ESTABLISHMENT OF AN INFORMATION CULTURE: ACHIEVEMENTS AND CHALLENGES IN ZAMBIA

by Alex Simwanza and Mary Church

Abstract: In mid 1996 the Government of Zambia, along with several partners, embarked on the design, development, and implementation of a Health Management Information System (HMIS) in the context of broad health reforms. The system was intended to:

• support decentralized and integrated planning and management of services, especially at the facility and district levels;
• provide timely and accurate information for evidence based decision making;
• improve the efficiency and effectiveness of data collection and transfer by replacing multiple reporting channels with a single reporting channel.

Other nations had implemented health information systems with similar objectives in the preceding decade, and the Zambia team tried to build on that experience.

Now, in spring 2001, nearly five years later, the system has been deployed nationwide for more than two years. Substantial progress has been made towards these initial objectives. In some locations one can see ongoing improvement in managers' skills and confidence in using information. But this is by no means the situation nationwide. As use of the HMIS has evolved, several new challenges have emerged. In brief, there is

• limited institutional guidance for the HMIS from upper to lower levels;
• substantial variation in ability to use the system among provinces, among districts, and among facilities;
• more difficulty than anticipated in stimulating use of information for management at facilities and districts, and, as a result, in collecting reliable data.

These constraints compromise the quality of the data and hence the evidence used for decision-making. Decisions made on the basis of poor quality evidence, even if not downright harmful, may result in poor or ineffectual use of resources.

To understand the reasons for these shortcomings of the Zambia HMIS, this system was compared with other systems that had served as models for Zambia. It appears that other systems have faced similar constraints. Frank acknowledgement of implementation difficulties faced by all will lead to solutions that reflect a broad experience.

It appears that many of the integrated nationwide systems are at the same evolutionary sticking point. We have substantially and measurably improved the flow of information and health workers' appreciation of the use of information. We have not yet achieved our goals of providing reliable information and institutionalizing evidence based decision-making at all levels of the health pyramid. And we don't have a way to estimate how far away we are from those goals. Deeper understanding of the determinants of the information system's viability after a few years of operation would produce more robust system designs and would help move forward the process of creating an institutional culture that values and uses information.

In summary, as a direct result of program reforms, Ukrainians now have evidence of previously hidden major constraints in their public health service delivery systems. Problem areas (raions) have been identified and interventions targeted to identify and correct the source of program deficiencies. Managers at every level have access to up-to-date supply balances with usage patterns, and tools for accurate forecasting and efficient, effective resource management, and program monitoring and evaluation. In their immunization programs, this has resulted in more children being immunized with those immunizations being more timely.

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