COURSE TITLE: HEALTH MANAGEMENT INFORMATION SYSTEM

COURSE CODE: CHE 264

CREDIT UNIT: 2
DURATION: 30 HOURS
Instructional Materials
- Flip Chart
- White Board
- Projector
- Textbooks
- Chart
- Pictures

Teaching Method

- Lecture
- Demonstration
- Group Discussion using Buzz
- Brainstorming/mind mapping

Assessment

- Assignment – Take home/group

- Quiz
- Multiple Choice Question

Learning Objectives

At the end of the unit, the learners should be able to:

1. Explain the concept of a Health Management Information

System (HMIS)

2. Describe the various levels of data collection for HMIS

3. Explain the concept of monitoring and evaluation

4. Explain the various health indicators for appropriate

intervention

5. Describe District Health Information System (DHIS)

 1. HEALTH MANAGEMENT INFORMATION SYSTEM (HMIS)

1.0. Introduction
HMIS was formerly known as medical records management and
sometimes equated to monitoring and evaluation. In some settings,
scholars use the terms health informatics (HI) and medical informatics
(MI) as well as e-health (electronic health) to describe the application of
information technology in organising and analyzing health records to
improve health care outcomes. In its broadest sense, HMIS encompasses
diverse concepts, methods, and applications from many related fields. Its
genesis may be traced to multiple roots, including general systems
thinking, information economics, management science, information
systems development methodologies, software engineering, computer
science and communication theory, medical computing, health
organization behaviour, health management, policy, and health services
research.

The health information system collects data from the health sector and
other relevant sectors, analyses the data and ensures their overall quality,
relevance and timeliness, and converts data into information for health-
related decision-making.
A good health information system brings together all relevant partners to
ensure that users of health information have access to reliable,
authoritative, useable, understandable, comparative data. This is because
sound and reliable information constitutes the foundation of decision-
making across all health system building blocks, and is essential for health
system policy development and implementation, governance and
regulation, health research, human resources development, health
education and training, service delivery and financing.

From a practical viewpoint, the evolution of HMIS over the past several
decades has been largely driven by strategic, tactical, and operational
applications of various information technology (IT) and advanced systems
concepts for healthcare services delivery within an individual, group, and,
more appropriately, an organizational perspective.

1.1. Explain the Concept of a Health Management Information

System

Health is defined as a state of complete physical mental and social well-

being and not merely the absence of disease or infirmity.

Management is the process through rules, regulations and procedures

by which goals are set and achieved.

Data can be defined as a formal representation of facts, concepts or

instructions in a formalized manner, suitable for communication,
interpretation or processing by manual or electronic means. In health
care, these facts describe specific information about individual patients or
a population.

Information is the outcome of processed health data which increases

knowledge about health .Therefore information is defined as data which
has been processed so as to make a meaning to the person receiving it.
Data is poor or useless as a tool for decision making whereas information
is an essential tool for decision making. However, in many cases both
terms are used interchangeably.

System can be defined as a complex whole formed from many parts that
are made to relate with each other or a combination of related parts
organized into a complex whole in order to achieve objectives.

Building Blocks of a Health System

1. Leadership and Governance for Health.
2. Health Financing
3. Health Human Resources.
4. Health Services.
5. Health Information System.
6. Medical Products, Vaccine and Technology.

Health Information System is defined as a set of components and

procedures organized with the objective of generating information which
will improve health care management decisions at all levels of the health
system.

A health information system usually describes one of these several

separate subsystems containing data:
• Disease surveillance and outbreak notification.
• Data generated through household surveys.
• Registration of vital events and censuses (births, deaths and causes of
death).
• Data collection based on patient and service records and reporting from
community health workers, health workers and health facilities.
• Programme-specific monitoring and evaluation (for example for TB,
HIV/AIDS, and EPI).
• Administration and resource management (including budget, personnel,
and supplies).

Health Informatics or Clinical Informatics generally refers to the

application of data methods in medicine, healthcare services, and clinical
practices.
Health Information Management is defined as the collection and
analysis of healthcare data to provide information for health care
decisions involving patient care, institutional management, health care
policies, planning and research.

Health Management Information System refers to a system designed

to integrate data collection, processing, reporting, and use for the
improvement of patient health services, effectiveness and efficiency
through better management of patient data at all levels of
implementation. It requires the monitoring of the health status of a
population, by provision of services as the coverage and utility, drugs
stocks and consumption patterns, equipment status and availability,
finances, and personnel on a regular basis.

Components of HMIS
a. Patient management information system and
b. Health facility management information system
These systems incorporate all the patient data and health facility data
with the use of information processing tools consisting of computer
systems based on various hardware platforms and software products
offered by (several) vendors.

Common Challenges affecting the HMIS of Nigeria

 Limited funding
 Inadequate human resources
 Irregular supply of data tools
 Lateral data collection by partners
 Lack of data analysis at the level of the data collection
 Lack of data use in decision making
 Frequent occurrence of power cuts
 Inadequate numbers of ICT devices
 Limited internet access
 Limited ICT skills
1.2. Explain the Importance of HMIS
The importance of HMIS in health care system cannot be overemphasized
because over the years, planning, monitoring and evaluation of health
services and programmes have been hampered by dearth of reliable data.
Nowadays, it is globally asserted that availability of accurate, reliable,
timely and relevant health information is the most fundamental step
towards informed public health action. Therefore, for effective
management of health and resources, government at all levels must have
interest in supporting and ensuring that health data and information are
available as a public good for all stakeholders to utilize.

Aim of NHMIS
The main goal of NHMIS is to provide reliable, relevant and timely
information to health system’s policy makers, managers, professionals,
and to the other sectors for effective decision making, planning,
monitoring and evaluation.

Objectives of NHMIS
• To provide information that can be used as a management tool for
decision-making
• To assess the state of the health of the population
• To identify major health problems
• To set priorities at all levels
• To monitor the progress towards stated goals and targets of the health
services
• To provide indicators for evaluating the performance of the health
services / programmes and their impacts on the health status of the
population
• To provide information to those who need to take action, those who
supplied the data and the general public

1.3. Describe the Data Management Cycle

Data can be defined as a formal representation of facts, concepts or
instructions in a formalized manner, suitable for communication,
interpretation or processing by manual or electronic means. In health
care, these facts describe specific information about individual patients or
a population.

