; and effective country mechanisms for review and action 1. List the surveys have been conducted in the country the last 5 years (since 2012) 1. Describe the main information products of the Libyan Health Information System. Year Periodicity / Key indicators Survey Major sponsors implemented next survey generated Capacities (HR, How are they related Periodicity analytical capacities) SARA-1 Health service How to strengthen to the Libya HRP, 2012 WHO/MOH 4 years needed to generate availability/readiness Product /last year SO1& HOs 1, 2, and/ the information these capacities? published or 3? Maternal Health, product BSC/WFP/AGFUND/ Smoking, NCD, PAPFAM 2014 4 years UNICEF/NCDC Disability, Reproductive Training in statistical health Statistical report software for hospital It related with the Annual /2014 HIC BSC, UNFPA, 2017 and health centre objective 1 Household multisector HMSNA 2016 UNICEF, UNHCR, assessment statistical staff need assessment WFP and NCDC survey Training in statistical Health service availability It related with the SARA-2 2016 WHO/MOH TB report Annual /2016 NCDC software for statistical And readiness objective 3 Workforce 2012-13 BSC Annually Unemployment rates officers at NCDC Training in statistical HIV in Blood NCDC, Regional It related with the 2011-2012-2013 Annually Prevalence of HIV HIV report Annual /2016 NCDC software for statistical donor Blood banks objective 3 STEPS officers at NCDC Training in statistical It related with the Polio report Annual /2016 NCDC software for statistical 2. Discuss how the SDG-3 related indicators can be captured in the Libya context, focusing objective 3 on those collected through surveys. How data sources can be strengthened to report these officers at NCDC Training in statistical indicators? Vaccination It related with the Annual /2016 NCDC software for statistical report objective 3 officers at NCDC SDG health-related indicators (potentially) collected How to ensure appropriate Training in statistical through surveys and/or CRVS collection and analysis of data? Surveillance It related with the Annual /2015 NCDC software for statistical report objective 3 Maternal mortality ratio CRVS/ surveys officers at NCDC Non Training in statistical Skilled birth attendants CRVS/ Household Surveys It related with the communicable Annual /2015 NCDC software for statistical Under-5 mortality rate CRVS/Surveys objective 3 diseases report officers at NCDC Neonatal mortality rate CRVS/surveys Training in statistical It related with the Number of new HIV infections per 1,000 NCDC, Surveillance Sara 2 report 2016 HIC software for statistical Objective 1 TB incidence per 1,000 population NCDC, Surveillance officers BSC, NCDC & It related with the PAPFAM 2014 Hepatitis B incidence per 100,000 population NCDC, Surveillance UNFPA Objective 1 Mortality rate from cardiovascular Constitutive Training in statistical diseases, cancer, diabetes or chronic respiratory HIC, NCDC, Cancer registry, surveys national 2015 GIA software for statistical No relevant diseases indicators guide officers Suicide mortality rate HIC, Ministry of interior report Global School- HIC, WHO, CDC Alcohol per capita consumption Stepwise surveillance based students 2007 (US), and Ministry No relevant Death rate due to traffic road accidents HIC, Ministry of interior health survey of Education Family planning coverage rate Surveys 2. Specify the planning, budget and review cycle. Adolescent birth rate per 1,000 women CRVS, surveys Monitoring, review Mortality rate attributed to household and air pollution CRVS, surveys Level Elaboration of annual plan Annual budget or evaluation Mortality rate attributed to unsafe water, unsafe CRVS, Surveys sanitation and lack of hygiene National e.g., June-July Mortality rate attributed to unintentional poisoning CRVS, Surveys Sub-national Prevalence of tobacco use 15 years+ CRVS, Surveys Other No budget for any planning since 2014

55 56 Annex 9. DHIS-2 requirements for implementation Annex 10. Agenda for the assessment workshop

