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UNIT Management in the 1 Context of District Health Services

Introduction

Welcome to Unit 1 of Using Information for Effective Management of Health Care Services I. Unit 1 discusses the health services context at district level and the information needs for managing health services at this level.

In the first session we introduce the context of health care services and the principles governing their running. We will discuss the implications of these principles for the management of health care services. The principles are discussed in the context of managing districts. The reason for this is that the district represents the ideal in the provision of health care. There is the additional reason that a district-based health care services is increasingly becoming the standard in the provision of health care, the world over. At the same time, let us stress that, even where the health service is not overtly district-based, the principles discussed in this unit – both for management of these services and for the information systems that service these systems – are good principles in general and are generally applicable in the provision of a good health service.

The unit will also extensively discuss the uses of information in the running and management of health care services. The session that deals with this subject echoes, and will be further enriched by, the final unit of this module, where we will discuss a holistic vision of the management health information system.

There are three Study Sessions in this Unit:

Study Session 1: Overview of District Health Services. Study Session 2: District Health Management Information Systems. Study Session 3: The Management Planning Cycle.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 1 Learning Outcomes of Unit 1

By the end of Unit 1, you should be able to:

. Define the District Health System and understand its implications for health service delivery. . Define the principles that guide provision of health care, (e.g. Primary Health Care Approach, coverage and quality of care, effectiveness, efficiency and equity in health service provision) and understand their implications on health service delivery. . Define the concept of population based service provision and its implications. . Argue the usefulness of routine information in district health services management. . Identify what routine information should be collected. . Discuss the merits of different techniques used to obtain routine information. . Discuss the Minimum/Essential Dataset concept. . Identify the hierarchical relationships in routine information systems, and their implications for data collection at different levels of the health system. . Appreciate the role that routine information could play in enhancing the decisions of managers. . Be familiar with the Management Planning Cycle.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 2 Unit 1 – Session 1 Overview of District Health Services

Introduction

The purpose of this module is to further your skills in providing health care services. The primary function of the health service is to meet the health care needs of the population through providing health services. The primary function of managers is to make sure that health services continue to be made available to those who need them, that they run in line with set goals and parameters, and within its means. Key roles of managers in this context are planning, monitoring, evaluating, and where necessary modifying the services provided. To do this adequately, managers must be informed about the context in which they operate, and appropriately modifying all aspects of the services.

In this session, we will demonstrate the function of information in the effective management of a health service, and show the value of routine health information as a tool for monitoring, evaluating and appropriately modifying health services.

To plan, monitor and evaluate a health service properly, a reference point is needed to guide these actions. Planning is undertaken to reach a particular point. Monitoring and evaluating is done to check that this point is being reached. These points are set in terms of goals and standards. The specifics of these reference points will naturally vary from context to context, though they should always be generally coherent within a national health system. Increasingly, however, there is global agreement on definitions of quality as it pertains to the provision of health services. We shall therefore refer to some of the major concepts which define the standards towards which health systems aspire.

Many countries throughout the world have endorsed two important principles that are relevant to understand the context of this module. Firstly, governments have embraced the Primary Health Care Approach (PHCA); and secondly, the mode of implementation of the approach is through the District Health System. Both of these concepts and their implications will be discussed in this session.

You are no doubt aware that the DHS is a decentralised mechanism of health service implementation and management, which brings services as close to the people receiving them as possible. Since district health services are focussed on addressing the health needs of populations/communities rather than single individuals, it is necessary to monitor how the services are performing. Therefore, routine health information is crucial at the district level. If we do not have access to routine health information at the district level, we cannot monitor and evaluate the effectiveness and efficiency of the DHS in implementing the PHCA for communities.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 3 Session Contents

1 Learning outcomes of this session 2 What is the District Health System? 3 Readings 4 Population based service provision 5 The Primary Health Care Approach 6 Effectiveness, efficiency and equity within the DHS 7 Coverage and quality of care 8 Session summary 9 References

Timing of the session

This session contains three tasks and four readings. It could take you up to four hours to complete. A good point at which to take a break would be after section 5.

1 LEARNING OUTCOMES OF THIS SESSION

By the end of this session, you should be able to:

. Define the District Health System and understand its implications for health service delivery. . Define the Primary Health Care Approach and understand its implications on health service delivery. . Be familiar with the concept of population based service provision. . Understand what is meant by the terms effectiveness, efficiency and equity in health service provision. . Understand the need for coverage and quality of care.

2 DEVELOPING YOUR READING STRATEGIES

At Postgraduate Diploma level, you are expected to read a substantial range of texts and to select and apply this information to your own context as well as to case studies or academic topics. By this stage, your reading skills are probably fairly highly developed, but even experienced readers can improve their skills. It may be reassuring to those of you who find academic reading a challenge: practice makes it easier, and in time, the frustration and feeling of frequently losing track of the writer’s arguments will disappear.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 4 Think about how you felt when you started studying for this qualification – has it become easier?

Over the first few sessions we will revise a few strategies for reading effectively, because we will not necessarily provide a guiding task for every reading. This means you will have to strategise to ensure that you get the maximum value out of the time you spend reading. Reading passively allowing your eyes to glide over the sentences uses time, but is ineffective. You seldom remember much and learn very little.

According to the experts on reading, at least three conditions help you to read effectively:

. Some background knowledge of the topic; . Recognition of most of the terminology; . Using strategies to internalise and remember what you have read, e.g. reading with questions in mind, summarising or monitoring your own comprehension. We will tackle this in the next session.

They describe reading as an active process, through which the reader “…converses with, or interrogates the text.” (Moran, 1997: 57) This is a constructivist view of learning, which assumes that the student is an active participant in making meaning from a text, adding their own background knowledge, applying ideas to contexts with which they are familiar. You also need to become an active observer of your own reading habits in order to improve your reading. For more information on how to read scientific literature more productively, refer to the notes on critical reading of articles developed by Gavin Reagon.

3 READINGS

The readings for this session are listed below. You are expected to read all of the readings provided below. For optimum benefit, it is expected that you should read the first two readings listed before going through this session.

Author/s Publication details Reagon, G. (2005). Summarising and Critiquing an Article. SOPH, UWC: 1 - 3. Amonoo-Lartson, (1984). District Health Care: Challenges for Planning Organisation and R., Ebrahim, G. J., Evaluation in Developing Countries. Macmillan. Hong Kong: 26 - 38. Lovel, H. J. & Ranken, J. P. Green, A. (1999). An Introduction to Health Planning in Developing Countries. Oxford: Oxford University Press: 137 - 149. Sandiford, P., 1992). What can Information Systems Do for Primary Health Care? An Annett, H. & International Perspective. Soc Sci Med, 34 (10): 1077 - 1087. Cibulskis, R.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 5 Byleveld, S. (2003). Emergency Medical Services Management Information. Unpublished Report. Health Information Systems Project, South Africa: 1 - 7. Monekosso, GL. (1994). District Health Management: Planning, Implementing and Monitoring a Minimum Health for All Package – From Mediocrity to Excellence In Health Care. Maseru: WHO: 15 - 25 & 59 - 65. School of Public (2004). The Cape Town Equity Gauge. Information Pamphlet. Bellville: Health. SOPH, University of the Western Cape: 1 - 3.

4 WHAT IS THE DISTRICT HEALTH SYSTEM?

The World Health Organisation has recommended that the PHCA be implemented through a District Health System. Districts are said to have the following characteristics (Hall et al, undated, 1):

. Includes a level 1 hospital . Has a population that does not exceed 500 000 . The geographical size of it allows the furthest clinic to be reached within approximately 3 hours from the district office . Are contiguous to other districts and has a clearly defined catchment population . Are of a reasonable size to ensure effective management . Possesses a decentralised management team responsible for the delivery of various health services

In South Africa, these characteristics cannot be applied to districts. South Africa embarked on a different strategy in demarcating its districts that were not driven by the health service. As a result, South Africa has much bigger districts. These are at times viewed as unmanageable and necessitated further compartmentalisation, i.e. the subdivision of districts. This gave rise to smaller administrative areas that are known by various names, such as local service areas, sub-districts, local areas, etc. At times, these sub-sections of districts are usually more aligned with the World Health Organisation’s definition of a health district.

The next figure shows an example of the districts demarcated in the Province of the Eastern Cape in South Africa, while Figure 2 shows the local service areas.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 6

Districts in the Province of the Eastern Cape, South Africa (2004)

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 7 Sub-districts (or local service areas) in the Province of the Eastern Cape, South Africa (2004)

Having split a country into manageable geographic regions allows an improved proximity of decision-makers to the communities they serve. The DHS allows that district health offices be created in each district. These district health offices are housed with human resources that would allow decentralised decision making to improve coverage and quality of health services. In this way, priority needs of communities are easily identified, rapidly addressed, community involvement facilitated, and transparency is enhanced. In other words, the closer you are to the community - the better.

This means that defining geographic areas (i.e. districts and/or sub-districts) are important to ensure a district health system that would render health services to their communities, but decentralisation of authority is equally (if not more) important. If managers do not have the necessary knowledge, resources, political support and authority to address health priorities of the communities in their district, then the district health system remains merely an ideal rather than a useful service delivery mechanism.

In answer to our initial question, “What is a district health system?” we can say that it is a strategy of health service-delivery that places providers (including SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 8 management) as close to the health needs as is practically feasible. It ensures that health needs expressed or observed are addressed by services planned and implemented within the district.

The fundamental assumption throughout this module is that a decentralised health service is in operation. This means that districts have been identified with an autonomous capacity to manage services. By implication, this means that decisions can be taken by district management teams to change things that would improve service delivery. If districts do not have the authority or means to change things, then routine information at that level is of little value (WHO, 1994, 22). Also, it is important to mention that the closer you are to problems, the easier it becomes to identify them. The routine health information system can show us these problems. It has been said that information is only as good as the action it provokes. In this context, action relates to the implementation of strategies to improve coverage, and quality of health services.

Coverage, appropriate provision of effective services in an efficient manner, and high quality of care are the main determinants of successful district health services.

Comprehensive Coverage

Coverage can be compared to a person lying in the bed covered by a duvet. During cold winter evenings, you would like to use the blanket to cover every inch of your body against the cold. Similarly, communities must be covered in their entirety by health services provided in the district (both definitions of a district and of the PHCA imply this). We may have very efficient services, but we are not covering all communities or parts of communities. This makes the service inequitable and clearly ineffective in attending to the needs of the entire population. Coverage indicators are usually expressed as a percentage of the target population and help one to determine shortfalls. When considering such measures of coverage, one would like to try and attain 100%. When interpreting the indicator values achieved for coverage of services, managers should be more interested in the difference between the 100% and the actual value achieved. This is important because we need to know how many we are not reaching, and more importantly, where they are, so that we can find them. Of course, it is no use to reach all the communities and people within them if we do not provide them, with a high quality of care.