Health Data or Health Care Data are items of knowledge about an

individual patient, a group of patients or a population.

Types of Data
Primary Data are obtained from the original data source, including
documentation in the patient’s medical/health record collected by staff at
either a hospital, clinic or health centre.

Secondary Data are data sets derived from primary data. They include
individual or aggregate health care data found in summary reports
produced from the source like the master patients’ index, disease and
procedure indexes, health care statistics, disease registries, patients’
name index and statistics.
Data Collection: the process of gathering data. Many methods are
available for doing this effectively e.g Forms, Interviews, Focal group
discussion etc

Methods of Data Collection

Health data may be collected on a routine/ regular basis and on ad hoc
systems,

A regular or routine health information system; of data collection

usually consists of a mechanism (a registration procedure) for collecting
the data as they become available.
Examples
A vital statistics registration system to collect data on births, deaths,
marriages and divorces;
A disease notification system to collect data on cholera, yellow fever,
whooping cough, etc.;
A reporting system for cancer cases (cancer registry);
Registration systems in health care facilities, to collect data on patients
attending the various clinics.
Ad Hoc Collection of data is usually in the form of a survey of collect
data that is not available on regular basis. The data collected may be for
research or administrative purposes.
Examples
A national health manpower survey;
A survey to estimate the proportion of children with malnutrition in a
defined population;

Sources of Health Data and Information for PHC

• Population and household census
• Vital events register – records of vital events such as births, deaths,
marriages and divorces
• Routine health services data dealing with morbidity and mortality data;
immunization, disease treatment, out-patient attendance and admissions
• Epidemiological surveillance data - including immunization records and
notifiable diseases
• Disease registers for specific morbidity and mortality
• Community surveys undertaken by Government agencies, International
agencies, Non-Governmental Organizations, research groups, etc

Health Data Management Life Cycle

Data
Acquisition

Data
Retrieval Data
Processing

Data
Storage

Figure of Health Data Management Life Cycle

Description of Health Data Management Cycle

Data Life Cycle is a conceptual tool which helps to understand different
steps that data management follows from data generation to knowledge
creation. The Health Care Data Management involves the evolution of the
database infrastructure required to handle clinical, managerial, and
population-based data in the health care arena.

The health data management life cycle is made-up of the following:

a. acquisition or collection
b. processing
c. storage and
d. Retrieval - becomes much shorter. That is, the time between
acquisition and storage is shrinking.

Health Data Acquisition/ Collection

The first step in health data management is the acquisition of the data to
be managed. The process of acquisition or collection of the data also
provides Community Health Worker with an understanding of the data
source, which may be easy or difficult to manage, depending on the form
and period of time between updates.

The main source of health data is the client/ patient’s medical/health

record, which should contain essential data used in the health care
decision-making process. A client/ patient’s medical/health record usually
provides information on the following:
who the client/ patient is and who provided health care;
what services were provided;
when and where the services were provided;
why the services were provided;
how effective the services were; and
what the outcome was of care and treatment.
Another important collection of data by health facility/ hospitals is the bed
census, which is collected daily and processed monthly and annually to
produce on the utilization of hospital services. Health care facilities,
regardless of type or size, collect data processed as statistics for specific
external reporting to meet the various needs of health care authorities,
local and national governments, and funding organizations.
Health Data Processing
Data processing refers to methods of rendering large amounts of data into
a form that can be stored, retrieved and manipulated by users or
computer system. It involves data or information organisation, which is
the process of structuring of data prior to content storage and archiving.
Therefore, effective data processing pre-supposes that the information
content has to be structured.

Health Data Storage

When the data is collected and processed, the next step is to store the
data in a retrievable repository, where the content format dramatically
affects the storage needs. There are two kinds of data storage: the
primary data storage, where data can be store temporarily for ready
access; and the secondary data storage, also called data archiving where
data is stored permanently mainly for preservation purposes.

Data storage involves organization of data content in a way that all

information must be tagged in some fashion so that users can readily
locate it later. This tagging may be as simple as document title or as
sophisticated as the Library of Congress meta-category method. In either
case, it's a good idea to develop a controlled vocabulary in a formal
metadata definition document to guide both the initial repository
development and the acquisition of new materials.

Health Data Retrieval

Health care data is considered sensitive information and in some countries
is by an Act of Parliament. As a result of improved technology, community
healthcare providers have information at their fingertips, and so desire to
be able to retrieve or have access to information about clients/ patients
and billed charges quickly and securely. Therefore, data retrieval is an
important stage of the health data management life cycle.

Community Health Workers and facilities need immediate access to client/

patient information and demographics. This is crucial for record keeping
and client/ patient collections. And in the event of an audit, it is also
important that a community health worker is able to provide
documentation to support all charges billed.

Data Quality is defined as “the totality of features and characteristics of

a data set that bear on its ability to satisfy the needs that result from the
intended use of the data.” High quality data effectively satisfies its
intended use in decision making and planning.

Attributes of Good Quality Data

1. Access Security: Data must be restricted and kept secure to ensure
confidentiality and the protection of civil liberties.
2. Accessibility: Data must be available or easily retrievable.
3. Accuracy: Data must be correct and free of errors.
4. Appropriate Amount of Data: The quantity of data must be
appropriate.
5. Believability: Data must be regarded as true and credible.
6. Completeness: Data must be sufficient in breadth, depth, and scope
for its desired use.
7. Concise Representation: Data must be represented without being
overwhelming.
8. Ease of Understanding: Data must be clear.
9. Interpretability: Data must be in appropriate language and units.
10. Objectivity: Data must be unbiased.
11. Relevancy: Data must be applicable to the task at hand.
12. Representational Consistency: Data must be presented in a
consistent format.
13. Reputation: Data must come from a trusted source.
14. Timeliness: Data should be recorded as quickly as possible and used
within a reasonable time period.
15. Value-Added: Data must provide valuable insight.

