Rapid Assessment of Bhutan's Health Management Information System:Randy Wilson, Scott McKeown, Hare Ram Bhattarai, Management Sciences for Health Abstract: As part of Management Sciences for Health/EuroHealth Group's (MSH/EHG) technical assistance for the enhancement of Bhutan's Health Management Information System, a rapid assessment was carried out over a 4-week period from May 22 to June 15, 2000. The rapid assessment was designed and conducted by HMIS Task Force staff from the Ministry of Health and Education with technical support from a 3-person team from Management Sciences for Health. This project was funded by DANIDA, the Danish government's development assistance program, at the request of Bhutan's Ministry of Health & Education. The purpose of the assessment was to provide quantitative and qualitative measures of the current performance of a health management information system in order to identify functional problems which can then be used to guide the design of improvements to procedures for recording & reporting; for data analysis, presentation, and communications; and for the use of health data for decision-making and action. Data were collected using 4 standard questionnaire formats by 3 separate assessment teams during 5 days of visits in 7 of Bhutan's 20 Districts. A total of 23 health facilities were visited, including Basic Health Units (BHUs), District Hospitals and District Health Supervisor Officer's (DHSO) offices. During this time, a detailed Information Technology Assessment was also conducted. The rapid assessment focused principally upon knowledge and practice of health workers with respect to data management (collection, processing & use), the availability and appropriateness of resources, the general organisation of system procedures. It also solicited health workers' attitudes about problem areas and suggestions for improvement. Five different information sub-systems of the National HMIS were selected for detailed review, these included:
Data were tallied manually and using electronic spreadsheets in order to prepare thematic data summary sheets, which were discussed by HMIS task force members and other health programme staff during a 2-day workshop. This group interpreted the data and came up with initial conclusions and recommendations. The principal conclusions from rapid assessment identified a wide variety of strengths of the existing HMIS. For example, adequate resources existed at the service delivery points and district levels for the uninterrupted recording and reporting of data, and there are good manual systems for filing and retrieval of past reports at the BHU/Hospital level. Staff seemed to have a good understanding of the potential uses of the information they collect and, particularly at the Basic Health Unit (BHU) level staff devote considerable effort to presenting key population and service data on wall charts, graphs and maps. Routine reporting from health facilities to districts was very effective as evidenced by very high reporting rates, although there is confusion about reporting deadlines for some of the sub-systems (e.g. Village Summary Sheets and Drug Reports). A number of problems were also identified, many of which are similar to those identified in other countries. These included the observation that too much data is collected in current recording and reporting formats and not enough is used. There is also confusion about the calculation of several key indicators and how to estimate population targets (especially in family planning and drug management). There was a lack of systematic feedback (especially written feedback) between levels of the health system regarding reporting errors and especially for providing analysis of reported data. Most alarming was the discovery of serious problems with data quality originating at the service delivery point, which are further compounded at the district level. The assessment also found that although computers exist and function well at the district level, they are not used systematically to help with data analysis and electronic communications. There was no mechanism, either at the central level or within districts, to build upon the individual initiatives of certain districts and cross-fertilise these uniformly throughout the country. At the national level there are also adequate numbers of computers, but the small team within the Health Information Unit is inadequately staffed and lacks skills in database management and computer hardware troubleshooting which are necessary to support more effective use of this technology. Changes in staffing have also had an important negative impact on the HMIS. Due to recent staff changes at the central level, the Health Information Unit now lacks personnel with training in epidemiology and health service delivery. This expertise is critical for ensuring that surveillance functions at the national level are carried out effectively and for helping to interpret data on significant disease or service trends for feedback reports and the annual health bulletin. Based upon these finding, the Ministry of Health developed 37 specific recommendations for improvements related to:
Conducting an HMIS Rapid Assessment such as this is an important early step in HMIS enhancement efforts. Doing this as a participative process (including all stages from instrument design to data analysis) builds ownership of conclusions and develops data collection & analysis skills. Certain rapid assessment procedures, such as the data audits, can be incorporated into routine supervision and help to monitor the effectiveness of system enhancement efforts. Conducting and indicator selection exercise before undertaking a rapid assessment helps to focus efforts to assess the 'use of data' on the important indicators - but it is less practical if those indicators are not yet being collected. |