Effective Services

Using the blanket analogy, effective services would then be if the blanket was thick enough to keep out the cold, and ensure adequate warmth while you are sleeping. Effective services therefore means that the service actually does what it is intended to do and thereby adequately attends to the health needs of the SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 9 population. In practice this means that at an individual level, the correct diagnosis and treatment is implemented, and at a population level, that all people accessing the health services are correctly diagnosed and treated. It would also mean that health promotion and prevention strategies that actually work, are implemented. To ensure that effective services are being provided, it is best to have prior evidence that the service is effective, or at the very least, it should be reasonably thought to be effective. It is sobering to note that by the early 1980s only 15% of all treatments commonly prescribed to individuals, were actually proven to be effective, and several treatments commonly prescribed were actually proven to be ineffective (Sackett, 1983). Regular monitoring of the effect of population based interventions would greatly assist in deciding which are effective and which are not. This is particularly important in population based interventions, as an intervention which works very well in one community could be of little value in a different community. This is the case because communities may be quite different owing to economic, social, cultural and disease prevalence characteristics.

Appropriate Services

Appropriate provision of services means providing those services which are most required by various groups within the population of the district. Within these groups, comprehensive coverage would be essential, but the various groups would receive different services. To continue the blanket analogy, in summer or during warm evenings, the coverage of your blanket may be deliberately low, which means that only a portion of your body is covered. Similarly some services are appropriately provided mainly or only for children, others mainly or only for elderly people, others mainly or only for pregnant women or women in the reproductive age group, etc. Within each of these groups services are provided in accordance with the need for those services.

Quality of Care

Quality of care is both an objective and a subjective impression, and indicates that not only was the service effective, but that people felt that the service was effective, worthwhile, or helpful, or it reached or exceeded their expectations. Although quality is mainly subjective, it is something real and tangible which people instinctively sense or feel. The blanket analogy would be that the blanket not only keeps you warm, but it smells nice and feels soft and comfortable. So services that are provided in a pleasant manner, within a welcoming environment, with convenient opening hours for which people do not have to wait long, and by staff who treat people with respect and dignity, would typically be classed as high quality care.

Efficient Services

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 10 In our ongoing analogy, this would mean obtaining a high quality effective blanket at the lowest cost. Efficient provision of services requires one to provide the same quality effective service at a lower cost, (e.g. lower cost in time or resources such as money), or a higher quality effective service at the same cost (or even better at a lower cost).

Routine health information systems can assist in measuring and monitoring all of the above five attributes of a well functioning district health service. The provision of information both assists health service managers and providers to constantly improve the health services they provide, but it also enables them to be directly accountable to the population that they serve.

As you can imagine, we cannot provide an efficient health service if we do not align our efforts to focus on prevention and promotion within a PHCA. This is so because prevention is better and cheaper than cure and rehabilitation. It is better because less illness means less suffering. The first step in doing this is to identify high-risk and at-risk groups so that preventive and promotive activities can be particularly targeted at these groups. If we do not identify all the priority health needs, then we cannot treat them effectively. Therefore, the need for health promotion, prevention and screening, cure and rehabilitation go hand-in-hand. We must try to detect health needs as early as possible to make sure that the interventions are more cost-effective and sufficiently effective to provide a high quality health service in the district. These detected conditions must also be cared for in a consistent and persistent manner. Cases of ill-health must be dealt with until the situation has abated. This is known as continuity of care. If not done, it has serious implications for the effectiveness and efficiency of the health care. In order to assist us with reaching successful outcomes, we need to know about the availability of the best care processes and technologies that we can afford. Also, reaching successful outcomes in only a few communities or members of communities is not equitable. We have to ensure that we reach all areas of where health needs exist and deal with all of them effectively. This can only be ensured if we have fully functional monitoring and evaluating strategies and mechanisms. Information systems, whether routine or not, can provide us with such tools and strategies.

TASK 1 - INSTITUTIONALISATION OF ROUTINE INFORMATION IN DISTRICT HEALTH MANAGEMENT

Try to think of mechanisms that are in place to ensure that managers in your district, or any other district, are regularly reporting on coverage and quality of services provided.

FEEDBACK

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 11 Information systems can help in promoting accountability, but in order to do so the information must be easily available. This is not often the case. To improve availability, it is useful if information required to monitor the implementation and performance of activities is institutionalised. Institutionalisation in this sense also means that data collected in the information systems must be analysed and reported at standing meetings and other forums to promote accountability in the achievement of predefined plans. This means that if there is no standing arrangement through in-house methods, such as routine information systems and periodic surveys, then the information system cannot be said to be institutionalised. This means that if there is no standing arrangement through in- house methods, such as routine information systems and periodic surveys, then the information system cannot be said to be institutionalised. Accountability is naturally shied away from, but the institutionalisation of reporting responsibilities can counter this problem.

5 POPULATION BASED SERVICE PROVISION

You have seen in the previous section that districts have been selected in most developing countries as the decentralised locus of health care service provision. We have also seen that the World Health Organisation has defined the numeric limit of the recommended population size within these districts. Therefore, a community or many different communities must be provided with health care services by the district health authority. This means that many health needs are in existence that must be addressed. If one had to try and attend to every individual’s health requirements on a one-on-one basis, it might prove very hard, expensive and time consuming to plan and implement comprehensive district health services. Try to think how every health need could be determined within a district that houses nearly 500 000 people. How could we best get the information and what would the costs involved be? Also, how long would it take? By the time that we have visited each person, the health needs may have changed already, making our expensive exercise a mere historic reflection!

We usually talk of a community diagnosis (Vaughan and Morrow, 1989, 5-6). This can be compared to seeing an individual patient. Heywood and Rohde (undated, p3) states that “Every time you see a patient, you take a history to get information on what the problem is, how long it has been present, how it has progressed, etc. You then do an examination, look at the affected area, feel it, move it and get a better idea of what is wrong. Sometimes at this point you can make a diagnosis, but often you need to do additional tests – laboratory tests, X- ray or other – to get a better idea of exactly what is wrong and precisely what the diagnosis is.” Similarly, in public health, we look at a patient (namely the community) and take its history through checking management reports, research and survey results. Census data and demographic and health surveys performed over the years are usually also good indications of what your patient SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 12 predominantly suffers from. Next you can do an examination by considering current information available in the routine health management information system and/or perform a situational analysis. Disaggregating this information may show priority areas (or sites of infection for our analogy). Surveys and current or recent research studies could assist with this examination. Finally, one may need to obtain additional information through a variety of methods to represent the tests we do on our patient. In this way one can formulate a community diagnosis. In contrast to an individual diagnosis, community diagnoses have the following common features:

 We consider the most common health needs within our communities.

Implication: Some health needs that are unique to a small group of individuals may not be afforded much attention and resources. This occurs because we want to address health priorities of communities, rather than individual health priorities. Health needs with a low prevalence will usually receive a low priority.

 Large groups of people stand to benefit from intervention.

Implication: The value of performing a regular community diagnosis and providing intervention far exceeds the benefit that one patient derives from an accurate diagnosis and treatment. Many people can benefit in our case. This does not make individual diagnoses less important.

 The diagnosis is done pro-actively unlike in the case of individuals who come to health facilities to complain about an illness. We are actively monitoring health needs with a community diagnosis, rather than waiting for problems to knock at our doors.

Implication: Formulating a community diagnosis requires routine information. Health service provision is matched to the priority needs of the community. If routine information is not available, or analysed to build a community diagnosis, then further implications arise. Firstly, the health services provided are determined as priorities from administrative levels far removed from the communities where the community health needs are easily determined and observed; and

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 13 secondly, baseline information required for objective performance appraisal and service provision planning is not obtained. The latter means that district-level managers merely try to keep the boat afloat rather than trying to improve service provision.

 Unless a fatal flaw occurred in the diagnosis and treatment of the individual patient, the patient will usually come back for a re- examination of his/her treatment (intervention). In a community diagnosis and treatment, the community does not necessarily come back if the interventions are poor.

Implication: The implication is that monitoring and evaluation must be a pro-active activity by the district health authority and also be continuous and they need to be responsive to findings. This illustrates the crucial role that routine health management information can fulfil.

This section showed you that the district health system is geared towards the provision of population-based health services. This means we have considered how we provide health services and to whom. What we need to consider now is what we provide to these communities.

The following two readings provide an approach for performing a situational analysis in your district. The reading by Andrew Green shows in detail how to conduct a situational analysis. The reading by Amonoo-Lartson, Ebrahim, Lovel & Ranken shows the typical information one is likely to obtain from a situational analysis of rural districts in poor countries. They also provide some depth of discussion on these examples.

READINGS

Green A. (1999). An Introduction to Health Planning in Developing Countries. Oxford: Oxford University Press: 137 - 149.

Amonoo-Lartson, R., Ebrahim, G. J., Lovel, H. J. & Ranken, J. P. (1984). District Health Care: Challenges for Planning Organisation and Evaluation in Developing Countries. Macmillan. Hong Kong: 26 - 38.

First go through the reading by Andrew Green. As you go through his suggested approach for conducting a situational analysis, assess with what degree of ease (or difficulty) you would be able to gather information on the various data categories he proposes should be assessed.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 14 Approach the reading by Amonoo-Lartson in the following way. Read through the first three paragraphs. Thereafter look at the tables in each section first (without reading the accompanying text) and for each table, determine the following: . What information does the table provide? . How would the information be useful in deciding on health service provision? . What health services should best be provided (in an ideal world with unlimited resources) to respond to the health needs identified? . What health services is the poor rural district likely to be able to provide?

Thereafter read the text associated with the table and see if you agree with the interpretation and comments of the authors.

6 THE PRIMARY HEALTH CARE APPROACH (PHCA)

The PHCA has been extensively covered in the core module, Health, Development and Primary Health Care II, and now would be a good time for you to revise that module, as key concepts from it will be assumed throughout this module.

The DHS is primarily developed to increase the quality and coverage achieved in rendering health services. The recommended health services that should be provided by district health authorities should coincide with the PHCA. This has implications on the routine information system, as we will see in this section.

Most developing countries have committed themselves to follow the PHCA of health service provision as developed and adopted by the International Conference on Primary Health Care, Alma Ata, the Kazakh Soviet Socialist Republic (now Kazakhstan). 6-12 September 1978. The conference adopted the following on Primary Health Care (available http://www.healthydocuments.info/public/doc9p.html):

 “Reflects and evolves from the economic conditions and socio-cultural and political characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical and health services research and public health experience;

 Addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly;

 Includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunisation against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs;

 Involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 15 husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors;

 Requires and promotes maximum community and individual self-reliance and participation in the planning, organisation, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate;

 Should be sustained by integrated, functional and mutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need;

 Relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.”

For the purpose of linking the key PHCA principles with information systems, some of the useful sections in this definition are included in the following table:

Extracts from PHCA Principles Implications for district health services

This means that interventions to deal with health problems must be adapted and made relevant and affordable to the different districts within a country. Recognition is given that different A “Reflects and evolves from … communities have different needs, and that characteristics of the country and its different settings require unique communities …” approaches given their capacity and competencies. Also, it is implied that communities are treated with the PHCA rather than focusing on individual health needs.