Challenges of Health Data Collection Process

 Poor /irrelevant data
 Inadequate data
 Lack of cooperation of the sources
 Hard to reach environment for data collection
 Season of the year or climate changes
 Infrastructural breakdowns
 Poor logistic support and poor quality of data collection
 Natural or man-made disasters: war, earth quake, flooding
 Selection bias
 Volunteer effect
 Information bias e.g. low validity of instrument
 Confounding variables
 Poor storage of data
 Falsification of records

Factors that Contribute to Good Quality Health Data

Health data may be of good quality if informed by the following:
I. Good planning;
ii. Data collectors properly trained;
iii. Resources and tools for data collection are adequate;
iv. Appropriate data collection instruments;
v. Complete routine health service records;
vi. Well organized facility data collection systems;
vii. Selective capturing of client information; and removing inconsistencies
in data collection processes

Students
Assessment
1. Define Health Management Information System
2. Differentiate between data and information
3. Enumerate any five challenges affecting HMIS in Nigeria
 4. Briefly describe the data life cycle
5. List and briefly explain any 10 attributes of good quality data
6. Itemise any eight challenges of health data collection process

2. DESCRIBE THE VARIOUS LEVELS OF DATA COLLECTION FOR

HMIS

Overview of some Key Terminologies

Community can be considered a social unit, such as a group of people,

who have something in common, such as norms, values, or identity.
Communities usually share a sense of place that is situated in a given
geographical area, such as village or neighborhood. For purposes of
provision of community health services, a community includes a set of
stakeholders who meet one or more of the following conditions:
● Reside in a defined geographic area.
● Share demographic traits (e.g. children under five, pregnant
women).
● Behavioral or occupational characteristics (e.g. sex workers, truck
drivers).
● Situational factors (e.g. orphans, prisoners).

Community Health Worker (CHW)

Community health workers should be members of the communities where
they work, should be selected by the communities, should be answerable
to the communities for their activities, should be supported by the health
system but not necessarily a part of its organization, and have shorter
training than professional workers.

Community Health Data is defined as data on health, health services,

and determinants of health derived from and relevant to community
administrative/geographic units, community members, and/or the
community level of health systems.

Community Health Information System (CHIS) is a combination of

paper, software, hardware, people and process which seeks to support
informed decision making and action taking of CHWs. This includes:
● Recording: recording of basic data such as population, health program
transactions, case based data, stock and resource availability
● Tracking and taking action on individual program based needs such
as disease surveillance, mortality and morbidity
● Reporting and feedback including routine upward reports, feedback
reports, ad hoc reports and specific reports for different stakeholders”

Diversity of CHIS
The nature of CHIS varies with contexts:
a. In some cases, they are manual and paper-based registers, diaries, tally
sheets, and reporting forms.
b. In other contexts, they are ICT- based using devices such as mobile
phones, tablets, and computers.
c. In most cases, they represent some kind of hybrid combining elements
of paper and ICT-supported solutions.

Currently, many countries including Nigeria are in the process of moving

towards more automated DHIS2 based CHIS,

Relationship between HMIS and CHIS

While the HMIS concerns information for services provided at a facility, a
CHIS concerns activities provided to members of a community, typically
by CHWs living in the community or through outreach services conducted
by CHWs from a facility.

Therefore, in order to achieve successful delivery of health care service,

CHIS data must feed seamlessly into the HMIS to avoid duplications and
redundancies, and the HMIS must be capable of providing feedback and
support to strengthen the CHIS.

Tool refers to any instrument/ process used in data collection for HIMS

2.1. List HMIS Data Collection Tools for the National Health
Management Information System and Community Health
Management Information System

The process of collecting health data is usually in form of paper

documents, forms and e-documents, which is then transformed during
data processing into accurate, retrievable information, and eventually
delivered into health system applications and databases for storage and
further action. Below are the lists of various tools for data collection for
both NHMIS and CHMIS:

a. Tools in Routine Health Data Collection and Reporting

I. Community Based Summary Form includes NHMIS Forms 000
II. Health Facility Community Outreach Forms
III. NHMIS Summary Form 001A and B
IV. Health Facility Based Forms
V. NHMIS Summary Form 001
VI. NHMIS Summary Form 002 for LGA
VII. NHMIS Summary Form 003

These forms capture data on antenatal care and pregnancy outcomes;

immunisation; family planning services and commodity utilisation; growth
monitoring and child health promotion. Others are in-patient cases; in-
patient deaths; outpatient cases; disease surveillance and notification;
pharmaceutical services and drug inventory/ utilization; laboratory
services; and occupational health services.

b. Tools in Health Disease Surveillances

I. ANC HIV Sero-Prevalence Surveys
II. Integrated Bio Behavioural Surveys (IBBS)
III. Behavioral Surveillance Survey (BSS), etc

c. Selected Tools in Health Facility Assessments:

I. Services Provision Assessment (SPA) MEASURE DHS
II. Service Availability Mapping (SAM) WHO
III. HF based Human Resource for Health (HRH) assessment Abt Associates
IV. Rapid-Health Facility Assessment (R-HFA) CSTS+/MEASURE Evaluation
V. Assessing Integration Methodology (AIM) (used mostly in operational
research settings)
VI. Population Council

2.2 Describe Health Information/ Data Flow

The health information/ data flow consists of a series of data movement
from the community to health facility, Local Government, State and
Federal levels:

At Community Level
All summary forms with the designation 000 in use in communities are to
be sent to the health facilities through the Junior Community Health
Extension Workers (JCHEWs).

At Health Facility
Daily registers have been developed for the health facilities for
standardized health data collection nationwide. Data on daily registers are
summarized monthly into form 001.

Summary forms with designation 001 are to be sent to the local

government area (LGA) – M&E unit to the attention of the PHC M&E
Coordinator.

At Local Government Level

Information from the health facilities will be summarized in the LGA
summary 002, which is in turn sent to state MOH, HMIS Unit.

At State Level
The state HMIS Unit shall forward a copy of the HMIS Summary Form 003
to the relevant department and units within the SMOH such as the PHC
department, the epidemiology unit, relevant health programmes, NGOs,
international health organizations etc with state level offices.

The state NHMS unit shall use the HMIS Summary Form 003 to send state
level summary to the Federal NHMS Unit.

