My dear Aru, probably we both are passengers of the same boat and let me allow to share a shear ground reality and though I know the solution to address this major issue of fragmented Health Information System (HIS) or Management
Information Systems (MISs) in Public Health Sector in Pakistan, yet I will request my CoP colleagues to suggest their solutions.
Now in the following text, what I am presenting is “The Reality” of many developing countries. The example is taken from only one sector i.e. Public
Health Sector and it will give you a glimpse of fragmented information systems in single sector. How can we move forward for Integrated RBM?
A brief Overview of Health Information Systems (HISs) in Public Health
Sector in Pakistan
1 Health Management Information System (HMIS)
Health Management Information System (HMIS) in Pakistan was established in
1992 and completed its implementation for the first level care facilities (HMIS-
FLCF) in August 2000. The review of relevant documents and reports showed that HMIS only collects routine data related to service delivery and utilization, logistics, and very limited disease surveillance from FLCF named Basic Health
Units (BHUs,) Rural Health Centers (RHCs) and Maternal and Child Health
(MCH) centers. It does not cater secondary hospitals, private sector and other autonomous and parastatal institutions.
2 Lady Health Worker Program Information System (LHW MIS):
The LHW program is managed by the Federal Program Implementation Unit
(FPIU) attached to the MOH. The FPIU is responsible for Primary Health Care
(PHC) policy advice, national reporting, internal monitoring and evaluation, training, procurement and distribution, payroll, operational planning, budgeting, and financial accounting. There are provincial PIUs and district PIUs to whom some level of management functions have been delegated. The implementation and management of LHW program in the district is responsibility of Executive
District Officer of Health (EDOH) and in principle information generated by LHW information system goes up to federal level through EDOH. The LHW program collects information from community level on specific hand full of indicators relevant to logistics and service delivery and reported to district program unit through Lady Health Supervisor (LHS). All reports are compiled with the help of software at district level and reported to FPIU. Therefore LHW program information is not shared at facility level with facility in-charges i.e. BHU & RHC), who are responsible for healthcare services for the catchment population.
3 Malaria, EPI and TB Program HISs
These programs are managed by the FPIU. At provincial and district level, provincial program managers and district program coordinators have certain level of management functions. As is the case for LHW program, EDOH has responsibility for implementation and management of these programs at district

level and information generated by HIS of each program goes up to federal level through EDOH. There is little sharing of information at facility level.
4 HIV/AIDS HIS
The HIV/AIDS PIU has been established at federal level with provincial offices in each province. The program is focusing on surveillance and preventive activities.
Any HIV positive case is reported to provincial office, which immediately take care of all the activities related to the handling of the case. The provincial offices compile quarterly reports and transfer to federal office for national level compilation of all data related to HIV/AIDS. These quarterly reports consist of new and existing cases and their follow up reports. Most of the staff is recruited and placed at FPIU and no specific designated staff available for program activities at district level. The regular district staff especially hospital consultants inform the provincial cell through EDOH regarding suspicious HIV positive cases.
As a parallel program, all resources are made available to provincial offices.
5 Population and Welfare Department MIS
The department runs Reproductive Health Services Centers (RHS Centers) at district level for provision of interventional contraceptive services. The field staff
(motivators) refers cases to these centers for contraceptive surgeries, while noninvasive services e.g. oral and injectable contraceptives are provided to the communities through field staff. The department maintains its own HIS, which mostly, captures logistics related information from central store down to community level. The data from outlets is transferred to district level, which compile and then send to federal level. The department collaborates with EDOH only during monthly district coordination meeting. The contraceptive material for services, stationary for MIS activities, and all other necessary support material are provided by the department.
6 DEWS Implementation System
The Disease Early Warning System (DEWS) has been introduced in a few pilot districts and main purpose is timely detection of epidemics. This is still in very premature stage and managed at federal level. The program related charts and other stationary have been made available in a few DEWS pilot districts for recording of data and information. The FPIU has also provided training to the selected staff in the DEWS pilot districts.
7 Service Statistics
The service statistics are collected and reported through HMIS-FLCF to the districts, while hospitals maintain their own records and only report on OPD,
Indoor admissions and deaths in the hospital. Annually, hospitals maintain abstract register for priority diseases and report to Director General Health
Services (DGHS), who simply transfer to Federal Bio-statistics Cell. The service statistics is maintained by the district and transmits relevant compiled reports to province for onward submission to federal HMIS and Biostatistics Cell. The hospital reports on a few selected indicators are sent to EDOH and DGHS