The phrase implies that one needs to know what the main health problems are in all the communities served by district health services. This means that objective determination of health needs must occur, and merely relying on one’s gut instinct is “Addresses the main health problems in not sufficient to plan. Clearly then, the community, …” B pertinent information must be readily available and communicated effectively so that the district management team is aware of the main health problems in various parts of their district.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 16 SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 17 Similarly to the last point, objective sources of information is crucial to know what common- and endemic diseases are prevalent in communities within districts. “…prevention and control of locally Also, information could give us a sense of endemic diseases; appropriate what treatments are appropriate and C treatment of common diseases and culturally acceptable to communities. The injuries; …” effectiveness of treatments and preventions strategies could also be gauged.

Communication between different sectors responsive to the needs of the population is crucial, because it ensures an integrated approach, thus maximising the “… demands the coordinated efforts of use of resources to ensure better D all (those) sectors;” coverage of the needs of the population, and avoid duplication and conflict. Information can be useful for accomplishing continuous communication.

This implies that efficiency is important in the provision of health services. If district health services do not have efficient and equitable health service provision, then “… making fullest use of … resources; E the scarce resources at its disposal are …” not fully utilised. Information can guide us as to the levels of efficiency and equity attained in districts.

Prioritisation must occur in providing district health services. The resources at our disposal are not sufficient to satisfy every single health need. Therefore, we F “…giving priority to those most in should try to address as many problems need;” with the little resources available. Information can assist us in finding this difficult balance between health needs and resource allocation.

TASK 2 - USING INFORMATION TO IMPLEMENT THE PHCA

(a) Try to identify from the table above, where you could access information in your district to fulfil the implications mentioned in the table. (b) What does this mean for you in planning the services during the next round of strategic or operational plan development?

You could develop a table like the one below.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 18 PHCA Likely Sources of Information Principles A B C D E F

FEEDBACK

This task is very context specific and the answers you give would have to fit the specific conditions in your district. If you would like to get more detailed input as to what you came up with, please contact one of your lecturers. They will be happy to assist you in ensuring that you have applied the concepts correctly.

Now read through the article by Sandiford, Annett and Cibulskis (1992). It describes and provides examples of the value of information systems to the rendering of primary health care.

READING

Sandiford, P., Annett, H. & Cibulskis, R. (1992). What can Information Systems Do for Primary Health Care? An International Perspective. Soc Sci Med, 34(10): 1077 - 1087.

7 EFFECTIVENESS, EFFICIENCY AND EQUITY WITHIN THE DHS

We have mentioned these terms before. They are not just abstract terms: adherence to them can profoundly affect the types, variety and manner in which health services are provided. For our purposes, we will define them as follows:

Effectiveness - Providing health services well so that health needs are addressed in the best possible way.

Efficiency - Providing the best health services at the lowest cost.

Equity - Fairness in the utilisation, distribution and use of resources to deal with health needs of populations.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 19 Effectiveness of services has been mentioned earlier in this session when we looked at the differences between individual patient diagnoses and community diagnoses. It was stated that a district health authority must pro-actively monitor and evaluate the impact of their services on a continuous basis. This is one of the few tools we have to ensure that effectiveness in service provision is brought about. Many methods for obtaining data to monitor and evaluate our services are available, such as the routine management information system, periodic- and ad hoc surveys, research and sentinel site monitoring. We should use these methods to constantly strive to do better in terms of addressing the health needs of the communities we serve. Different approaches are required in different settings. This means that an effective approach may not be effective in another setting. Therefore, the rationale for the DHS to implement the comprehensive PHCA is again illustrated. Since the district health authority must be entrusted with sufficient authority and independence to deal with its communities’ health needs, the best and most effective ways to deliver comprehensive PHCA could and should be locally devised, within health districts. But it should be mentioned that the best approach could only be determined and sustained if one constantly monitors and evaluates.

The best way of providing a health service to address health needs of communities may not be affordable. It is here that one needs to find a balance between cost-effectiveness and effectiveness in service provision. As mentioned earlier, efficiency refers to the spending of resources sparingly, yet providing an effective service. At times, one may find that some services are just not affordable and cannot be provided. One may need to consider how best to channel the limited resources available. This does not mean that different ways in which to provide services should not be sought. You are encouraged to read a report developed in one of the districts of South Africa that considered the amount of saving that could be brought about by carefully tracking efficiency indicators for the vehicles used by the Emergency Medical Services (EMS). Many similar examples could be mentioned, but suffice it to say that the report shows clearly how careful monitoring and evaluation, using routine information, can assist managers in accomplishing efficiency in service provision.

READING

Byleveld, S. (2003). Emergency Medical Services Management Information. Unpublished Report. Health Information Systems Project, South Africa: 1 - 7.

Political decisions, managerial incompetences and many other factors can influence the inefficient spending of resources in particular geographic areas. Once a situation has arisen where certain communities or portions of communities are unfairly provided with too many resources, relative to others, a situation of inequitable resource allocation has arisen. This means that one area unfairly takes or drains scarce resources from another. This leads to ineffective health service provision and inefficiencies. However, inequity is the hardest of the three concepts to change. The difficulty in changing inequities lies within its root cause in the first place, which is usually political. Therefore, change can be very painful and complex to bring about. To learn more of the intricacies involved with the equitable re-allocation of resources, see the reading provided.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 20 READING

School of Public Health. (2004). The Cape Town Equity Gauge. Information Pamphlet. Bellville: SOPH, University of the Western Cape: 1 - 3.

TASK 3 - IDENTIFYING AVAILABLE INFORMATION TO IMPROVE EFFICIENCY, EFFECTIVENESS AND EQUITY

In the district where you work, or any other district, try to

(a) Identify pieces of information contained in your information system that show successful continuity of care, or coverage figures.

(b) Also try to identify pieces of information that represent the health needs of communities.

FEEDBACK

(a) Typical pieces of information that consider continuity of care include fully immunised before 1 year of age coverage, Tuberculosis cure rates, TB default rates, etc. All of these indicators have one thing in common. It allows one to determine the effectiveness of service provision. For instance, if one is diagnosed with Pulmonary Tuberculosis, and you do not complete your treatment, it is unlikely that you will be cured. Those who are not cured have then mostly likely not received good continuity of care.

(b) Outcome measures that present, case detection rates, incidence and prevalence values are all indicators that show health needs. In other words, if the occurrence or existence of a condition is high in a community, then the need for health services to deal with them is high. By looking at these indicators, one can gauge the relative health needs of communities and prioritise services.

It should be clear to you that information can clearly show managers whether effectiveness, efficiency and equity has been achieved in the utilisation of scarce resources. If we do not have information relating to these issues, then it would be hard for us to monitor the effectiveness of interventions to improve these features of health care delivery.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 21 8 SESSION SUMMARY

This session served as a brief reminder of some of the concepts you have learnt in previous modules. However, the prime intention of this session was to take some of these concepts and discuss them in a way that would assist you in conceptualising the context in which routine health management information systems function. The readings have also been provided to enrich your view of the most important concepts covered in this session. You are encouraged to read them and to perform the tasks set out throughout the text. The main considerations in this session that should guide your framework for interpreting the different facets of routine information systems will be mentioned below.

The DHS has been established to affect the PHCA to which most developing countries subscribe. Many health care workers function in a district setting and must strive to provide effective, efficient and equitable health services. This must be done for all the people finding living and working in the districts. A high coverage of health services is one facet of providing good quality services, but many other determinants can also be identified. All of these goals of district health services should be monitored and evaluated on a continuous basis, because we need to know how we are affecting the lives (and therefore health needs) of the population we serve. It is in this context that routine health management information comes to life.

10 REFERENCES

. Hall, W., Haynes, R., McCoy, D. (2002). The Long Road to the District Health System. Legislation and Structures for the District Health System: An Appraisal as at August 2002. Durban: Health Systems Trust.

. Heywood, A. & Rohde, J. (undated). Using Information for Action: A Manual for Health Workers at Facility Level. Pretoria: Equity Project.

. http://www.healthydocuments.info/public/doc9p.htm

. http://www.who.int/whr/2002/chapter5/en/index5.html

. Moran, A. (1997). Managing Your Own Learning at University. University College Dublin Press, Dublin.

. Sackett, David. L. (1983). Clinical Epidemiology: A Basic Science for Clinical Medicine. David L. Sackett, Brian Haynes & Peter Tugwell (Eds). Boston, Mass: Little Brown.

. Vaughan, J. P., Morrow, R. H. (1989). Manual of Epidemiology for District Health Management. Geneva: WHO.

. World Health Organisation. (1994). Information Support for New Public Health Action at District Level: Report of a WHO Expert Committee. Geneva: WHO.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 22 SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 23 Unit 1 – Session 2 District Health Management Information Systems

Introduction

Session 1 of this unit described the context in which routine management information systems function. This context is important to bear in mind throughout this module, because all that we do occurs within the DHS and aims at providing comprehensive PHC services that are effective and efficient. We also constantly strive to improve the quality and coverage of services provided to communities. So at various points in Session 1, we have mentioned the utility of routine information systems in accomplishing an ideal or objective within the broad context we discussed. This will provide an overview of what these routine information systems are. It sets the stage for all the ensuing units and sections of the module that delves deeper into the intricacies of routine health information systems.

This session will look at various aspects that can help you to define what a routine information system is. Some questions that you may have are asked and answered. You are also provided with some readings that may provide you with greater insight into specific aspects of routine health information systems. As this unit forms the foundation of your study in routine information systems, you are strongly encouraged to work through the tasks and do the additional reading suggested. Once your frame of reference is solid, the later sessions will be easier to comprehend.

Session Contents

1 Learning outcomes of this session 2 Readings 3 How can information be used in health care provision? 4 Information required to manage a health service effectively 5 Why should information be collected routinely? 6 Determining what routine information to collect 7 The Minimum/Essential Dataset 8 How is routine information obtained? 9 Hierarchical relationships in routine information systems 10 The relationship between routine information systems and research 11 Session summary

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 24 12 References

Timing of the session

This session contains four tasks and two readings. It could take you up to six hours to complete. A good point at which to take a break would be after section 6.

1 LEARNING OUTCOMES OF THIS SESSION

By the end of this session, you should be able to:

. Argue the usefulness of routine information in district health services management. . Identify what routine information should be collected. . Discuss the merits of different techniques used to obtain routine information. . Explain how often routine information should be obtained. . Discuss the Minimum/Essential Dataset concept. . Identify the hierarchical relationships in routine information systems. . Discuss the main differences between routine information systems and research, and identify the unique contribution of each of these to improving health service provision.

2 READINGS

The readings for this session are listed below. You are expected to read all of the readings provided.