At Federal Level
Within the Federal DHPR, NHMIS Unit are to be located designated desk
officers/data expediters who will be responsible for facilitating the sharing
and transfer of data to relevant FMOH level departments and agencies
such as NPHCDA, Epidemiology Division of Department of Public Health,
Hospital Services, Community Development and Population Activities, and
other federal institutions such as the National Bureau of Statistics (NBS)
and international agencies etc.
 Chart showing Data flow

2.3. Types of Records/Data Collection Registers at all

Levels:
The overall objective of the PHC information system (which is a sub-
system of the NHMIS) was to develop a dynamic and responsive system
that would provide information for strategic planning, management and
operational functions of PHC activities at all levels.

For effective management of patient/ client health care, the monitoring

and evaluation system came up with records to be used in collection of
data at various levels for operational and administrative purposes in PHC.
They are:
1. The home
2. The community
3. The health facility
4. The ward
5. The Local Government
6. The State Government
7. Federal Government

1. Home-based Records
At the home level, two (2) records were developed. They are cards
designed and issued to household members bearing health and health
related information of each recipient. The cards are:
a. The PHC child health card
b. Personal health card

The Child health card is issued to the child from birth to 5 years (0- 59
months). It contains a child health chart and treatment card. Information’s
contained in the child health card includes, child’s name, PHC personal
No., date of birth, immunization schedule and status, growth monitoring
chart, treatment of diarrhea etc.

The personal health card is issued to individuals - 5 years and above.

Information in it include the recipient’s name, age, sex, LGA, marital
status, number of children, PHC personal number, occupation,
immunization status, health & health related information.

The home based record is a passport to the primary health care system.
Each home-based record should be kept in a polythene bag to avoid stains
or damage. They are kept at home but taking along anytime a health
worker is to be contacted for completion.

Purpose of the Home-Based Records

a. Reduces the time spent waiting at any health center by clients
b. Used at any level of health care for referral purposes
c. Facilitates follow-up of patients
d. Allows for continuity of care
e. Facilitate flow of information
f. Ensure full involvement and participation of community in health care
g. Provide information to mothers and care givers on the preparation and
use of salt sugar solution
h. Steps In Placing Home Based Records
i. Estimate the number of home based records required for children and
adults in the area.
j. Order home-base records and clinic master cards
k. Contact community leaders for their support
l. Mobilize (preferably) appropriate volunteers and health team who
could carry out house numbering, like teachers, CHO, Health/Medical
Students
m. Train mobilized persons to place home-based records. The content of
training for the mobilized persons should include:
i. Definition of household
ii. Observance of courteous entry into a household
iii. Respect for local beliefs and customs
iv. Probing adequately information on age by obtaining either:
• The birth Certificate. EPI Card
• Church minister/Imams birth records
• TBA records relating to Child’s birth and national and local events; or
• Reconciling Child age with obvious discrepancies
• Observing birth days on body tattoos
• Examining house-hold walls for child’s age
n. Record age according to findings
o. Supervise placement of home-based records
p. Visit a sample household to determine how well these records have
been placed
q. Write report on the exercise

1. Community-Based Records
They comprise of:
a. The Voluntary Village Health Works/Traditional Birth attendants
(VVHWs/TBAs) record of work
b. The community profiles, namely;
 i. Demographic profile
ii. Pregnancy profile
iii. Family planning profile

The VVHWs/TBAs record of work & the profile booklets are the
basic tool for collecting information at the community level. It consists of
pictorial tally sheets coded as follows:
1. NHI’VIIS /PHC/CB/O 1 -Tally sheets for tracer diseases
2. NHMIS /PHC/CB/02 -Tally sheets for ANC/Family Planning
3. NHMIS/PHC/CB/03-Tally sheets for pregnancy outcome/death
4. NHMJS/PHC/CB/04-Tally sheets for VHW/TBAs community activities
5. NHMIS/PHC/CB/05-Referral slip for emergency cases
6. NHMIS/PHC/CB/06-Referral slip for routine cases
7. NHMIS/PHC/CB/07-Community Demographic Profile
8. NHMJS/PHC/CB/08-Community Pregnancy profile
9. NHMIS/PHC/CB/09-Community family planning profile

2. Health Facility-Based Records

These are coded record booklet used in the health facility to collect
information on its activities as well as those performed by the VHWs/TBAs
it supervises in the area. The Information is collected on daily, monthly
and annual basis. In this way the health facility can monitor its
performance, those of the VHWs and the health trends in the area.
Forms usually in use include:
a. The facility based family master card (Clinic master card)
b. The health facility/Attendance Registers
c. The monthly records
d. The Annual records of PHC services and
e. Other facility-based forms

Health Facility-based Record/ Family Master Card (Clinic Master

Card)
It is coded as - NHMIS/PHC/FBO1
This card is usually kept in the clinic. It links the home-based record with
the health facility. It gives detailed information on the living condition, the
personal health and disease history of each member of the household.
Information on family name, PHC house no, house condition, water supply
and others as relevant are also included. It gives a picture of the health
status of individuals and families without having to go to the community
to undertake a survey. One can scan through the clinic master cards of a
village and discover which children, in what houses have not received any
immunization or growth monitoring services for a given period of time.
The service can them be channeled to such children directly.

The clinic master cards for each village or neighbourhood will be arranged
serially and kept in a box. When a health worker is visiting the village or
neighbourhood, the box for that community must be carried along and as
soon as information is recorded in the home- based-records, it is also
recorded in the family/clinic master card. The card containing all this
information enables the health worker to know his patient better, easier to
locate and communicate. It is also used to issue another home-based card
in case of loss.

b. The Health Facility Registers

This is very essential to enhance data collection. They provide
complimentary relevant information for calculation of health indicators
and record purposes. These include:
i. General out-patient Registers
ii. In-patient Registers
iii. ANC/Maternity Registers
iv. Family planning Registers
v. Child welfare Registers and,
vi. Immunization registers.

c. The Monthly Record Forms:

NHMIS/PHC/MSR 01 -Monthly record of tracer diseases
NHMIS/PHC/MSR 02 -Monthly record of A.N.C & Pregnancy outcome
NHMIS/PHC/MSR 03 -Monthly record of family planning
NHMIS/PHC/MSR 04 -Monthly record of Immunization
NHMIS/PHC/MSR 05 -Monthly record of growth Monitoring &
NHMIS/PHC/MSR 06 Promotion
NHMIS/PHC/MSR 07 -Monthly record of In-patient care
-Monthly record of Environmental Health
There should be a designated health management information officer at
this level. The officer should be supplied with adequate number of
monthly, quarterly and annual summary forms to last at least one year.

