Woinshet Abdella
PhD Student
Department of Informatcs
University of Oslo

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Background
• Ethiopia / Health Care System
HISP Ethiopia
DHIS Implementation in Addis &
Oromia
Challenges

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Population - 72+ million
Area – 1.1 million km 2
Decentralized administrative structure
• 9 regional states & two city administrations
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580 weredas (districts)
Regional sates are autonomous
Poor literacy, education, health status

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MOH, Regional health bureaus, Zonal health departments, Wereda/Sub-city health offices, Health Facilities
Under developed
Health service coverage – 61%
MMR – 871/100,000, U5MR – 140/1000
High Infectious & communicable diseases
HIS is primarily manual & under developed

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Project Initiation
• Through a collaboration of the
Department of Information Science,
Addis Ababa University (AAU) and the
University of Oslo in February 2003.
Partners
• AAU; regional health bureaus of
Ethiopia; global HISP

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Objective
• Introducing computer based HMIS in
Ethiopia in view of supporting local analysis and use of data

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HISP Members
• 4 PhD students / 7 Masters students
(one Norwegian)
• 5 DHIS facilitators hired by HISP
Research Sites for HISP Ethiopia
• Addis Ababa, Oromia, Tigray, Amhara,
Benishangul-Gumuz
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DHIS implementation is being carried out
• Addis & Oromia – since Jan 04
• Others – since June 04
Different stages of implementation

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Research Objective
• key research objective is to broadly understand the challenges and opportunities with respect to the integration of existing paper-based HIS with computerbased systems in Ethiopia.
Theoretical Perspective
• ANT
Research Approach & context
• PAR
AR intervention:
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HIS implementation Intervention into health organizations
(AAHB & OHB)
One DHIS facilitator for each region

Research Approach & context
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Research Site
• Addis Ababa health bureau (AAHB) ,
• 10 sub-cities (districts)
• 500 public & private health facilities,
• located in Addis Ababa city
Administration (Province).
• Addis Ababa is the capital city of
Ethiopia (540 km2 )
• Population is 3 millions.

Research Approach & context
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Researcher Role.
• The role assumed was an involved researcher through action research.
• Qualitative data collection method was employed including
 photography, observations, interviews, discussions, meetings, workshops, training, action experiments, document analysis, telephone calls, visit related institutions, informal lunch/tea meetings.

Research Approach & context
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Research subjects
• managers and planners at different levels of the health structure, the health workers responsible in data collections and analysis.

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Negotiate research access (KK)
Situation analysis (Mar 03 – Aug 03)
• Visits to Health bureaus & HFs
Initiating the Design / implementation process with
AAHB/OHB (Dec 03) (Bureau)
EPR was just introduced then
Prototype system was developed and populated with 9 months own data

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Demonstration of the prototype DHIS
Addis (Jan 04)
• The experiences gained revealed the problems with the existing HMIS
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Data duplication, fragmentation, …
• Local requirement (Morbidity/Mortality data handling) identified that DHIS does not support efficiently
Developing minimum health data set
& health indicators was proposed

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Major decisions
• The proposal for standardizing data set/health indicators accepted
• Adapting DHIS based on new dataset and reporting requirement
• Adding module to accommodate M/M data handling
• Implementing DHIS to ALL Sub-cities.
Team formed

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The research team was composed of
Bureau level ,
• Bureau head;
• health service head (leader of the project on the part of the bureau), team leader, and senior expert;
• family health head, team leader and expert;
• Disease Prevention and Control head; IDSR team leader, TB /
Leprosy and HIV/Aids program team leader and senior expert;
• IEC expert;
• Network administrator;
Sub-city Level
• two family health experts
Facility Level
• two health facility managers;
And the researcher.

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Two Parallel activities performed
• Standardized data set, health indicators, data collection & reporting instruments & procedures (data flow, …) development
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Draft prepared by the group presented for workshops, comments incorporated, the draft was further developed in a series of long meetings,
• Development of Morbidity & Mortality module
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Iterative / incremental (involved one major revision)

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Use of DHIS as a prototyping tool
 to better understand user requirements for producing an improved & useful system – which potentially increases data use
The standardized data set is implemented in all facilities
DHIS adapted, the new module incorporated
• ( Input Form , DHIS Data Flow , Data Entry (next slide), Pivot
Table Report , Standard Report )

Monthly Routine
Data Entry/Edit
Form
Monthly Morbidity and Mortality Data
Entry/Edit Form

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DHIS is implemented
• All districts (10 sub-cities) and AAHB initially
• Scaled to health facility levels
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18/23-Health centers & 5/5-Hospitals (when resource / situation allowed )
Training (DHIS/computer basics) was given to sub-city/bureau/HF health staff / managers / data clerk / DHIS facilitators (with own data)
Technical support is being provided by the facilitator
Participatory design
July 2005, Workshop for evaluating one year experience of the use DHIS

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DHIS Software is well-tested & supports
• Data aggregation; data sharing; health structure implementation; easily adaptable for new needs, which is inevitable; rapid set-up of
DHIS application for a new setting
Complaints from different actors (use of
MS Access in DHIS – DHIS 2 is a response)

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Collection/reporting instruments and software prepared for Addis is shared by
Oromia & other regions
Followed similar approach
• Some of the differences
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The process was slower when compared to Addis
The minimum data set prepared for Oromia not yet adopted by the region
DHIS implementation status
• Some Weredas of East Shewa zone (based on computer availability)
• Is being rolled out to the remaining zones (at the zone level only)

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Improving data quality, data analysis and use
Reduce / Improve dataset
Achieving partnership with MOH
Scaling & Sustainability
Over burdened health worker
Limited resource
Negotiating with multiple actors
Parallel systems