Author/s Publication details Heywood, A. & (2002). Using Information for Action. A Manual for Health Workers at Facility Rohde, J. Level. Pretoria: Equity Project: 21 - 34; 35 - 41. Lippeveld, T., (2000). Design and Implementation of Health Information Systems. Geneva: Sauerborn, R. & WHO: 1 - 10. Bodart, C. Opit, J. Louis (1987). How Should Information on Health Care Be Generated and Used? Round Table & Discussion, World Health Forum, 8: 409 - 438. Reagon, G., (2004). The National Primary Health Care Facilities Survey 2003. Durban: Irlam, J. & Health Systems Trust and the SA National Department of Health: 1 - 20. Levin,J. Sandiford, P., (1992). What can Information Systems Do for Primary Health Care? An Annett, H. & International Perspective. Soc Sci Med, 34 (10): 1077 - 1087 Cibulskis, R. World Health (1994). Information Support for New Public Health Action at District Level: Organisation. Report of a WHO Expert Committee. Geneva: WHO: 1 - 10.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 25 3 HOW CAN INFORMATION BE USED IN HEALTH CARE PROVISION?

As mentioned earlier, well designed and implemented routine information systems can help us obtain an objective perspective of health issues affecting the population, especially those communities served by this particular health service.

TASK 1 – THE VALUE OF INFORMATION SYSTEMS

In Session 1, try to find:

(a) All the instances where reference was made to the usefulness of information, and write them down;

(b) Summarise the likely uses of information emanating from these sections, and

(c) Try to list some additional situations in which information would be useful to improve service provision.

FEEDBACK

(a) and (b): Some of the main likely uses of information emanating from Session 1 include: . Objective identification of health needs of communities (i.e. a community diagnosis). Also, whether these health needs are unique or not. . Prioritising health needs found in communities served. . Continuous performance appraisal of health services provided. . Pro-active monitoring and evaluation is possible and enhanced. . Prioritising specific geographical areas for health service intervention and appropriate resource allocation. . Informing the appropriate interventions required and it can describe the effectiveness and efficiency of the interventions. . Promotion of continuous communication to enhance multi-sectoral approaches to health care. . Equitable allocation of scarce resources can be determined, leading to greater fairness. . To determine and improve the coverage of health services provided. . To determine and improve the quality of health services provided.

(c) This part of the question will be covered in the discussion that follows.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 26 Uses of information

One of the most important uses of information is to improve the decisions that we make as managers. Just consider the consequences of your decisions if you did not monitor the amount of money you had in the bank. If you do not have information on the amount of money that you have available, or information on your budget, you may end up heavily indebted. Similarly, we need to have information to make managerial decisions for health care delivery. More specifically, we can use information to help improve our decisions during:

 Strategic planning for the future: Planning what direction the health services will take with clear goals, targets/objectives and indicators.  Daily operational activities: Planning how the strategies will be implemented on a day-to-day basis, who will perform the activities, how and by when.  Implementing controlling activities: Making sure that finances are spent sparingly, yet addressing the health needs of the communities served or ensuring that sufficient personnel are placed at the correct service points with the correct skills, workload and equipment.  Appropriate policy development: Policies address in broad terms what, how, where and when we do things, or would like to do things. Information can give us answers to all these questions to ensure that policies are relevant and implementable.  Problem areas and areas where health services should be improved can also be identified with information. It is important that we address the health needs of all our communities. Also, our health services must reach the entire community. If problems exist, either due to the coverage or quality of the services, we need to address them. Information can point the way in solving these problems.  Information can also be used to directly increase the staff and communities’ understanding of how the organization functions and what its outputs are. Staff must be aware of the needs and norms of communities. If this is not known, the staff cannot be expected to provide an effective health service to the communities they serve. They also need to know who it is that they serve. Similarly, you will recall that the PHCA endorses the need for communities to participate in health care services provided to them. They have the right to know what it is that the DHS is providing to them, how well it is addressing their health needs, what they can do to assist in health care provision, and what improvements are being implemented or are planned to be implemented. In this way, information can create a better understanding and partnership between the health services and the communities they serve.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 27  A very important use of information that is often neglected by health authorities is its motivational role. Information can be used in positive ways to increase morale and levels of motivation. For instance, showing how well facilities are performing in relation to others, or the district target, can be very inspiring and provoke a greater interest in district performance by all staff. It is commonly understood that managers should praise often and reprimand only when necessary. Information can help us to see and show success and improvements, sing praises and motivate for sustained improvement of health care services.  Information can provide evidence and back-up for claims and requests advocating for improvements in the health service. Many district-level managers complain that their problems are not addressed by higher levels. “We don’t have enough money to … we don’t have enough staff… our needs are not considered …,” etc. These are all common phrases used by managers to justify poor performance of health services. However, managers at higher levels receive, and have to address, requests complaints from many different areas. Frequently, the requests for changes are not backed-up with solid information. Consider a situation where a district level HIV/AIDS manager has a low counseling coverage at facilities in the district; the manager believes this to be due to the fact that they have too few counselors. The request goes to the decision-makers that they need more counselors. The decision-makers would probably think that they have a similar problem in all the districts, and why should this district be advantaged above the others? They also have no idea as to the extent of the problem. However, if the manager indicated the actual coverage currently achieved, the potential workload in the health facilities, the exact number of counselors needed, and the district’s relative performance against others, he/she would probably receive more serious consideration.

These are a few of the ways in which information can be useful in improving health care services to the communities we serve. Also, the pro-active use of information can make the job of a manager much simpler and with greater impact. As a manager, you would know that provincial and national offices usually request information at short notice at various points in the year. This is usually very upsetting and difficult to obtain at short notice. However, if pertinent information has been used continuously by managers throughout the year, then such requests would easily be met.

4 INFORMATION REQUIRED TO MANAGE A HEALTH SERVICE EFFECTIVELY

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 28 In order to provide a good health service, we need to attend to several steps. In order to illuminate and attend to each of these steps, pertinent information is required.

In the following reading, Heywood and Rohde (2002) provide a brief description, with examples, of common types of routine health information. The reading provides a simple introduction to the variety of routine health information. Note that the authors use the terms “indicators” and “information” interchangeably. Indicators are simply specific pieces of information which shed light on a particular health problem or health service objective (desired health system achievement). While going through this reading, note the manner in which the authors group the information, and reflect on their explanations regarding the value of grouping the information in the way that they have.

READING

Heywood, A. & Rohde, J. (2002). Using Information for Action. A Manual for Health Workers at Facility Level. Pretoria: Equity Project: 21 - 34.

Note: Start reading with heading “Essential Dataset for a Health Facility” on page 21.

Let us now consider a hypothetical example to make the steps clear.

TASK 2 - IDENTIFY INFORMATION REQUIRED TO PLAN AND MONITOR THE PERFORMANCE OF HEALTH SERVICES

Imagine that an island has been discovered off the coast of the African continent, and you are requested to render health services to this island’s large population. What would you need to know in order to plan and implement health services for the people?

Write down the different categories of information that you would need to plan and provide health services to the population of the hypothetical island mentioned in the scenario. (a) What would you need to know about the population? List broad categories. (b) Identify and list what specific information you would need within each information category.

FEEDBACK

In order to provide a good health service, we have to at the very least obtain information on the following things, namely:- . Being clear on which population or community we have to serve . Assessing the health needs of that population

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 29 . Being clear on what inputs or resources we have such as staff, money, facilities, equipment etc . Deciding on what services to provide and how to provide those services (process) . Evaluating how much services we actually provided and how well we provided those services (outputs) . Assessing what difference those services made to the needs of the population (outcomes)

Each of the steps above can easily be understood using the following simple analogy. You are managing a restaurant and need to provide supper for a group of people. The steps you then have to attend to are: - Population: How many people do you have to prepare supper for? Needs: What would they like; are any of them vegetarian; Inputs: What ingredients do you have/need; what kitchen staff do you have/need Process: Decide on the menu; decide how to present the food Output: Did everyone have enough; any compliments? Any complaints? Outcomes: Did they enjoy themselves so much that they will come back again?

Providing health care services is more complicated than the example above, but the principles are the same. Information can and should be used when considering and deciding upon each of these steps. Under each of these steps there are many things that have to be considered and each of these things can best be considered if information on them is available. Since we routinely have to consider these things it therefore makes sense to routinely collect information on them, if necessary. So in order to provide adequate health services to the population for our hypothetical island, the categories of routine information required and the individual information elements in each category are shown below.

 Population As the first step, you would have to be clear on various aspects and characteristics of the population that needs to be served. For instance, we would need to know: o Total size of the population – this would determine the number of people for whom health services have to be provided for. o Since different sections of the population need different health services, we would need to know: How many children, elderly people, women in the reproductive age-group, males and females, etc. o Literacy levels – what is the educational status of the people? o Dietary habits – what foods do the people predominantly eat? o Cultural practices – do the people have particular behaviours that would increase their risk to particular conditions/afflictions?

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 30  Health needs Knowing the size and characteristics of the population still leaves their health needs unanswered. You would next have to determine aspects such as: o In what type of terrain do they live? Are they scattered over a vast area or are they concentrated in large cities? How accessible is the terrain? o How do they make a living, i.e. what types of production and employment are being engaged in. o What are the unemployment levels? This would make certain sections of the community more vulnerable to infirmity. o What kind of housing do the people have? Certain housing structures are not conducive to good health, e.g. poor ventilation and lighting. o How many people have access to clean water and sanitation? This could have serious implications for the spread of communicable diseases. o What diseases are common and would require prevention and treatment strategies? o What diseases do people commonly die from? (These are very serious health problems that must be prioritised for intervention.) o How many children die before they are one year old? (Infant Mortality Rate) – this gives a good indication of the state of health care services and how extensive the resultant health needs are.

 Inputs After knowing the population characteristics and their health needs, it would be wise to consider what health service resources the population already have available to them. What inputs can you utilise that is already available, and what additional resources would have to be acquired? o What condition are the health facilities in? Will much money have to be spent on infrastructure? o What condition is the equipment in? Is the equipment functional and/or outdated? Would new equipment have to be purchased? o What types of staff and how many of each do we have? What services can we effectively provide with the current staff complement, and what professions are needed? How many? Why? o How have previous budgets been spent, and what should the new budget be? Is a large amount of capital investment necessary?

 Process Once you are clear about the inputs available to implement a health service, you need to consider how the services should be delivered to the people. All of the characteristics of the population and the available

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 31 resources (inputs) must be borne in mind. You may want to know the following: o What services should be provided? o Where and at what times should we provide services? Would these services be accessible to all, and would you achieve a high coverage of the communities? o Is the health care staff adequately trained to deliver the services? Is it necessary to re-train staff or to conduct refresher courses? o Are the best available technologies used to address health needs? Should you change some of the practices to more appropriate and effective methods? o Do we have high staff absenteeism levels? What do you need to change in the service-delivery processes to increase staff morale?

 Outputs Now that you are providing services to the population of the island, you need to establish whether you are attaining an adequate coverage of your services. You may want to know: o What proportion of the communities are you not reaching? All communities and community members must be reached. o How was the services utilised? How many people came and how often (headcount and utilisation)? o How efficiently has the services been provided? What was the cost per patient per visit? o What are the workloads of various staff? Are some staff members working too hard and others too little? o What are the waiting times for the services? Do people wait too long to be assisted? What can be done to improve this? o What level of quality in service provision are you attaining?