The summary forms completed by the officer are then forwarded to the
higher levels. These forms should reach the LGA at the end of the third
week of the following month, and duplicates kept at the ward.

Some basic analysis and interpretation can be done at this level for
planning and decision-making.

c. The Annual Records of PHC Services,

They are the annual record of immunization in the health facility, annual
record of births and deaths and the ward demographic profile.

d. Other facility-based forms

These are the referral slip, discharge summary forms and the quarterly
summary records of PHC services at the health facility.

4. Ward Level based Records

At this level the various summary forms submitted by health facilities are
used to collate information for the ward as a reporting unit.

5. LGA Level based Record

Summary forms collected from the various wards in the LGA are compiled
and analyzed in line with the NHMIS guidelines. At this level the data
enters the national structure. Further basic analysis and interpretation is
also done at this level for planning and decision-making.
There should be feedbacks from each higher levels, it should be in form of
profiles, reports, letters and minutes of development committee meetings,
etc.

2.4. Describe how to Monitor Register of Births and Deaths and

explain their Significance

Civil Registration
Civil registration is the continuous, permanent, compulsory and universal
recording of the occurrence and characteristics of vital events (live births,
deaths, foetal deaths, marriages and divorces) and other civil status
events pertaining to the population as provided by decree or regulation, in
accordance with the legal requirements in each country. Such information
is invaluable for assessing and monitoring the health status of
populations, and planning interventions.

Vital Registration
Routinely collected data on birth, death, marriage, and migration are
essential sources of demographic information. The quality of tools,
procedures, and consistency in data collection require serious attention to
ensure accuracy and usefulness. Births and deaths outside the primary
health care system must also be captured.
Birth is a delivery after 28 weeks of gestation including still births.

Birth Register is an administrative register which is used to record all

births (deliveries after 28 weeks of gestation) including still births. If
weight at birth is not available, the weight within the first seven days of
birth may be recorded.

Importance of Birth Register

 To monitor population growth in catchment area
 To monitor delivery outcome in catchment area
 To monitor birth weight as a proxy indicator of maternal nutritional
status, and a risk for childhood morbidity and mortality
 To identify newborns in catchment area for preventive follow-up
Death refers to cessation of life and all associated processes

Death Register is an administrative register which is used to record all

deaths and causes of death

Monitoring of Births and Deaths Registers refers to checking the

operation of births and deaths registration system in order to control its
efficiency, accuracy, timeliness and coverage on an ongoing basis.

Registration is the formal act of reporting a birth or death, and obtaining

a birth or death certificate issued by the civil registration authority. At this
stage, details of the event are written into the official civil register by the
registrar. Registration is the essential step prior to obtaining a certificate.

Description of Births and Deaths Registration Processes

The information in the various registers usually contains the full
particulars required by law to be provided by the informant, such as:
1) The dates of occurrence and registration of births, deaths, stillbirths
and marriages;
2) The place of occurrence;
3) The characteristics of the newborn child, e.g., sex; and of the
deceased, e.g., sex, age, marital status and occupation;
4) The characteristics of the parents of the new- born child and sometimes
of the deceased;
5) Other details such as the causes of death, attendant at birth,
hospitalization, and particulars about the informants.
6) Nationality of parents of the newborn child.

Significance of Monitoring Birth and Death Registers

Reliable vital statistics on the numbers and distribution of births and
deaths – and including causes of death – are needed to inform social and
economic planning across both public and private sectors including
health, education, labour and employment, urban planning, finance and
economic development, industry and trade, social insurance, environment
and population.
The health sector has a particularly strong need for functional birth and
death registration system in order to:
a. track the progress of strategies to reduce the levels of child,
maternal and disease-specific mortality
b. address inequalities in all these areas requires reliable, continuous
and timely data on age- and cause-specific mortality
c. monitor the spread and distribution of both communicable and non-
communicable diseases and,
d. guide public health programmes, monitor population dynamics and
measure key health indicators.

Students Assessment
1. Write short note on the relationship between HMIS and CHIS
2. With the aid of a well labeled chart describe the pattern of Health
information flow in Nigeria
3. What are the major types of health records under PHC?
4. Differentiate between home and community based records
5. List any ten purposes of home based records
6. Enumerate any five means of detecting the age of person in the
community
7. Identify the main registers and forms used at health facility level
8. Highlight the importance of births registration in community health
9. Itemise four reasons for monitoring births and death registers in
community

3. EXPLAIN THE CONCEPT OF MONITORING AND EVALUATION

3.0. Introduction
Monitoring and Evaluation System was first developed in Nigeria in 1987.
M&E is important management tools to track the progress of services and
facilitate decision-making process. It is an essential component of any
intervention, project, or program. It provides community health workers,
organizers, government officials, development managers, and civil society
with better means for learning from past experience, improving service
delivery, planning and allocating resources, and demonstrating results as
part of accountability to key stakeholders. It must be built into the health
programme and should be an essential feature of each health unit no
matter how small because failure to include mechanisms for monitoring
and evaluation is one of the commonest causes of waste in health
services. Using objective indicators, baseline data must be collected, the
planned interventions must be monitored and the impact of the activities
must be studied.

3.1. Define Monitoring and Evaluation

The term monitoring refers to:
 an ongoing process that provides routine information on whether a
program is making progress toward its objectives.
 a continuous systematic process of collecting, analyzing and using
information to track the efficiency of achieving program goals and
objectives
 Is measured through the tracking of changes in program inputs,
activities, and outputs over time

Monitoring implies a continuous check of PHC activities to ensure it

achieves its stated goals. It is used to track changes in program
performance over time. Its purpose is to permit stakeholders to make
informed decisions regarding the effectiveness of programs and the
efficient use of resources.

Monitoring Process
Monitoring process is a continuous cycle that involves constant feedback.
There are four steps in monitoring process:

Collecting and analysing data: the first step in the monitoring

process is measuring, recording, collecting and analysing data on
actual implementation of the programme

Detecting deviations from plans: following data analysis, any

deviations from the plan is communicated to the programme
managers
 Diagnosing causes for deviations: the program manager detects
the causes of the deviation after analysis

Taking corrective action: corrective actions are plan and

implemented to achieve the desired goal (s), and then the cycle
begins again

Data
collection
and
analysis

Taking Monitoring Detecting

corrective deviations
action: process from plan

Diagnosis of
causes of
deviations

Figure showing Monitoring Process

Evaluation is a periodic review of PHC activities by comparing

achievements with the objectives set at the beginning of the program. It
measures how well activities have met expected objectives and/or the
extent to which changes in outcomes can be attributed to the program or
intervention.

