Health Information Systems Program HISP & DHIS 2: Past, Current, Future

1. Health Information Systems Program HISP & DHIS 2: Past, Current, Future • HISP : global network for HIS development, Open Source Software, education and research • DHIS 2 open source software : reporting, analysis and dissemination of health data & tracking individuals • Started in South Africa in the 1990’s- Now 40+ countries using DHIS 2 • DHIS 2: core funding from Norad and PEPFAR. • Global Fund: Country implementations • Partners: WHO, Global Fund, GAVI, UNICEF

2. DHIS2 country systems & PEPFAR Early phase / pilots Early implementation / many states in India Nation-wide PEPFAR

3. DHIS – District Health information Software HISP – Health Information Systems Program Background: • HISP started 1994 in “New” post apartheid South Africa • Development DHIS started 1997 & 2002 National Standard • DHIS v1 & HISP to India from 2000 • DHIS v1 spread to many countries in Africa from 2000 • 2000-2013 - Develop Masters Programs in Mozambique, South Africa, Malawi, Tanzania, Ethiopia & Sri Lanka • PhD program, 40 students from Asia and Africa …… who are later running the Masters programs

4. Background in ‘NEW’ post apartheid South Africa 1994-2000 HISP approach – from South Africa: • Local use of information; • Maximise end-user control; • Local empowerment & • bottom-up design and system development Focus: Integration and use of data1) standardisation of primary health care data &2) ‘flexible’ – easy to change and adapt new data sets • 1998/99: implementation in two provinces • 1999/2000 - onwards: National implementation

5. HISP / DHIS timeline (2): From ‘Stand alone’ MS Access – to DHIS2 Web & global footprint • 2004 – 2010: New technological paradigm: • Web based open source – Java frameworks • 2006 Kerala; 2009 Sierra Leone • 2011 – 2013: ‘Cloud’ and online • ‘Cables around Africa’: • Kenya, Ghana, Uganda, Rwanda, … • 2014 – 2016: 40+ countries in Asia and Africa use DHIS2 as national HIS

6. HISP Approach to information systems – Background • Information for decision making • Data use – culture of information • ‘Power to the users’ – Empower health workers, local levels, communities • Training & education • Participatory design • Focus on important data & indicators: • Data standardisation, harmonisation of data sets • ‘Less is better’

7. Data Use, for what • Data: • Where? • What? • When? • Analysis& decisions: • Why? • How to?

8. ‘When, What, Where’: Basis for DHIS2 data model When Dates, time period, e.g. August 2011, Quarter 3 2011 National Period State / Province 1 Where N 1 Data Value Location (OrganisationUnit) District N N Organised in an Organisational hierarchy Sub-District 1 Data Element Disaggregated by Dimensions, e.g. sex, age Organised in Data sets Health facility What

9. Data collection, analysis, action

10. TALI Tool: Tool for Measuring levels of Information USAGE & The DHIS2 Level 0: The DHIS2 may be in various stages of development, but not yet fully functional Level 1: System is functioning technically : data reporting completeness as a key indicator Level 2: Data is analysed, disseminated and used. Data quality (accuracy, timeliness, completeness) and feedback reports and graphs on the wall are key indicators Level 3: Data used for planning and decision making: Indicators: evidence of use of data to measure achievements in reaching targets in e.g. annual planning process

11. Motivation for ‘Standardisation’: South Africa 1994 /95 – Problems & challenges: • Inequity between blacks & whites, rural & urban, urban & “peri-urban”, former “homelands”, etc. • “Equity” main target • Need data to know whether targets are achieved • Need standard data from across the country on • Health status & Health services provision • Problem: No coordinated data system – no standards • HISP key actor in developing the new unified Health Information System in South Africa • ‘

12. DNHPD Cape Town Western Cape RSC Cape Town PAWC Clinic Clinic Malmesbury RSC RSC Clinic Clinic PAWC Clinic PAWC Clinic Hospital PAWC Private NGO School Health School MOU Hospital Health PAWC Private Private NGO Example South Africa, Atlantis District 1994: First Architecture approach: From fragmentation to integration; Health programs Higher levels Family Planning Mother Child Database Info. office A B • Post-apartheid centralised, vertical and • fragmented structure in Atlantis (simplified). B) Decentralised integrated district model As according to the ANC Health Plan Intergation: Still the same challenge !!