 Outcomes If you are sure that you have reached all the communities and community members, that your processes to deliver health care are appropriate, and that your inputs are sufficient to deal with the health needs of the population, you must consider how your efforts have changed the health status of the population. You should consider: o Have the death rates and illness rates declined? (Have mortality- and morbidity rates dropped?) Therefore, has the health of the population improved?

This hypothetical example provides a graphic demonstration of the sort of information that is of value in providing health services. Thus, the value of including the types of information identified in the discussion above in a health service information system has hopefully been demonstrated. SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 32 SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 33 TASK 3 - IDENTIFYING PERTINENT INFORMATION AVAILABLE TO YOU IN THE

DISTRICT

In your district, or any other district, apply the steps described above to any health programme.

(a) Try to determine what should be known under each step to ensure that a good service is provided.

(b) Now determine which of the pieces of information that you require is available in the district.

FEEDBACK

(a) Make sure that you have correctly classified what pieces of information you would need, i.e. . Population – demographic, population size and target population sizes. . Health needs – socio-economic factors and information that explains health needs of communities. . Inputs – these must relate to things that are provided, or available to, the health authorities for use in rendering health services. . Process – this relates to how we do things. Types of services and modes of delivery. . Outputs – the information would have to denote what proportion of the population we have reached or not reached with our services, quality, etc. . Outcomes – these are measures of illness or death rates. Outcomes describe the health of the community.

(b) The point of the task is to assess the adequacy of your information system – these questions are often not considered adequately when designing information systems. Hence, the required information is often not available.

As this task is context specific, you are encouraged to contact your lecturers for specific comments if you would like to obtain more detailed feedback.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 34 5 WHY SHOULD INFORMATION BE COLLECTED ROUTINELY ?

We have now learnt that there are types of information that are useful in guiding the provision of an adequate health service. In this section, we consider how this information is obtained. The question that now arises is how we should obtain that information and how frequently we need to collect it.

5.1 What is routine information?

With regards to frequency, information is typically available in three time-interval formats namely, episodic, routinely and ad hoc.

Ad hoc information This time-format of information is almost exclusively the domain of formal research. Formal research does not provide sufficient information for assessing a health service because what is researched and when the research results are available depends on the interests and time constraints of the researcher/s and the funder/s of the research rather than the specific needs of the health services. While usually the research results are useful to the health services the research may not address what the health service deems to be priority issues and it might not address the particular aspect of a health problem or health service provision that health managers are most interested in. In many instances though formal research does address priority issues and does address issues that managers are most interested in, and at these times the usefulness of research to health managers is clearly extremely high. Formal research is also only available on an ad hoc basis (at irregular intervals) because its availability depends on when the research is completed and this is dependent on the timetable of the researcher/s rather than that of the health service.

Episodic Information In general this refers to regular periodic surveys. These surveys could be done as formal research or they could be incorporated into a routine information system as a routine survey which is performed at regular intervals. These surveys are valuable for regularly assessing health needs and/or health service provision. An example of a survey initially conducted as formal research but which it is hoped would be incorporated into routine health information systems is the survey of primary health care facilities in South Africa.

Go through an excerpt from the report on this survey which describes the type of services provided by primary care facilities in South Africa and while you are reading through it, try to determine how you as a manager would use the information provided by the survey.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 35 READING

Reagon, G., Irlam, J. & Levin,J. (2004). The National Primary Health Care Facilities Survey 2003. Durban: Health Systems Trust and the SA National Department of Health: 1 - 20.

Routine Information This is information which is continually collected and available to health services. It is required in order to adequately design and monitor health service provision. This type of information is as essential as is a financial accounting system for the health department. Health departments are virtually obliged to collect this type of information themselves, as researchers seldom have the interest or the resources to collect this information. Routine information is that information which is: . Directly aligned to the measuring and monitoring of health needs . Directly aligned to monitoring health service provision . Rapidly and continually available to health services . Available in the format in which health services require it to be available . Adaptable to the changing information requirements of health services

In order to provide this Routine Health Information, health services require a functional Health Information Systems unit staffed by at least one Health Information Officer who should, at a minimum, be skilled in epidemiological and health systems research techniques. More and more health managers are realising that Health Information Officers should ideally have specific training on Routine Health Information Systems and should be able to manage large volumes of data.

Determining what routine information should be collected is tackled in the next section (section 6) and the manner in which routine information is obtained is elaborated on in section 8 below.

The question that now arises is how often routine data should be collected, in order for information to be routinely available to health services, in a sufficiently timeous manner.

5.2 How often should routine information be collected?

Historically, all routine information has been collected daily. It is valid to ask: why has this been the case? But nobody seems to know the answer to this question. There is no clear rationale for insisting on daily collection of data; it is, in most instances, a practice bureaucratically imposed from high levels of the management hierarchy.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 36 The next best question would then be to enquire whether it is advisable to collect routine information daily? The answer is that in many cases it is advisable, because staff get used to collecting the data and they do it automatically. This means that the data gets collected regularly without any problem. A problem does however arise when staff are expected to collect too much data. The data collection then becomes too time consuming and the accuracy of the data collected becomes much worse. Also, staff become demoralised as they feel that they are being imposed upon to collect unnecessary data. To resolve this it is best to collect some routine data only on specific occasions, e.g. for one week per year. This would of course lead to the question: which data is best collected on specific occasions only? The answer is simply those data that do not change much over several months. This would allow one to count at one point in time (e.g. one week in a year) and estimate the monthly and annual figures by assuming that all weeks would be relatively similar to the one when the counting took place. The data that should be collected daily is then those data elements that could change over short periods of time, such as weekly or daily.

We can then say that we should collect data as seldom as possible. However, much data is best collected daily!

Now, we would like you go through the reading by Opit (1987) on the value and usefulness of routine information to health managers. This article was written two decades ago, when routine information systems in most countries were functioning sub-optimally, so Opit starts out by criticising existing routine health information systems, and then goes on to describe the value that routine health information systems could contribute to health services. Although routine health information systems have improved considerably since the time Opit wrote the article, in many countries and especially in poor developing countries, the criticism he levels at information systems then, might still apply. As you work your way through the article see if Opit’s criticisms apply to the routine information systems present in the district in which you work or live today. Also assess if the solutions he proposes to improve routine information systems could be applied to your district. As a rider to the article by Opit, there are several commentaries on Opit’s criticisms and proposals by other authors working in health information systems. Read through these and while noting the diversity of views expressed, assess how valid you think each of their criticisms are.

READING

Opit, J. Louis. (1987). How Should Information on Health Care be Generated and Used? Round Table & Discussion, World Health Forum, 8: 409 - 438.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 37 6 DETERMINING WHAT ROUTINE INFORMATION TO COLLECT

The information that we collect routinely should be information that is essential to know. In other words, the information should be sufficient to allow us to attend to all the steps necessary for providing a good health service (WHO, 1994, 17; Lippeveld, T., Sauerborn, R. & Bodart, C., 2000, 59). The following diagram will help us illustrate the concept of essential information:

Figure: Types of Information Absolutely Necessary to Know Information

Valuable to Know Information

Nice to Know Information

Dangerous to Know Information

The figure shows that there is a lot of information that one can collect. Only a small amount of this information can be said to be the core information required to ensure that health services are managed effectively and efficiently – i.e. absolutely necessary information. The next band in the diagram, valuable information, is information that may not be absolutely necessary in ensuring that health services are managed effectively and efficiently, but still provides valuable information to aid this management. “Essential information” encompasses these two bands. The third band of the Figure represents nice to know information. This information is not particularly useful in fulfilling a role in improving the management of district health services. It merely satisfies someone’s curiosity, and will in all likelihood not prove useful in guiding decisions. The fourth band of the Figure contains dangerous to know information. This is information which will not in any way influence decisions. It is considered dangerous to know because it provides no benefit (does not influence decisions) but yet it consumes resources (staff time), in its collection. It is also dangerous because it greatly increases the volume of information available and hence distracts staff from concentrating on the “essential information.” Usually, the need to collect a large amount of information is defeating the purpose of the information system since staff collecting the data would be burdened to such an extent that they often resort to SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 38 fabricating figures rather than doing the actual counting accurately. They usually resort to this as they do not see the value of some of the information, considering it superfluous. It is recommended that managers steer clear of collecting information that can be classified in bands three and four of the Figure.

What information should we then collect? The discussion above makes it clear that we should only collect the information that is absolutely necessary for us to manage district health services well, with a little of the valuable information included. Once one exits these two bands, the information becomes increasingly less useful. An information system that contains a lot of information that is outside the two central bands becomes limited in its usefulness. The reason for this is that the information outside of the two central bands is, by definition, of little or no value and merely increases the volume of work for data collectors. The risk of inaccuracy increases when people regularly have to collect large amounts of data.

TASK 4 – CATEGORISE INFORMATION TYPES

In Task 2, you identified various pieces of information that you would need to plan and monitor the performance of health services. Take the pieces of information you identified in Task 2, and assign them to the different bands in Figure 3. First, start by drawing the Figure on a piece of paper.

(a) Write on the diagram, assigning each of the pieces of information into the appropriate band.

(b) How much have you reduced your information set, i.e. if you only count the number of items in the first or core circle (absolutely necessary).

(c) Then check by how much you have reduced the information if you only include the two inner circles (= essential information).

FEEDBACK

The answer to this task is specific to the context in which you work and also the programme that you chose to work with. Therefore, you may wish to consult your lecturer for specific comments on what you have produced. Also, if you have not reduced your initial information set by a large proportion, then you have probably not been critical enough in interrogating each piece of information.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 39 7 THE MINIMUM / ESSENTIAL DATASET

As we have seen above, the routine information system should only contain information that is essential in attending to all the steps of providing a good health service. The raw data required to generate this information is called an Essential Dataset (EDS), also known as the Minimum Dataset (MDS).

The Minimum or Essential Dataset is a collection of data sufficient to ensure that all the Absolutely Necessary information, and some of the Valuable information required to provide an excellent health service is available. The EDS eliminates pieces of information that are nice to know or dangerous to know. The EDS is a small enough amount of data that it requires only a little staff time to collect.

Simply, we can define a MDS/EDS as a comprehensive list of raw data elements (not processed in calculations). Data elements refer to the pieces of data that must be collected or counted on a routine basis. These data elements are counted up at the point(s) of collection, e.g. if health facilities are required to count all patients attending the facility, then attendance is referred to as a raw data element.

For instance, if we want to calculate the pulmonary Tuberculosis (PTB) cure rate, we need two pieces of data: the number of PTB patients cured, and the number of PTB patients who commenced treatment. The number of PTB patients cured and the number of PTB patients who commenced treatment are both data elements. To get these figures, we require the people at the point of collection (i.e. those responsible for recording the information) to count, usually from the registers, how many people are considered cured, and to count the number of people who commenced treatment. This process of counting up qualifies the information to be called a data element.

Can you see that we did not do any calculation to obtain the data elements, except for adding all the individual cases together? (We instead collated - grouping pieces of information together - since we are considering groups of people rather than individuals). The individual cases on treatment or cure are raw data.