For example, an HRH evaluation might use interviews and observations of

client-provider interactions to assess community health worker
performance following the introduction of supportive supervision
Monitoring and Evaluation refers to a set of procedures & analytical
tools to examine:
 how programs are conducted (inputs & activities)
 their level of performance (outputs)
 whether they achieved what they were intended to achieve
(outcomes & impact)
One of the most critical steps in designing an M&E system is selecting
appropriate indicators. Therefore, the M&E plan should include
descriptions of the indicators that will be used to monitor program
implementation and achievement of the goals and objectives.

Principles of Effective Monitoring and Evaluation of Health

Programs and Services

i. Right indicators
ii. Adequate and timely report
iii. Usage of information technology tools IT
iv. Incentives for reporting
v. Monitoring bodies
vi. Public access
vii. Participation of civil society
viii. Coordination
ix. Ensuring compliance
Tools for Monitoring and Evaluation
• Sign-in (registration) logs
• Registration (enrollment, intake) forms; checklists
• Program activity forms
• Logs and tally sheets
• Patient charts
• Structured” questionnaires
• Focus group discussion guide
• Direct observation checklist
• In-depth interview guide

3.2. Discuss the Importance of Monitoring and Evaluation in

Health Services and Programmes
Key Questions in M&E
 Did the program achieve its objectives?
 Did the target population benefit from the program?
 At what cost?
  Can improved health outcomes be attributed to program efforts?
 Which program activities were more (or less) important/effective?
 What would have happened in the absence of the program?
 How can we know or measure this?

Importance of M& E in Health Services and Programmes

1. Determining whether a plan or program is on schedule with planned
activities
2. Assessing whether a policy, plan or program has produced desired
impacts
3. Generating knowledge:
 Identify factors (individual, community, programmatic) that
influence health outcomes
4. Helping inform policy, planning or program decisions: new services,
resource allocation, corrections, etc.
Students Assessment

1. Differentiate between monitoring and evaluation

2. Define monitoring and evaluation
3. What are the principles of effective monitoring and
evaluation of health programs and services?
4. What are the tools for monitoring and evaluation?
5. Identify any four importance of M& E services and
programmes

4. HEALTH INDICATORS FOR APPROPRIATE INTERVENTIONS

4.0. Introduction
Indicators are clues, signs or markers that measure one aspect of a
program and show how close a program is to its desired path and
outcomes. It is one of the most critical steps in designing an M&E system
because they are used to monitor program implementation and
achievement of the goals and objectives. They are used to provide
benchmarks for demonstrating the achievements of a program.

Carefully selected and regularly reviewed core indicators are vital to

strengthening a health information system and can be viewed as the
backbone of the system, providing the minimum information package
needed to support macro and micro health system functions. In its annual
publication of 'The Progress of Nations', UNICEF compares the
performance of countries using specific health indicators like the under 5
mortality rate.

4.1. Define Health Indicators

The term “indicator” is derived from the Latin “indicare”, which means to
announce, point out or indicate. It is a piece of information which is part
of a specific management process, and has been assigned significance
beyond its face value”

Indicators are observable, quantifiable criteria which will be measured as

part of monitoring and evaluation to determine extent of attainment of
objectives. They help to measure the extent to which the objectives and
targets of a programme are being attained.

Health Indicator is a variable, susceptible to direct measurement that

reflects the state of health of persons in a community.

Health Indicator is a measurable characteristic that describes:

 the health of a population (e.g., life expectancy, mortality, disease
incidence or prevalence, or other health states);
 determinants of health (e.g., health behaviors, health risk factors,
physical environments, and socioeconomic environments);
 health care access, cost, quality, and use.
Depending on the measure, a health indicator may be defined for a
specific population, place, political jurisdiction, or geographic area.

Types of Indicators
Indicators can be either quantitative or qualitative.
a. Quantitative indicators are statistical measures that are numeric
and are presented as any of the following:
 Percentages
 Number
 Rate (example: birth rate—births per 1,000 population)
 Ratio (example: sex ratio—number of males per number of
females)

b. Qualitative indicators are descriptive observations and can be used

to supplement the numbers and percentages provided by quantitative
indicators. They complement quantitative indicators by adding a
richness of information about the context” in which the program has
been “operating. Qualitative indicators reflect people’s judgments,
opinions, perceptions and attitudes towards a given situation or
subject. They can include changes in sensitivity, satisfaction,
influence, awareness, understanding, attitudes, quality, perception,
dialogue or sense of well-being.
Qualitative indicators measure results in terms of:
 Compliance with…
 Quality of…
 Extent of…
 Level of …

Characteristics of Health Indicators

- Should be valid
- Should be reliable & objective
- Should be sensitive
- Should be specific
- Should be feasible
- Should be relevant
4.2. List Types of Health Indicators
1. Mortality indicators
2. Morbidity indicators
3. Disability rates
4. Nutritional status indicators
5. Health care delivery indicators
6. Utilization rates
7. Indicators of social & mental health
8. Environmental indicators
9. Socio‐economic indicators
10. Healthy policy indicators
11. Indicators of quality of life.
12. Other indicators.

