Health service provision and
Health Information Systems
Two parts:
• Primary health care and the debate on how to provide it
– Some history of WHO and so-called «global health»
– Comprehensive vs selective PHC
– Implications on information systems
• The Health District
– Why is the software called DHIS?
– District as the area of managing primary health care
(Warning: the two concepts Primary Health Care and Primary care are
not the same.. More later…)
Part one: Primary health care and the
debate on how to provide it
• Main learning points
– WHO early focused on eradicating certain diseases
– The Alma Ata declaration from 1978 changed the focus towards general health, taking
into account social and economic issues also
– Decentralized Primary Health Care was seen as the core of government health
provision, a change away from curative hospital-based care
– How to implement it remains a debate: an integrated comprehensive (and complex)
way, or a selective (simpler) way?
– A selective approach has become dominant, and it has led to a fragmentation of efforts
– Fragmentation remains a challenge
WHO’s history of success with focused
programmes
•
•
•
•
Smallpox eradicated in 1977
Eliminating polio in the Americas in 1985
Eliminating measles in Southern Africa
Reducing guinea worm disease by 99% in 20
African countries between 1986 and 2005
• Relative successful compared to other UN
agencies (such as World Bank).
• Each disease eradication program operated
autonomously, with its own administration
and budget and very little integration into the
larger health system
4
Health systems continued to be
inefficient
•
•
•
•
Short-term successes were not addressing
poor populations overall disease burden
Health systems were urban based, hightechnology, curative oriented.
Gave little contact with the population for
preventive care
Health is socioeconomic:
– Health services, economy, security, education,
nutrition…
More comprehensive approaches emerged in a
number of developing countries
5
The Alma Ata declaration (1978) and
Primary Health Care (PHC)
“Primary Health Care is
essential health care based on
practical, scientifically sound
and socially acceptable
methods and technology
made universally accessible to
individuals and families in the
community through their full
participation and at a cost that
the community and country
can afford to maintain at every
stage of their development in
the spirit of selfreliance and
self-determination”
6
Primary Health Care
• Promotive, preventive, and curative
• Involves related sectors (education, food, agriculture etc), and
wider aims (equity, affordability etc)
• Promotes community and individual involvement and committment
• Came as a reaction to older, high-tech, curative approaches. Based
on bottom-up experiences from ”developing world”
• How to implement it? Comprehensive vs selective? Overarching
question ever since.
7
Comprehensive PHC
• “Some argue that comprehensive primary health care was an
experiment that failed; others contend that it was never truly
tested.”
– Magnussen, Ehiri, Jolly 2004
• Cuba a good example where it has been tested, and worked.
Also Mozambique and Nicaragua in the 1980s
• Abandoned as a WHO strategy already a year after it’s
formulation in 1978
• Why?
8
Selective PHC
• Launched just one year after Alma Ata, as an ”interim”
strategy to achieve results
• Abandoned the social and economic side of the health
strategy, and systems thinking in general, also for ICTs
• Narrow selection of specific conditions, mostly for women of
child bearing age, and children
– Immunization, growth monitoring, breastfeeding, oral rehydration
therapy
– Family planning, female education, food supplementation added later
9
Comprehensive vs. selective now?
• Both exists
• WHO is still very fragmented in specific programs, which are replicated at
country level
• http://www.who.int/about/structure/organigram/en/
• Cross-cutting units have been created (and died); Health Metrics Network
• In other areas, new agencies have been created to target specific areas:
Global Fund, UNAIDS, GAVI Alliance
10
HMN Framework: An example of
comprehensive appraoch to HIS
11
Comprehensive vs. selective:
information systems
• Comprehensive: integration, comprehensive information
needs, varied outputs
• Selective: Silos, fragmentation, inefficient development and
utilization of infrastructure. Closed-boundary ICT systems.
Potential for cross-comparison of indicators is lower.
• Both: provision of health services decentralized. IS needs to
allow local levels to collect, process, and use information
12
The MDGs in the PHC tradition
• Adopted by UN in 2000, to reach by 2015 goals related to:
1.
2.
3.
4.
5.
6.
7.
8.
Poverty and hunger
Universal primary education
Gender equality
Child mortality
Maternal health
HIV/AIDS, Malaria, and other diseases
Environmental sustainability
Developing global partnership for development
13
The MDGs in the PHC tradition
•
•
Despite the comprehensiveness of the MDGs, selective approaches
within health continues
Addresses some critique of selective PHC
– Take into account the broader context of development
– Does ackowledge the role of social and gender equity
•
Still challenges related to:
– Donor-driven technocratic approach to priorities, rather than grassroot
approach of Alma Ata
– Vertical objectives, fighting one disease at a time
– Little coordination among vertical programs
•
New actors find legitimacy in the MDGs for focusing on specific areas,
contributing to and sustaining fragmentation
•
The post-mdg era is approaching, what will it bring?