To determine a rate (as in the cure rate for pulmonary TB), we have to perform a calculation. Once we do a calculation - to determine a rate, ratio or proportion – we have analysed the data elements and transformed them into indicators or information. Once we have analysed the data elements we get information, since the rate (cure rate) tells us more than the mere fact of this individual or that individual having come for treatment or been cured. Rather it tells us the proportion (or percentage) of the group who have been cured. This helps us to assess how well the health service is performing. Data becomes useful SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 40 information only once pieces of information have been placed together in a particular relationship – in other words, once a calculation has been performed on it.

If we take all the data elements that must be counted by data collectors and put them in a single list, then we have a dataset. This is the minimum information we should have, to manage a district effectively.

We can distinguish between three main types of Minimum/Essential Datasets (MDS/EDS).

. Data-Led, . Action-Led, and . Information-Led

This distinction is based on the manner in which the datasets have been developed. We will briefly discuss each.

The Data-led Dataset

The data-led dataset is based on elements or pieces of data that, often, a manager decides they should have in the dataset.

The point of departure for developing the dataset is the dataset itself, without recourse to why the dataset is wanted. It’s like, “Oh, we must have a dataset. What should the dataset contain?” No thought is given to what use the dataset will, or should, serve.

It is merely a wish list for information, taking no consideration of what the information obtained will be used for. It is usually developed in a prescriptive manner from the top down. Managers are usually approached to state what information they would like to have included in the routine information system. They then make a list of all the data elements they would like collected. No consideration is given to the information requirements of the manager; it is only a list of data requirements. The main outlook of this approach is that data is a means in itself, i.e. just having lots of data is good enough. This is the most common approach (Sandiford, Annett, & Cibulskis, 1992, 1083). Often, a wish-list of data elements is supplied to the information unit, which is then expected to devise useful indicators that use the data elements contained in the wish-lists. Quite often it is not possible to develop any useful indicators from the data elements, precisely because when compiling the data elements little thought was given to what indicators could be produced from them.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 41 The Action-led Dataset

The action-led dataset is created to serve primarily the needs of users concerned with whether goals and targets established for the health services are being met. To determine the data elements to be included in the dataset, it has to be decided what measurements (i.e. indicators) would be necessary to measure whether the targets have been met. From these indicators, the data elements that will comprise the MDS/EDS are then determined. Usually, indicators are determined from two pieces of data which are then used as a numerator and a denominator in the calculation to determine the indicator, e.g.

cervical smears done on females over 30 years of age x 100 females 30 years and older

Sometimes both pieces have to be collected by the health services. In other cases, one of them may be obtained from another source. The data elements that have to be collected by the health services then have to be included in the MDS/EDS.

If, for example, a manager needs to know whether a programme has reached the target for cervical smear coverage in the high risk population of females over 30 years of age, then the cervical smear coverage indicator must be routinely calculated. Since the manager knows that the calculation is done by dividing the number of cervical smears done on females over 30 years of age by the target population of females 30 years and older and multiplying by 100, he/she can specify the data element with ease. It is: cervical smears done on females 30 years and older. This is then one data element to include in the MDS/EDS. The denominator – population of females over 30 years of age – would be gathered from the census figures.

In other words, specific goals and targets are set and then the indicators for these targets are determined. The data collected is then that required to produce the information about achievement of targets. The process is as follows: Identify Goal and Target  Information required about the Target  Data required for Information. Thus, before you can develop this type of MDS/EDS, you need to have determined all your Goals and Targets.

This is a desirable type of dataset (Sandiford, Annett, & Cibulskis, 1992, 1084), but it has a limiting factor in its application, because some targets are poorly conceived. If, for example, a politician proclaims a target without comparing or gauging it against baseline information, it would be difficult to gauge the realism of the target. The target may thus be flawed in that it is impracticable to achieve, or impossible to measure. This then results in the formulation of poor indicators, which results in the definition and collection of unsound data elements. SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 42 The Information-led Dataset

The final dataset, and the most useful of the three, is the information-led dataset. The departure point for this sort of dataset is to specify what information (i.e. indicators) is required that would be absolutely necessary to manage the health services well. The process for determining this type of dataset is: Identify Essential Information  Determine data elements required to produce the Information. Thus, the dataset is not specifically linked to particular goals and targets, as these may not yet have been set.

The procedures required to produce this information are then identified. These are:

. Determine the numerator – item that must be counted or gathered. . Determine who will collect/gather the numerator. This assigns responsibility. . Determine how the numerator will be collected. This ensures that practically feasible data elements are specified for collection and inclusion in the MDS/EDS. . Determine the denominator – item that must be counted or gathered. . Determine who will collect/gather the denominator. This assigns responsibility. . Determine how the denominator will be collected. Again, this ensures that practically feasible data elements are specified for collection and inclusion in the MDS/EDS.

TASK 5 - EVALUATE THE THREE TYPES OF DATASETS

(a) What is the purpose of a dataset? What functions does it fulfil?

(b) What qualities should a dataset therefore have (given its purpose)? Rate the three types of datasets in terms of usefulness.

(c) How would you decide which essential information, and hence which essential data elements to include in an information-led data set?

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 43 FEEDBACK

(a) The purpose of a dataset is, of course, to be a source of information for those responsible for the provision of health services, at whatever level, and to assist them in carrying out their functions better in running the health services.

(b) A dataset should, therefore, be comprehensive, while retaining the quality of “essentialness” in the information it contains. It should be helpful, as the key source of information, to different functionaries in the health service. It should provide needed information; information which provides a good enough picture of the situation to enable sound, (i.e. relevant, reflective and appropriate) decisions to be made.

(c) The following box lists some useful criteria to judge data elements against for a decision on whether to include or exclude them from the MDS/EDS:

Criteria to Judge Data Elements for Inclusion in the MDS/EDS

Before data elements are added to the MDS/EDS of any province or district, the following criteria should be considered:

. Is there an essential reason for the inclusion of this dataset? Has this reason been endorsed by a management group? . Is the event/occurrence being measured a problem (appropriateness)? . Will the indicator enhance comprehensive service delivery? . How long will it take to resolve the problem? (does it warrant continuous monitoring until the MDS/EDS is scheduled for a further review?) . Is sufficient information on the problem / issue already available elsewhere? . Are the numbers foreseen to be large enough (i.e. the counts) to justify inclusion into a routine information system? Is there no less labour-intensive technique to collect the data? . Is changing the indicator value within your direct scope of authority? . Will the calculated indicator change often enough to warrant routine monitoring (i.e. sensitivity towards intervention and changing health needs)? . Is the data element likely to be collected accurately and objectively, hence can it be defined clearly (i.e. validity)? . Are sufficient resources, time and personnel available to execute training on data collection before the new elements are introduced into the dataset? . Is it easy to count and will it require little staff time? . Will an intervention change the indicator value significantly, and often enough (i.e. monthly or at least quarterly)? . Are the necessary resources available to collect the information (both routinely and via surveys)? . Will the information be useful at the point of collection to improve the health services there?

Data elements that are selected as necessary for calculation of indicators, they must be judged against the criteria listed above. This is to avoid an over-inflated MDS/EDS.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 44 Whose Essential Dataset?

One more issue needs to be examined. We have stated that only the core information required to manage health services well must be included in the MDS/EDS. However, absolutely necessary information for one person may not be absolutely necessary for another. The problem is that different health programmes and various types of health staff would all have their own ideas of what the “Essential to Know” information is. In addition, regional, provincial and national management might require people at district level to collect information that district level people have little interest in. Defining this core set of information thus becomes a problematic issue. A valid question would be: how do we resolve this problem? There is no easy answer other than to say that the core information identified should not be identified by one person alone. Rather, the core set of information must be determined by a group, and by consensus.

Also, it is useful to specify in advance why information is regarded as falling within the absolutely necessary to know or the valuable to know band. In this way, the inclusion of certain pieces of information at the expense of others can be justified and explained by the entire management group.

8 HOW IS ROUTINE INFORMATION OBTAINED?

TASK 6 - IDENTIFY DATA COLLECTION TOOLS

Once data elements for collection in the routine information system have been specified, the practicalities of collecting the data would now have to be dealt with. We need to know what tools will be used to collect the data.

(a) What data collection tools do you know of?

FEEDBACK

The main tools available for data collection are: Individual Patient based Data Collection Tools Folders Clinic cards Patient held records Patient held cards e.g. “Road to Health cards” Combination of patient based and group based Data Collection Tools Registers (mainly used for short to medium term follow-up of patients) Birth register Malnutrition register SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 45 Tuberculosis register Immunisation register HIV/AIDS register

Forms (mainly used to collect detailed data) Birth notifications Death notifications Infectious disease notifications Tick-registers For collecting a combination of routine monthly data and individual patient data; Individual data is obtained by looking at an individual patient along a particular row of the tick-register to see what was done for him/her. Summarised monthly data are obtained by adding up the various columns that correspond to a data element. Lists Staff establishment lists and work attendance sheets Staff training courses lists Group Based Data Collection Tools Ticksheets Facility routine information Lists Facilities location, size and state of repair lists Equipment and furnishings list Prescription dispensing counts

Financial accounts Operating income and expenditure summary accounts Capital income and expenditure summary accounts

Surveys Housing (numbers, types, over-crowding) Municipal services (water provision, sanitation systems)

The following reading provides further discussion of data collection tools.

READING

Heywood, A. & Rohde, J. (2002). Using Information for Action. A Manual for Health Workers at Facility Level. Pretoria: Equity Project: 35 - 41.

A more detailed discussion of the correct use of these tools will be provided in the next unit of this module.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 46 9 HIERARCHICAL RELATIONSHIPS IN ROUTINE INFORMATION SYSTEMS

The managerial hierarchy of health services encompasses 5 general levels, and all these managerial levels require information. Each needs to know about all types of indicators, but at higher levels, they need less information as they are further from the service delivery point. Try to see if you can understand what the diagram (Figure 4) is depicting.

Figure 4: Hierarchical relationships in routine management information systems

Figure 4 shows that at the international level, international health agencies, such as the World Health Organisation, would require a specific set of information that is usually centered on assessing the health needs of populations and the outcomes of health service provision in different countries. A typical example of this type of information would be the Infant Mortality Rate. As you know, information is collected at the point of service provision. This has the implication that the information required by the international level has to be obtained from SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 47 the lowest levels of the hierarchy, because this is where the events/occurrences are counted. This further means that the package of international information- needs must pass through all managerial hierarchical levels to reach the international level.

Similarly, national levels may need more detailed information than the international level, since they are closer to the point of delivery and have greater responsibilities for managing the services. Again, the additional information must be collected at the lowest level and pass through all the managerial levels until it reaches the national level.

The same holds true for the provincial and district levels. Each needs a bit more detailed information, but only passes on the necessary required information to the higher levels. In our diagram, the lowest, i.e. first, level is the community and includes the health facilities. This means that of all the levels in the hierarchy, the health facility and community needs the most detailed information to manage the health services optimally. Of course, this diagram is only applicable to countries that have a fully decentralized district health system, because this allows action to be taken in response to information at lower levels.