Examples of Key Health Indicators of Nigeria

Population (in 2015) 182.2 million
Life expectancy at birth 55 years in 2013
Maternal mortality ratio (in 2015) 814 per 100’000 live births (the fourth‐
highest maternal mortality ratio in the world)
Infant mortality rate (in 2015) 69 per 1000 live birth
General government expenditure on health as a % of total government
expenditure 6.5% in 2013
General government expenditure on health as a % of total expenditure on
health 23.9% in 2013
Out‐of‐pocket expenditure as a % of total expenditure on health 72.9% in
2013
Distribution of years of life lost by major cause group (%) in 2012
Communicable diseases 73%
Non‐communicable diseases 16%
Injuries 10%
Prevalence of HIV (% of ages 15‐24 years) 3.2%

4.3. Uses of Appropriate Indicators for Various Health Assessment

and Intervention
a. Measurement of the health of the community
 b. Description of the health of different communities
c. Comparison of the health of different communities
d. Identification of health needs and prioritizing them
e. Evaluation of health services
f. Planning and allocation of health resources
g. Measurement of health successes
h. Monitoring the trends of health related issues
i. Assessment of the effect of interventions,
j. Assessment of policy impact

Students Assessment

1. Define health indicator

2. Identify the characteristics of health indicator
3. List any ten types of health indicators
4. Highlight any ten uses of appropriate indicators for various
health assessment and intervention

5. DISTRICT HEALTH INFORMATION SYSTEM (DHIS)

5.0. Introduction
Complete, correct and consistent data gives managers the confidence to
use that data in decision-making. This has led to some initiatives in many
countries to reform the existing paper-based systems through
computerization. The District Health Information System Software (DHIS)
is a free and open source database and application for collecting,
processing, and analyzing health information, and whose development
and implementation was started in 1998 by the Health Information
System Programme (HISP) based in South Africa. HISP is a research
network which is organized by the University of Oslo and is devoted to the
development of Health Information System in developing countries.
Presently, DHIS is listed as one of the successful national systems in place
in many countries.

5.1. Describe the Concept of District Health Information System

(DHIS)

Feature phones Smart phones PDAs Laptops + Wireless Modem

DHIS2 Hosted on the Cloud
Pictures of Range of Devices used in DHIS2 (in increasing cost)

e-Health was described as “the use of information and communication

technologies (ICTs) for health to, for example, treat patients, pursue
research, educate students, track diseases and monitor public health’’.

District Health Information System refers to an open source software

platform for reporting, analysis and dissemination of data for all health
programs, developed by the Health Information Systems Programme
(HISP).

DHIS is designed to support decentralized decision making and health

service management by allowing health care workers to use their data to
analyze their levels of service provision, predict service needs, and assess
performance in meeting health service targets. Community Healthcare
Practitioners and other professionals can also use this and other HIS data
for training and research, and subsequently in production of research to
policy briefs to inform national health policies and programs.
Types of DHIS Versions and Releases
  DHIS 1.3
 DHIS 1.4
 DHIS 2

DHIS2 is the most commonly used worldwide and presently designed to

facilitate generation, analysis and dissemination of quality health
information for informed decision making. The role of quality data in
enabling informed healthcare decision making cannot be over-
emphasized, for instance good quality routine HIS data delivered in a
complete and timely manner can be used in surveillance of diseases of
public health importance to prevent or control outbreaks, as well to
strategize on adequacy of service delivery under the various disease
programs.

5.2. Explain the Use of DHIS for Data Entry and Analysis

DHIS as a health information management tool written in Microsoft®

Access® and Visual Basic® for applications which run on most Microsoft®
Windows® platforms, supports Windows® XP up to Windows® 8.0 and
Microsoft® Office 2003, 2007 or 2010.

DHIS2 is able to support collection and analysis of routine health services

data, as well as non-routine data such as population estimates, facility
workload and survey data. Currently this data is collected by means of a
paper-based system of registers, tally sheets, and monthly data collation
forms at each health facility. The collated monthly data is either entered
directly into the web-based DHIS2 or sent to the district level where is
entered on to the web-based DHIS2 software, then analyzed in the
system. The web-based DHIS2 is intended to capture health facility
service delivery data and allow analysis at that level, promoting data use
at all levels for decision making.

DHIS2 is configured to allow the generation of reports, which can be either

standard or customized to meet the user requirements; and to also carry
out data quality analysis and provide a dashboard for monitoring and
evaluation of health programs’ indicators. The essential reports have
already been built into the system and are immediately available for
review at all levels i.e. by the health facility, district, province and national
health departments. Data quality is addressed through mechanisms
incorporated into the data collection process and functions within the
DHIS software.

Another advantage of the DHIS2 platform is its very modular web

interface which allows for easy incorporation of various modules, enabling
easier replication of the complex paper reporting formats that are unique
to each country of implementation.

DHIS2 contains 43 templates/data sets, almost double the

number of paper forms filled in the health facilities. The reasons
for this include:
(a) Split of information received from the health facilities (e.g. a single
form is used for PMTCT (Prevention of mother‐to‐child transmission of HIV)
at health facilities, the reporting of which is entered using two DHIS2
templates: one for infants and another one for mothers)
(b) Modules of the data of which are not necessarily reported in health
facilities (see metadata analyses below); and
(c) DHIS2 modules which are inactive for comments on the practical
implementation of DHIS2.

List of Paper‐based Tools and DHIS2 Templates

Paper Printed Forms

1. Child health card (the home‐based record) Child health card
2. OPD card OPD
3. Pregnant woman TT vaccination card TT
4. Ante‐natal care appointment card ANC‐PNC
5. Tuberculosis patient treatment support card TB
6. Daily general attendance registers Attendance
7. Health facility inpatient daily registers Inpatients
8. Children treatment card OPD
9. OPD treatment card OPD 1
10. Health Facility daily OPD registers OPD
11. Health facility daily immunisation tally sheet IMM tally
12. Child Immunisation registers IMM register
13. Health facility GMP daily registers Nutrition
14. Tetanus Toxoid register for women of child bearing age TT
15. Health Family Planning Daily Register FP
16. Daily labour and delivery register Delivery
17. Ante‐natal care card ANC‐PNC
18. Health Facility ANC daily register ANC‐PNC
19. PMTCT/ARV registers PMTCT/ARV
20. Tuberculosis patient treatment card TB
21. Tuberculosis stock card TB
22. Monthly summary form Monthly summary
23. Health Facility monthly immunisation summary* IMM monthly
24. Quarterly summary Quarterly summary

