UNIVER SITY OF OSLO Departtttmentttt of Informattttiiiics ... ... Data Flows in HealthHealth Information Systems An action research study of reporting routine health delivery services and implementation of computer databases in health information systems Juma Hemed Lungo Master Thesis nd 2 May 2003 DATA FLOWS IN HEALTH INFORMATION SYSTEMS AN ACTION RESEARCH STUDY OF REPORTING ROUTINE HEALTH DELIVERY SERVICES AND IMPLEMENTATION OF COMPUTER DATABASES IN HEALTH INFORMATION SYSTEMS by Juma Hemed Lungo THESIS SUBMITTED AS PARTIAL FULFILMENT OF THE REQUIREMENTS OF THE DEGREE “MASTERS OF SCIENCE IN INFORMATION SYSTEMS” AT THE DEPARTMENT OF INFORMATICS, UNIVERSITY OF OSLO, NORWAY DECLARATION I, Juma Hemed Lungo, declare that Data flows in health information systems: An action research study of reporting routine health delivery services and implementation of computer databases in health information systems is my original work and that all the sources that I have used or quoted have been indicated and acknowledged by means of complete references. juma hemed lungo 2nd May 2003 i ACKNOWLEDGEMENT First, I wish to thanks my research supervisor, Prof. Jørn Braa, for his guidance. Thanks to my classmates Faraja, Gertrudes, and Teotónio, I enjoyed their hot discussions and exchanging idea all the time we have been together. Special thanks are due to my lecturers who actually made it possible: Prof. Jens Kaasbøll, Prof. Judith Gregory, Dr. Knut Rolland, and Prof. Sundeep Sahay, all from the University of Oslo; Dr. Daudi Simba from the University of Dar es Salaam; and Prof. Yussuf Adam from the Eduardo Mondlane University. To Eduardo Mondlane University, my thanks for accommodation in Mozambique, and thanks to Mr. Paulo Eduardo for translations of my questionnaires. To my housekeeper, Mr. David Zimba, thanks for making coffee for me during the writing of this thesis. I also wish to acknowledge with thanks personally to Samuel Ngatunga, Wilfred Yohana and Theonas Mkoba from the Ministry of Health in Tanzania; Christian Haule, Omary Dihenga and Wambura from Bagamoyo District Medical Office, Bruno Pióti and António Sitói from the Ministry of Health in Mozambique; Nhampossa, Emilio, and the whole HISP team in Mozambique. I am most grateful to Eurico Romao for his through editing. To my father, Hemed Abdallah Madende, and my mother, Khadija Zuberi Mnese, thanks for your support throughout my life. My son, Hemed Madende, thanks for your patient while I was living away from the family, and I would like to give special thanks to my wife, Tatu Sultan Ally, for her unconditional love, care, and encouragement throughout my career. It is difficult to mention all individuals and appreciate the contributions every one gave me. I wish to express my sincere gratitude to all those who have helped me in various ways making this research come through. The research has been generously funded by The Norwegian Agency for Development Cooperation (NORAD) Fellowship Programme. Finally, I would like to mention that the material discussed in this thesis are relevant to the facts obtained during the fieldwork and the conclusions suggested are my opinions based on my professional judgement. ii ABSTRACT This study evaluated the reporting of routine health delivery services and prototyped a computer database, district health information software (DHIS), in the health information systems in Tanzania and Mozambique using case study sites in Bagamoyo district and Gaza province in Tanzania and Mozambique, respectively, from March to August 2002. The purpose of the study was to assess and determine the quality and quantity of reporting of health delivery services; and the benefit, challenges, and conditions for implementing a computer database at the district level of the health information systems in both countries. The study falls under the framework of action research, where the phases of action research (diagnosis, action planning, action taking, evaluation, and specifying learning) were executed in sequence and cyclically. The diagnosis phase of the study was carried out through interviews, questionnaire, analysis of texts and documents, and participant observations. Appropriate actions were planned. In the action phase, software was developed in order to migrate data from existing computer databases to the DHIS; data were migrated from paper-based databases to the DHIS; and the DHIS was translated into Swahili while adopted in Tanzania. Evaluation of the actions taken was conducted through group discussions and workshops with health workers. To specify learning, reports of the results were prepared and presented to the Ministries of Health for review. The results were analysed using the DHIS, SPSS computer software, and using content analysis. The findings were presented quantitatively and qualitatively using tables, graphs, figures, photos, and elaboration. The findings indicated that the health data being reported were not sufficient to support informed decision-making and health planning. The causes of the low quality of the data identified include incomplete, inaccurate, and untimely reporting; lack of resources and office space; existence of legacy information systems; and the existence of parallel reporting systems in the health information systems. The findings also indicated the major challenges in introducing computer databases to be the participation of users and the existing computer database systems. The study demonstrated that the DHIS is suitable software for the health information systems, and that data locked in legacy information systems can be safely extracted and migrated to new information systems. iii TABLE OF CONTENTS DECLARATION................................................................................................................ i ACKNOWLEDGEMENT................................................................................................ ii ABSTRACT......................................................................................................................iii LIST OF TABLES .......................................................................................................... vii LIST OF FIGURES ........................................................................................................ vii LIST OF PHOTOS ........................................................................................................viii LIST OF ABBREVIATIONS ......................................................................................... ix CHAPTER 1: INTRODUCTION.................................................................................... 1 1.1 Why health information systems? ......................................................................... 1 1.2 The research domain area...................................................................................... 2 1.3 Relevant previous findings in the research domain area .................................... 4 1.4 The research problem............................................................................................. 6 1.5 Research objectives................................................................................................. 7 1.6 Personal motivation ................................................................................................ 8 1.7 Intended audience................................................................................................... 9 1.8 Research approach.................................................................................................. 9 1.9 Organisation of the thesis document................................................................... 10 CHAPTER 2: LITERATURE REVIEW ..................................................................... 11 2.1 Information Technology (IT) and Information Systems (IS) ........................... 11 2.2 IT in Developing Countries.................................................................................. 12 2.3 Information Systems (IS) as Social Systems....................................................... 15 2.4 Legacy Information Systems................................................................................ 19 2.5 Approaches to information systems development ............................................. 22 2.6 Efforts to Reform Health Information Systems................................................. 27 2.7 Chapter Summary ................................................................................................ 33 CHAPTER 3: RESEARCH SETTINGS AND RESEARCH METHODS ................ 34 3.1 Research settings................................................................................................... 34 3.2 The research design .............................................................................................. 41 3.3 Methodology .......................................................................................................... 41 3.4 Data collection methods........................................................................................ 47 iv 3.5 Data analysis techniques ...................................................................................... 53 3.6 Justifications of the use of participatory action research methodology........... 55 3.7 Chapter summary ................................................................................................. 57 CHAPTER 4: APPLICATION SOFTWARE AND DISCUSSION........................... 58 4.1 The computer database of the Ministry of Health in Mozambique