Some of the implications of this diagram that has a bearing on the relationships between different levels in the routine information system are as follows:

. International- and national levels must embrace the concept of a MDS. Only the absolutely necessary information must be required. Otherwise, the dataset will be excessive at the point of collection. . Lower administrative levels in the hierarchy may add to the dataset specified for a country, but may not subtract. . The weight given to different steps in the rendering of good health services must be acknowledged at different levels of the hierarchy. This means that decentralisation should be complete in authority and resources. . Reporting must be timely, complete and accurate; otherwise, incorrect decisions may result at higher levels.

The reading by Sandiford et al (1992) discusses this issue in greater detail.

READING

Sandiford, P., Annett, H. & Cibulskis, R. (1992). What can Information Systems Do for Primary Health Care? An International Perspective. Soc Sci Med, 34 (10): 1077 - 1087.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 48 TASK 7 – CATEGORISING INDICATORS

(a) Group the list of indicators from your national health dataset into categories consisting of:

 Inputs  Process  Outputs  Outcomes

(b) Determine the proportion of indicators that should not be at their management level in a decentralised district health system (as per Figure 4).

10 THE RELATIONNSHIP BETWEEN ROUTINE INFORMATION SYSTEMS AND RESEARCH

Research can add value to the information collected by the district through the routine information system. Routine information systems focus on a core (minimum) set of information, and therefore cannot provide all the answers to questions pertaining to health service delivery. As a result, additional information should be obtained to assist us in completely addressing all the steps necessary for rendering good health services.

The Characteristics of Research

Research is very flexible in that it can give us a ready mix of quantitative and qualitative data to enhance our interpretation of events or situations. At times, research findings can also serve as the golden standard against which we judge the accuracy and performance of our routine health information system. Therefore, it is very useful to include research initiatives as part of the routine data collection of a health service, and to devise ways and means to integrate these initiatives into the routine information system.

The Differences Between Research and Routine Information

Some of the major differences between formal research studies and routine information systems can be summarised as follows:

 Research studies are carefully designed with usually a small number of data collectors involved. This facilitates the training of data collectors to ensure a common understanding of data elements. The data collectors are also usually appointed particularly for their role in data collection and SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 49 do not have to do much else. Therefore, data collection is their prime responsibility and they can easily see the relevance and importance of their efforts. In routine information systems, data collection is a secondary activity to the efforts of health care providers. Also, an extremely large number of data collectors are involved and they change often, due to staff turnover. This makes training difficult and hampers continuity in the training provided. The importance and relevance of this add-on duty is also more difficult to impart to data collectors (health staff) in routine information systems.  Research studies require complex analysis of data since the research is usually confined to a small area or sub-group of a population, (i.e. a sample). Therefore, careful statistical analysis is required so that generalisations can be made to the entire population. Routine information systems do not require these complex analyses since the entire population is covered, or attempts are made to cover it. Also, the majority of the readers/users of research reports are at different educational levels.  Research studies are usually conceptualized and supervised by highly skilled and trained professionals in the field of research. This is not the case in many instances of routine information systems.  In a good research study, the determination of the data that will be collected is a well thought-through process. Many routine information systems are based on a data-led type of dataset that does not render much useful information.  Due to the skills of the people involved in research, the findings of research studies are generally well accepted by health managers. Whereas with routine information systems, managers are less likely to accept negative findings or reports showing dramatic shortcomings, as they have a lower level of trust in routine information.  The people whose efforts are reflected in the findings of research studies are often not the ones involved in collecting the data, which means that the fabrication of data is less likely to occur. Routine information systems reflect the success or failure of the very people who collect the data. As a result, use of the information can serve as catalyst for data fabrication if accuracy checks are not applied, as people may not want to have their shortcomings exposed.  When one considers the amount of time spent (person-hours) on data collection, research studies are far cheaper than routine information systems.

There are many other differences between research and routine information systems, but the few discussed above are the main differences that will help you to conceptualise what routine information systems are and how they relate to formal research.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 50 11 SESSION SUMMARY

This session explained what a routine information system is. It explained the usefulness of the product of the routine information system, namely regular monitoring information, and showed you how it can be applied to improve service delivery in the district health system. It also covered what information we should obtain, and briefly mentioned how we obtain such information. The process of practically developing a MDS/EDS and how often data should be collected, was also explained. Finally, the hierarchical relationships within routine information systems and its differences to research studies were explained. If you feel comfortable in your understanding of the sections discussed in this session, you are well on your way to understanding the concept of routine information systems.

In summary, routine information can be useful to the DHS in the following ways:  To inform and thereby improve decision making with regard to: - Strategic Planning for the future - Daily Operational activities - Controlling activities (finances, personnel) - Policy Development  To identify problem areas and areas where health services need to be improved;  To directly increase the staff and community’s understanding of the functioning and outputs of the organisation;  To improve motivation of staff by highlighting improvements where appropriate;  To advocate for changes to facilitate further improvements in the health service.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 51 12 REFERENCES

. Lippeveld, T., Sauerborn, R. & Bodart, C. (2000). Design and Implementation of Health Information Systems. Geneva: WHO.

. Sandiford, P., Annett, H. & Cibulskis, R. (1992). What can Information Systems Do for Primary Health Care? An International Perspective. Soc Sci Med, 34 (10): 1077 - 1087.

. World Health Organisation. (1993). Guidelines for the Development of Health Management Information Systems. Manila: WHO.

. World Health Organisation. (1994). Information Support For New Public Health Action at District Level: Report of a WHO Expert Committee. Geneva: WHO.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 52 Unit 1 – Session 3 The Management Planning Cycle

Introduction

This session is the last in this unit. We continue to build a foundation for understanding the ensuing sessions and units in the module. We have up to know explored the District Health System context in which routine information systems operate, and we have answered some basic questions relating to the characteristics of routine information systems. This session describes the operational frameworks that information systems are built on. You are encouraged to keep these frameworks in mind throughout the module and try to see how each session fits into either of the management planning and information cycles. In this way, you are more likely to understand how routine health information systems should work, and how we can strengthen their role in ensuring that coverage and quality of health services are continuously improved.

The name of this course should suggest to you that we would like managers to use information to improve the effectiveness of their decision-making. This session will look at how managers make decisions and will explain the fundamental frameworks in which information is required to ensure rational management of health services. We will start by considering how managers make decisions.

Session Contents

1 Learning outcomes of this session 2 Readings 3 What information is used to make managerial decisions? 4 The Management Planning Cycle 5 Session summary 6 References

Timing of the session

This session contains one task and three readings. It could take you up to three hours to complete. A good point at which to take a break would be after section 4.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 53 1 LEARNING OUTCOMES OF THIS SESSION

By the end of this session, you should be able to:

. Appreciate the role that routine information could play in enhancing the decisions of managers. . Be familiar with the Management Planning Cycle.

2 READINGS

The readings for this session are listed below. You are expected to read all of the readings provided. It would be helpful to read them before you start the session.

Author/s Publication details Heywood, A. (2002). Using Information for Action. A Manual for Health Workers at Facility & Rohde, J. Level. Pretoria: Equity Project: 11 - 19. Monekosso, (1994). District Health Management: Planning, Implementing and Monitoring a G. L. Minimum Health for All Package – From Mediocrity to Excellence in Health Care. Maseru: WHO: 33 - 51.

3 WHAT INFORMATION IS REQUIRED BY MANAGERS TO MAKE DECISIONS?

In a decentralised health care system, much of the decisions that would enhance the performance of the health services, are made at the district level. For managers to make effective decisions that have a direct and appropriate influence in the actual situation, they need to draw on information. Generally, managers are motivated by many different reasons in taking their decisions. One of the most important motivations is related to the accountability of managers to higher levels (Gordon et al, 1998, 454-455). For this reason, if a decision is queried, the manager must be in a strong position to explain why the course was taken. As a result, it is useful to draw from one’s own resources to explain certain decisions since those are the things that we understand best. For instance, your knowledge of a specific topic would guide the decision that you would take in a specific situation, but faced with the same crossroads, a manager with a different professional background would probably take a different decision. It has been said that we look at the world through our own professional windows. This means SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 54 that a person trained as an Environmental Health Practitioner is likely to interpret, understand and act on a problem in a different way to say a Laboratory Technician. This may lead one to ask why the differences in understanding and resultant decisions. To help explain this, you are provided with Figure 5:

Figure 5: Information used to make managerial decisions

General Knowledge: (Lessons of Life)

Common Sense

General Training: (School)

Specific Training: (Tertiary education)

Experience/ Gut- Feel

Experience of Others: Routine (Respected Research: Information: Opinions, Group (Quantitative (Mainly Consensus) and Quantitative) Qualitative)

Figure 5 shows you that managers have various inherent resources to draw information from to guide the decisions that they make. These are often specific to individuals and therefore lead to differences in understanding and interpretation when confronted by issues that require a definitive choice. A brief description of each of these inherent resources is as follows:

 General Knowledge (Lessons of Life)

During our professional and personal lives, we learn many lessons. These lessons are usually the things that we hold dear and value. As a result, the motivation is strong to use this resource to understand and make choices in our professional careers. SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 55  Common Sense Some decisions are very easy and can be made by common sense. If you have very few alternatives and the justification for a particular decision is obvious, then we can say that the decision was taken with the aid of common sense.

 General Training (School) Most managers in the health care services have been through school training. Many managers attended different schools, or even at different eras of the schooling system. The lessons and skills that one learnt at school are often used during one’s day to day activities. Consider skills learnt through doing mathematics, geography, etc.

 Specific Training (Tertiary Education) The tertiary education that one receives plays a large role in the way that one understands and responds to health care issues. The example provided earlier is a case in point.

 Experience/ Gut Feel Usually, managers are appointed after having gained sufficient experience and skills to enable them to make good choices when confronted with critical decisions. It is generally agreed that if they do not have the necessary experience, they would not be in a position to make sound decisions in the management of health services. If you are a manager, you would realize that it has taken time to gain experience, and that you would probably make different decisions today (even if confronted with the same problem) than the day that you finished your basic tertiary qualification. Quite often, this general knowledge is the greatest resource that managers draw from when making decisions in their daily work.

 Experiences of Others (Respected Opinions, Group Consensus, etc) The opinions of others can be very valuable at times. Sometimes it is advisable to consult knowledgeable individuals before making important decisions. In this way, one can draw on their experiences, specific knowledge, gut feel, etc to enhance one’s own inherent resources. At times, one has to obtain group consensus before a decision is taken, this also informs one’s own decision.

 Routine Information and Research Most managers have access to research and routine information that has been collected in their districts. Unfortunately few managers use this information to inform the decisions they have to make. The diagram has

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 56 been purposefully drawn to illustrate the small proportion that routine information and research contributes to decision taking.

Many external, and powerful, factors also influence the decisions taken by managers. For example, the management styles of superiors, political influences, lack of resources, bureaucratic rules, regulations, etc.