DHIS2 Datasets
1. Adverse Drug Reaction A
2. Adverse Drug Reaction B
3. Commodity Availability
4. Facility Attendance
5. Facility Attendance
6. Family Planning A
7. Family Planning B
8. HIV care & treatment
9. HIV Counselling & Testing A
10. HIV Counselling & Testing B
11. IMCI IMCI
12. Immunization
13. Inpatient
14. Inpatient Admissions
15. Laboratory
16. Malaria Cases
17. Malaria in Pregnancy
18. Malaria Prevention (LLIN)
19. Malaria Testing
20. Malaria Treatment
21. Maternal Health (Ante & Postnatal)
22. Maternal Health (Labour and Delivery)
23. Maternal Mortality A
24. Maternal Mortality B
25. Mortality
26. Neonatal Deaths
27. Non Communicable Disease NCD
28. Nutrition
29. Obstetric Fistula A
30. Obstetric Fistula B
31. Pharmaceutical Service
32. PMTCT ‐ Infant PMTCT
33. PMTCT ‐ Mother PMTCT
34. Pregnancy Outcome – Complication Pregnancy
35. Pregnancy Outcome ‐ Live births
36. Pregnancy Outcome ‐ Still birth
37. Referrals
38. Sexually Transmitted Infections STI
39. SRH‐HIV Integration
40. TB-HIV
41. TB‐LP
42. Tetanus Toxoid (Women of child‐bearing age) TT
43. Under five (5), Mortality

5.3. Discuss the Importance of Dissemination of Information for

Planning and Policy Formulation

Dissemination is the targeted distribution of information and materials

about an evidence-based intervention to a specific community health or
clinical practice audience. Furthermore, well-designed dissemination
strategies can improve access to a guideline and lead to improvement in
health outcomes
Planning is a systematic process of identifying and specifying desirable
future goals and outlining appropriate courses of action and determining
the resources required to achieve them.

Policy is a set of clear statements and decisions defining priorities and

main directions for attaining a goal.

Guidance for Policymakers

Ideally, policymakers are guided by core principles. For example;
• Politicians and public servants are accountable to the public.
• Elite, in politics and the private sector, do not have the right to pursue
their interests without constraints.
• Government bureaucratic and decision processes must be open,
accessible, and transparent, as well as being responsive to public
concerns.
• Individuals and communities affected by projects have the right to
information regarding proposed developments; the right to challenge the
need for, and the design of, projects and the right to be involved in
planning and decision-making processes.

Stages in Policy Making Process

Formulation stage is a stage where government or policy actors
take decision as to what to be done? And how it is to be achieved?
Implementation stag is the process of interaction between setting
policies and actions geared towards achieving them.
Feedback and Evaluation stage is the stage of comparison
between the intended outcome of policy and actual achievements on
the basis of experience gained during the implementation stage

Health policy is a set of clear statements and decisions defining

priorities and main directions for improving health and health care in a
country.

Rationales for Information Dissemination for Planning and Policy

Formulation
a. DHIS comes with easy to use analytics through tailored Dashboards,
charts, pivot tables and maps, and can be extended with Apps or
used by third-party software through the open Web-API. It has been
translated into a number of languages and is applicable in over 60
countries.

b. DHIS supports the capture of data linked to any level in an

organisational hierarchy, any data collection frequency, a high
degree of customisation at both the input and output side

c. DHIS uses open software for processing, and open access to

information across the country which will provide easy access of
health data to all stakeholders for appropriate decision making

d. DHIS allows for incremental expansion to accommodate the many

demands of managing the health care system.

e. DHIS facilitates effort in undertaking standardized training, on-site

mentoring and communication of Community health workers, more
recently extending to the orientation of managers at all levels of the
health system.

f. DHIS data keeps tabs on the rapidly changing health care system by
community health workers and other stakeholders to monitor
priority health problem trends and the coverage of services such a
EPI, TB and STI in specific geographic areas.

g. DHIS Help in equitable distribution of resources for health care, thus

allowing allocation of increased resources to those facilities found to
be lagging behind. Analysis of certain indicators, such as workload,
has also assisted in the reallocation of staff and the determination of
new places requiring introduction of health services.

h. DHIS promotes decentralization of decision-making by providing

data used in the formulation of implementation of health
programme plans and for monitoring their implementation.
 i. DHIS produces a health facility comparative analysis tool showing
facility performance, which the DHMT use to identify poorly
performing facilities in need of support

Students Assessment

1. Write short note on District Health Information System

2. What are the rationales for information dissemination for planning
and policy formulation?

References
BENJAMIN S. U., OBINNA E. O., & NKOLI E. A.,(2014). The District Health System in
Enugu State, Nigeria: An Analysis of Policy Development and
Implementation.2014-
Vol 3 (1): 0001 E PUBLICATION AHEAD OF PRINT No of pages: 14 African
Journal of Health Economics December 2014. Pages: xxx

BRIDGET N. O.,(2009). PRIMARY HEALTH CARE IMPLEMENTATION (Made easy)

IN DEVELOPING COUNTRIES. Snaap Press Ltd.
http:// [Link]

http:// [Link]

Global Health University (2020). Quality Health Data. Retrieved from http: //
[Link]/ global-Health-University/quality-data

Kenneth I. N.U., (2011). HEALTH DATA MANAGEMENT NATIONAL OPEN

UNIVERSITY OF NIGERIA COURSE GUIDE. NOUN PRINTING PRESS

Kristi M., Matt M., Maarit M., & Boya D., (2018). Data Management Life Cycle Final report
Texas A&M Transportation Institute PRC 17-84 F

National Primary Health Care Development Agency (2017). Characterisation of the Health
Information System in Nigeria the health information system programme Final
Report
Submitted to the Norwegian Agency for Development Cooperation. Retrieved from
[Link]

Oliha F. O., Ebietomere E. P., & Ekuobase G. O., (2019). AN ELECTRONIC BIRTH
RECORD MANAGEMENT SYSTEM FOR NIGERIA Nigerian Journal of
Technology (NIJOTECH) Vol. 38, No. 3, July 2019, pp. 763 – 768
[Link]

Shehu J. E.M.(2020): MONITORING AND EVALUATION OF HEALTH

PROGRAMS AND SERVICES. NATIONAL OPEN UNIVERSITY OF NIGERIA
COURSE GUIDE. NOUN PRINTING PRESS

Wikipedia(2020).DHIS. Retrieved from https:// [Link]/ wiki/DHIS

Wikipedia (2018). Health Information System Programme. Retrieved from

[Link] wiki/ Health_Information_System_Programme
WORLD HEALTH ORGANISATION (2015). Global Reference List of 100 Core Health
Indicators. ([Link])