monthly and annually. The logistics support for services statistics/HIS activities is procured through respective institutional budgets.
8 Logistics MIS
The record keeping for stores, drugs and equipment is maintained by the store keepers on prescribed instruments/registers. As a separate, logistics HIS does not exist in the district with regular reporting. The paper-based record keeping is done and managers are informed whenever procurement is required. The district health institutions e.g. EDOH, DOH and Hospital Managers (MSs) maintain their stock registers through respective store keepers. The managers are responsible to verify the stocks on regular basis. The registers and indent books are purchased through regular stationary budget, and regular staff of DHD is designated as storekeepers, where such vacancies are not available. No specific training is provided; all learning is through experience and guidance from senior storekeepers.
9 Financial MIS
The Financial Management Information System (FMIS) is one of the most organized and accurate paper-based system in the district. The budget is dispersed by EDO (Finance & Planning) through EDOH to all the institutional
Drawing and Disbursing Offices (DDOs), which are EDOH, DOH, in-charges of training institutes and MSs of Tehsile and District (THQ and DHQ) hospitals. The budget is broadly provided into salary and non-salary component and then each broken into line items. The actual money is officially transferred to District
Account Officer, (DAO) who is responsible to release payments on production of original bills/invoices duly signed and verified by the DDOs.
10 Human Resource MIS:
The HRMIS is second to FMIS in terms of its data quality. This is again paper based and only provides information on vacancy position, personal files, transfer and posting, disciplinary proceedings and actions. The original appointment records are also maintained in the office of EDOH/PHD and respective institutions. The personal files at duty station are maintained. Otherwise there is no proper system to maintain overall data for human resources. Mostly information is generated on demand from higher levels. The office stationary and other registers are procured through regular budget. The establishment branch at
EDOH office and senior establishment clerks at DHQ hospital and DOH office maintain these records.
11 Notifiable Disease Surveillance
The data and information on notifiable disease is provided through routine HMIS-
FLCF and EPI MIS. Currently AFP (Polio) surveillance is the most active and accurate in Pakistan. These reports are also collected from private sector. Other source of information is from media and reporting by some very vigilant facility incharge. Apart from EPI preventable diseases, the disease surveillance system is quite poor and almost non-existent. The resources for routine notification of

diseases are the responsibility of the district. The stationary for program specific surveillance activities is provided by FPIU through provinces. The staff belongs to the district and paid by DHD.
12 Vital Statistics:
The vital statistics are recorded and maintained in the office of the nazim (elected district assembly member) union council. The births and deaths are reported only for the purpose of getting certificate for some legal requirement. The information from union council office is transferred to Tehsil office to be kept in master register. The births and deaths are reported in the office of union council nazim, which issues a certificate. The monthly compiled statistics are sent to tehsil office. None of the information is shared with Health Department at any level.
13 Capital Asset MIS
There is no MIS for assets as a system. All institutions maintain a master stock register for assets e.g. major equipment, vehicles, ambulances and building. The store keeper maintains the records in master register for future reference. A separate register for repair and maintenance history is also maintained especially at hospitals and DOH offices.
This is just one example from one of the key social sector and same picture regarding fragmentation of MISs can be seen in other social sectors e.g. education, Ministry of Population and Welfare.
Every expert and professional knows the solution, many a times proposed as recommendation by internal MIS study teams (most recent being JICA Study
Team —I was also member of this study team and worked with them for three years to improve HIS in Pakistan) but………………………..!
So what is needed “First” for IRBM……………….Capacity or Commitment!!!!!!!!!!
Integrated or Enclave Approach
I leave it to you to decide.
Again Thanks to EID Holidays
Dr. Sohail Amjad