It should be clear to you that we have to increase the role that routine information and research plays in influencing decisions taken by managers. But how do we accomplish this? What inherent resources that we draw on should we reduce? Should we reduce any? These questions are easily answered when considering Figure 6:

Figure 6: Information we should use to make managerial decisions

General Knowledge: (Lessons of Life)

Common Sense

General Training: (School)

Specific Training: (Tertiary training)

Experience/ Gut- Routine Feel Information: (Mainly Quantitative) Experience of Others: (Respected Opinions, Group Consensus

Research: (Quantitative and Qualitative)

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 57 Figure 6 shows that we need not sacrifice anything to increase the contribution that routine information and research plays in our decisions. Our inherent resources are not packed into a rigid container that is limiting our ability to expand our knowledge. We are using our brains that are very flexible and accommodating in increasing our inherent resources. Therefore, we do not want to limit the valuable role that experience, specific- and general knowledge, etc. plays in our decision-making processes. Rather, we want to enhance these resources by drawing more on routine information and relevant research. Using routine information and research results adds value to the manager’s decision making, enhancing the effectiveness of managerial decisions, at the same time increasing over time the manager’s overall knowledge.

So, how do we get managers to use routine information in a more disciplined manner when making decisions affecting the health service? Unfortunately, this concept is easier said than done. We surely cannot expect managers to drastically change the way they make their decisions overnight simply because we have provided them with these two diagrams. The answer is training managers in a more systematic way of reaching decisions. One such important technique is to follow the Management Planning Cycle. This will be discussed next.

4 THE MANAGEMENT PLANNING CYCLE

How health services are planned and provided is something that is often under discussion. When problems arise, critics are quick to point out that all aspects of a health service have not been planned properly and are poorly managed. It has also been mentioned on occasion that health services are only managed by gut-feel and no attempt is ever made to improve health services significantly. Hence: “The boat is merely kept afloat.” Pertinent information is ignored and services are not monitored and evaluated. At times, you may find that the press is the first to know of poor conditions arising from bad management and implementation of services. This is an unacceptable situation, but in defence of the managers, many managers do not know where to start or even how to go about the effective management of health services. In addition, many managers do not appreciate how information should be used in the planning, monitoring and evaluation of health services. The Management Planning Cycle is one useful framework to assist managers in accomplishing this seemingly difficult task. The framework asks four simple questions (Monekosso, 1994, 36). These are contained in Figure 7 below:

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 58 Figure 7: The Management Planning Cycle Stages

Tools Outputs Where are we now? Review of Situation Analysis Priority plans proble ms

Quality How will we know when information Where are we going? we arrive? Goals, Targets & Monitoring & Evaluation at every Indicators stage MDS

Key Key strategi interventio es ns How will we get there? Action Plans

You will note from Figure 7 that each of the four questions have tools to allow one to answer the questions. In addition, the tools should allow one to reach certain outputs. Also note that information has been placed in the middle of the diagram to show its relevance to each of the stages. Each stage could be explained as follows:

 Where are we now? The first question that needs to be asked for general- and programme district health services is where we are now. We need to determine what our departure point is (i.e. our baseline). We need to know how the health programmes and -services are performing. We may also need to know what resources we have to determine later what practically feasible interventions we can plan and implement. The tool that we use to answer the first question is the situation analysis. A situation analysis should be regularly performed in every health district to ensure that the profile of the district is up to date and to enable the management team to prioritise where scarce resources should be spent. It has been mentioned in session 1 of this module that we need to prioritise where intervention is needed the most in a district. Information can assist us in performing such a prioritisation exercise. If one considers the health need indicators for a specific district, then the indicator values could be compared to regional- or national averages (means) and the ones below the means could be

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 59 used as the first step in prioritising areas requiring intervention. Many different methods of prioritisation could be employed, but this module will not delve into this aspect of performing a situation analysis. Suffice it to say that the main aim of the situation analysis should be to gather information that would identify priority areas where we need to concentrate our efforts and scarce resources.

It is crucial to understand that a situation analysis does not need to involve expensive surveys and studies to be performed by outside agencies. Consider first what you already have available to you. For instance, interrogate the information already available in the routine health management information system. Consider reports produced by other agencies such as NGO’s, universities, other government departments, local government, etc. All of these agencies regularly produce factual reports that contain pertinent information to district health care services.

Once the priorities have been objectively identified for a district, one should move on to the next stage of the Management Planning Cycle. This requires us to state where we are going; now that we know where we are.

 Where are we going? Clearly we need to address the health priorities identified for the district. So the direction we are heading in is to satisfy the priority health needs of the high-risk areas we have identified. These priorities must be used as a baseline to gauge what is practically feasible to do about the situation. We need to develop strategies that would address the health needs of the communities served by the district in the best way possible. The statements that we compile to clarify strategies, are known as goals (broad objectives) and their related targets (specific objectives). In order to ensure that we can be held accountable for the achievement of these specific objectives, they need to comply with certain characteristics. These will be discussed in greater detail later in the module, but two of these characteristics are for them to be realistic and measurable. Specific objectives that are realistic must be determined after consulting information that depicts the current situation. If the current situation is not considered, then we cannot have realistic specific objectives that would be practically feasible to aim towards. Also, since they need to be measurable, we need units of measurement that can be tracked and communicated to all relevant (responsible) officials; these are known as indicators. The indicators that are specifically developed in relation to realistic specific objectives also need to conform to certain criteria. These will also be discussed later in the module.

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 60 This process of stating goals, determining sound specific objectives and their indicators is known as strategic planning. It needs to be understood that goals, specific objectives and targets must all be closely related to each other. If this is not the case, much time has been wasted in its development. In example, we could make the following related statements:

Goal: Improve the Tuberculosis Control Programme Specific Objective: To improve the Pulmonary Tuberculosis Care Rate to achieve 75% by the end of the 2004/2005 financial year Indicator: Pulmonary Tuberculosis Cure Rate

The next stage in the Management Planning Cycle that follows on from the strategic planning exercise is known as operational planning.

 How will we get there? Operational planning is different from strategic planning in that it is more specific (and usually over a shorter period). The outputs from the strategic planning phase are strategic directions of the health services that are practically feasible with clear timeframes attached. The outputs of operational planning are plans that list the individual activities necessary to achieve the specific objectives, with a responsible person, timeframe and budget clearly specified for each. As a result, the operational plans relate to the day-to-day activities that health services undertake. It allows control in that it ensures that commitments can be continuously tracked and non-performance can be immediately detected and rectified. The following extract of an operational plan is provided:

SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 61 Activity Timeframe Responsible Output Budget Train all health facility staff on treatment 100% training regimens for Pulmonary TB coverage of health 30 July R 30 000 Tuberculosis and Coordinator facilities providing procedures relating to TB services. sputum-taking. Written table Determine number of comparing community DOT Information available number of supporters required in 15 August officer and TB DOT supporters R 100 each catchment Coordinator per health facility population. with ideal number required. TB 90% of ideal Recruit and train Coordinator, number of DOT community DOT 15 Clinic supporters R 30 000 supporters for each November Supervisors recruited and catchment population. and Training trained for all health Coordinator facilities. Chief Continuous Ensure that an effective Pharmacist, monitoring system drug stock-out Clinic 15 developed with monitoring system is Supervisors, R 20 000 November action plans developed and Information developed for each implemented. Officer and TB health facility. Coordinator

The operational plan is an excellent source of information to ensure that the health services stay on track. It is closely related to the strategies determined in the strategic plans and contains a description of the interventions determined to improve the indicators specified for the attainment of the specific objectives. As a result, it is more flexible than the strategic plans. The key to well functioning operational plans is the continuous monitoring of the implementation of the activities, with highly responsive adaptation or amendment when needed. In other words, if indicator values do not improve, we need to change our operational plans to become more effective.

 How will we know when we have arrived? Information is crucial in monitoring the move towards attaining specific objectives. As stated before, if activities specified in the operational plans are not yielding the desired effect, the activities should be reviewed and adapted. This can only be done by closely monitoring the indicators determined for the district and relating their achievement towards the successful implementation of the activities noted in the operational plans. For this reason, together with the budget, the operational plan is the most important management tool of a health manager that must be continuously monitored and tracked in relation to the routine health information system SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 62 and its foundation (i.e. the strategic plan). Operational plans are dynamic documents and must be continuously reviewed by both individual managers and the district management team.

Once the timeframes of the specific objectives have elapsed, one needs to review their achievement and adjust the situation analysis accordingly, because this is when one moves forward to the first question in the cycle. Again, the new situation is analysed and the processes of strategic- and operational planning starts afresh. The fact that the Management Planning Cycle is circular implies that the cycle is continuous and attempts to continuously improve health services.

It is crucial that each of the stages in the cycle be supported with accurate, timeous and relevant information yielded from available sources. For the routine information system, one should follow stages contained in the information cycle to ensure that the information is available and useful. We will discuss this cycle in the next session.

TASK 1 - GATHERING INFORMATION FOR A SITUATION ANALYSIS

Make a list of all the places where you could obtain information to build a health profile (situation analysis) of your district.

FEEDBACK

Some of the sources that you may wish to consult include:

Formal internal information sources: o Routine health information system o Periodic surveys o Ad hoc surveys o Research- and consultancy reports.

Informal internal information sources: o Minutes from meetings o General knowledge o Contextual- and cultural knowledge gained through experience o Information gained by way of interaction with colleagues o Background knowledge of political ideals and priorities.

Formal external information sources: o Births and deaths registration system SOPH, UWC, Master of Public Health: Using Information for Effective Management of HealthCare Services – Unit 1 63 o Census o Demographic and health surveys o Research reports and dissertations o Information from the private health sector o Information from NGO’s, CBO’s and PVO’s.

Informal external information sources: o Media reports o Interaction with external role players.

5 SESSION SUMMARY

In this session, we showed the inner workings of typical managerial decision- making and argued for a greater role for routine information in decision-making. We also argued that, systematically used, routine information would enhance managerial decision-making. We introduced the Management Planning Cycle, as a strategy to improve the decision-making process, and ensure that managers use information to a larger extent in making decisions. A good understanding of this session can contribute to an improvement in your own performance at work, and set the scene for understanding the ensuing sessions with ease.

The most important aspects covered in this session relate are that strategic plans, operational plans and indicators generated in the routine information system are all closely related and form the basis for monitoring and evaluating health care services at district level. An understanding of the relationship between these elements is crucial for improvement in management of district health care services.

6 REFERENCES

. Gordon, D., Chapman, R., Kunov, H., Dolan, A. & Carter, M. (1998). Hospital Management Decision Support: A Balanced Scorecard Approach. IMIA: 453-456.

. World Health Organisation. (1993). Guidelines for the Development of Health Management Information Systems. Manila: WHO.

. Heywood, A. & Rohde, J. (2002). Using Information for Action. A Manual for Health Workers at Facility Level. Pretoria: Equity Project.

. Monekosso, G. L. (1994). District Health Management: Planning, Implementing and Monitoring a Minimum Health for all Package. Maseru: WHO.

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