The requirements can be grouped into four main areas: Time Topic Responsible I. Requirements gathering Day 1: Tuesday, 9 May 2017 · High level system requirements in terms of objectives to be achieved from DHIS/HMIS. 08:30-09:00 Registration of the participants WHO support staff · Understanding As-Is Workflow · Understanding To-Be Workflow Dr Syed Jaffar Hussain · Essentials for HMIS Instance such as Organisation unit hierarchy; Facility types; Shape files 09:00-09:15 Remarks by WHO Representative to Libya WHO Representative and Head of for GIS (if required); Language translations with Unicode; Business Rules and Validations; Mission, for Libya and Tunis and User Management His Excellency Dr. Omer Basher 09:15-09:30 Remarks by the Minister of Health Altaher, Minister of Health, Libya II. Customization requirements Muhammad Ibrahim, · Basic flow of information from facility level to the national level at the MoH. 09:30-09:45 Remarks by DG, Health Information center Director General, Health Information · Data Input such as: Center, Libya o Formats for data inputs with respective frequencies Type of data being entered: aggregate or patient Dr Atef El Maghraby o 09:45-10:15 EU Project for Strengthening HIS and SCM Project Coordinator, o Rationalization of service delivery data elements across facilities · Outputs, that is type of reports either static or dynamic and reporting formats with formulae. WHO, Libya · Data Analysis which mainly includes list of indicators 10:15-10:45 Group photo/ Coffee break Participants

III. Infrastructure Dr Haroon Ur Rashid, HIS Officer, WHO Libya HIS Workshop Overview, Methodology and 10:45-11:00 and Muhammad Ibrahim, · Server hosting and management Expectations · Level of computerization at facilities Director General, Health Information · Internet availability and connection type at data entry levels Centre, Libya Muhammad Ibrahim Presentation 1: MOH Health Information IV. Capacity building 11:00-11:45 Director General, Health Information Centre (HIC) Human resource mapping based on broad skills at the Ministry, District and Facility levels. The skills Centre, Libya focus on: Presentation 2: Bureau of Statistic and · Technical people for application’s development and maintenance; 11:45-12:30 BSC · Application super users for customization and technical support; and Census (BSC) · Trainers 12:30-13:00 Discussion on presentation 1 and 2 Moderator V. Managing historical data 13:00-14:00 Lunch break Participants This is important to ensure that any historical data are integrated in the system. Presentation 3: National Centre For Disease 14:00-14:45 NCDC Control (NCDC) 14:45-15:30 Presentation 4: Vital Registry Authority (VRA) VRA 15:30-16:00 Review and debriefing Review Team Day 2: Wednesday, 10 May 2017 Assessment tool 08:30-08:40 Recap of Day 1 WHO Presentation 5: Social Information Center & 08:40-09:10 MOH Health Information Centre 09:10-09:40 HIS rapid assessment: overview WHO 09:40-11:00 Group work (I: scoring) Participants 11:00-11:15 COFFEE BREAK Participants 11:15-13:00 Group work: continuation Participants 13:00-14:00 LUNCH BREAK Participants 14:00-15:00 Feedback to plenary and summary of results Rapporteur 15:00-16:00 Group work: qualitative aspects Participants 16:00-17:00 Review and debriefing Review Team

57 58 Time Topic Responsible Day 3: Thursday, 11 May 2017 Assessment tool (cont’d) 09:00-11:00 Group work (II: priorities) Participants 11:00-11:15 COFFEE BREAK Participants Group work: continuation and feedback to 11:15-13:00 Rapporteur plenary 13:00-14:00 LUNCH BREAK Participants Group work: chronogram, costing, and next 14:00-16:00 Participants steps 16:00-17:00 Review and debriefing Review Team Day 4: Friday, 12 May 2017 District Health Information System Presentations Overview of DHIS 2 system § Architecture § Attributes of DHIS 2 (online and 09:00-10:00 offline), processing, analytical, and HISP India reporting functionality § Success stories of DHIS 2 in selected countries Transitioning to DHIS 2 based on current context in Libya 10:00-11:00 HISP India § General requirements § Timelines 11:00-11:15 COFFEE BREAK Participants 11:15-11:45 DHIS 2 Implementation plan for Libya HISP India 11:45-14:00 LUNCH BREAK/ PRAYER Participants 14: 00-14:30 Any unfinished agenda Debriefing: Review of outcomes for the HIS 14:30-15:30 WHO assessment 15:30-16:00 Conclusion and closing remarks WHO, MOH

59 60