14
Concluding example: integration of data sources
supports comprehensive PHC management
CHIEFDOM LEAGUE TABLE
2ND QUARTER APRIL – JUNE 2009
Chiefdoms
% Full
Immunized
2nd
Quarter
% PHU
Delivery
2nd
Quarter
% 3rd
ANC
Visit
% 2nd
Dose
of
IPT
%
MMRC
Submitted
% Exclusive
Breastfeeding
at
Penta3
Average
Score
Ranking
Kongbora
98.2
45
170.9
96.6
86.6
93.3
5.3
1
Fakunya
124.3
62
154.3
86.2
100.0
48.1
5.0
2
Dasse
134.9
57
90.5
86.3
100.0
45.9
4.8
3
Kaiyamba
90.3
55
162.7
93.4
75.0
71.3
4.8
3
Timidale
140.3
46
106.8
91.7
91.7
33.0
4.8
3
Kowa
118.4
52
96.5
46.7
100.0
78.2
4.7
6
Lower Banta
88.3
48
201.6
120.8
100.0
35.6
4.7
6
Bagruwa
61.4
37
110.3
92.4
93.0
32.1
4.3
8
Kamaje
55.6
35
69.7
140.7
100.0
86.5
4.3
8
Kargboro
80.4
45
93.2
77.6
100.0
36.5
4.3
8
Kori
49.8
40
92.6
89.4
86.6
64.0
4.3
8
Ribbi
71.8
26
53.7
57.4
100.0
60.5
3.7
12
Upper Banta
61.1
29
68.0
101.2
77.8
38.6
3.7
12
Bumpeh
54.9
29
73.8
38.2
100.0
28.3
3.2
14
Total
91.4
43
114.3
32.4
93.6
20.8
15
The Health District
or
Searching for efficient management of
primary health care
Part two: The Health District
• Main learning points
– We talk about health management information systems;
assisting in managing health services is the goal
– The «District» as a concept of appropriate first level of
management
– There is no ideal district; it is a balance of resources, aims,
organization etc. They exist in most countries under names
like district, county, kommune, etc
District: Bridge between primary,
secondary, (tertiary care)
Primary care: most health
care, first point of
consultation for all patients
Secondary care: provided by
medical specialists who in
general do not have first
contact with patients.
Referrals; for example to
radiology (x-ray)
Tertiary care: specialized
health care for inpatients in
hospitals
(not in districts)
What are the characteristics of a health district ?
Clearly delineated geographical area
Population between 30,000 and
500,000 (most cases)
Identifiable form of local government
Managed by few officers
Balance between population size and availablity of technical
specialised staff
What advantages presents the health district ?
It is close enough to the community (“the patient” to
understand and act on its problems and constraints
It is the most suitable place to provide support to
health workers in the health posts and health centres
It has easier communication with the community to
ensure its participation in planning and organization
It presents large potential for effective collaboration with
other sectors towards the health of the community
It is the most appropriate level for coordinating top-down
and bottom-up planning
It has the ability to handle decentralisation of
resources and of decision-making
Why size matters ?
If the health districts are too small:
....greater number of health districts, then...
 more management structures and systems
 cohesion and co-ordination more difficult at a national or provincial level
 it will cost more and fail to capture economies of scale
 district hospitals will be managed as separate entities from the rest of
primary level health care
 could create a further dislocation between primary level services and
district hospital services (many health districts without a district hospital)
If the health districts are too large...
 district-level management can become unwieldy and bureaucratic
 the District loses its “service delivery" functions
The District becomes too remote from the community.
Health Centre/Dispensary
• Curative care of acute and chronically sick patients who do not require a
doctor (ideally up to 85% of all cases)
• Antenatal care
• Obstetrics
• Family planning
• Infant care including vaccinations and development checks
• Community development (primary disease prevention in particularm as
regards drinking water, disposal of solid waste and waste water,medical
back-up for traditional birth attendants,village health workers, social
workers, youth initiatives)
District Hospital
• Treatment of outpatients and management of emergencies
• Surgery (moderately complex surgery in the fields of obstetrics, general
surgery, traumatology, urology)
• Treatment of serious internal and pediatric cases
• Technically complex diagnostics (radiology, ultrasound, laboratory)
• Training and upgrading (especially for other district staff)
• Collaboration on both clinical and public health studies and operational
research
• Collaboration on the supervision of health centres/dispensaries
• echnical services and maintenance (for the entire district)
District Health Management Team
• Planning and management of the DHS including financial planning
• Personnel assignment and further training
• Management of physical resources including procurement of drugs,
medical supplies and equipment
• Organisation of supervision
• Responsibility for the uninterrupted supply of drugs
• Coordination of studies and operational research
• Inter-sectoral cooperation
Lov om kommunale helse- og omsorgstjenester
What is the role of the HMIS in the health
district?