13. Different levels of the health system – different needs for information Level of health system Quantity of data Data granularity Information needs Global/Region Summary indicators General, e.g. MDG Less data Countries/ Health Programs Indicators National /program District Indicators district management Facility Facility management Patient Patient records, tracking & care More data

14. Hierarchy of data standards: • Balancing national need for standards with local need for flexibility to include additional indicators • All levels – province, district, facility – can define their own standards as long as they adhere to the standards of the level above Hierarchy of Indicator & Data Standards Standard Indicators, & datasets: Regional Level Patient National Level Facility Sub-National Level Sub National National Health Facility Level Regional - ECOWAS Patient – individual client Level

15. 3 components of the HISP ‘Network of Action’ Free & Open Source Software Distributed DHIS2 development – Sharing across the world knowledge & support Health Information Systems Integration, standards, architecture Use of information for action Health management Mozambique Building Capacity, Academies, Education, Research Training of health workers Graduate courses, Masters, PhD Sharing teaching /courses South Africa Vietnam Uganda Norway Nigeria India Sri Lanka Kenya Rwanda Bangladesh Ghana Phillipines Indonesia others Laos

16. Regional approach: Implementing DHIS2 through HISP nodes Early phase / pilots / preparation Under implementation / many states in India Nation-wide PEPFAR HISP Kenya Tanzania Uganda Rwanda HISP West Africa Nigeria, Ghana, .. HISP India & Vietnam & HISP Sri Lanka! HISP South Africa

18. HISP – DHIS2 Community: principles • Free and Open Source Software & training / educational materials, etc. • Development and implementation of sustainable & integrated Health Information Systems • Empower communities, healthcare workers and decision makers to improve the coverage, quality and efficiency of health services • Developmental approach to capacity building & research • Research based development • Engage HISP groups and health workers in action research!

19. WHY SUCH EXPANSION ? And how to continue to build the network and open source platform

20. Mobile subscribers per 100 persons, Africa Source: World Bank

21. Internet: Total bandwidth of communication cables to Africa South of Sahara Source: AFRINIC

22. DHIS 2 implementations DHIS2 implementations /initial projects correlated with increase in bandwidth DHIS = 1/1000 2014 2015 Source: AFRINIC

23. Improved Internet & mobile network – ‘cloud’ infrastructure Rapid scaling – from ‘hundreds’ of installations to 1

24. Online system – one server Easier to integrate / interoperability with other systems which are also online: web API & central server Interoperability with Other systems

25. Improved Internet and mobile network: Rapid scaling Implementation Using central server & “cloud” infrastructure Online data use; web pivot reports, charts, maps Online Data capture DHIS2 Mobile Data Use Browser Mobile Data Capture Offline Data Capture Online / / Offline Offline data use application BCG:12 PENTA1:10 PENTA2: 7 PENTA3:11 • Datamart • pivot tables • Archive • reports, • Charts, maps

26. HMN architecture (2007) – Integrated National data warehouse:

27. DHIS2 Country platform: Integrating health programs & data sources Web Portal Data capture from paper forms -Data mart -Meta data -Visualising tools Dashboard Data from Mobile devises Data warehouse DHIS 2 Extract Transform Load LMIS Graphs EMR HR Maps Mobile Getting data in - Data warehousing Getting data out - Decision support systems – ‘Business intelligence (BI)

28. Integrated Health Information Architecture (“Horizontal integration”) - integrating sub-systems, technologies, health services & programs Users of processed & integrated data Data Warehouse Aggregate & indicator data Interoperability Interoperability Paper reports Performance Based financing reporting SDMX -HD Electronic Medical Records HR Management Paper based systems: OPD, EPI, RCH, other programs Logistics & drugs Mobile reporting Users of primary data & data providers Finance Users of primary data & data providers Integration of technologies, systems, data & health programs

29. Integration and interoperability DHIS : Data warehouse Statistical data Data transfer from iHRIS to DHIS, e.g.: #midwifes @health centre X for month of May Data transfer from OpenMRS To DHIS, e.g.: #deliveries @health centre X for month of May DHIS is calculating the indicator: Deliveries per midwife Per facility per month Interoperability Interoperability iHRIS: Human Resource records OpenMRS : Medical records Integration

30. Extending the reach through mobiles • User friendly & ’close’ data entry individual level/aggregate data • Tracking clients in programs • sending reminders, e.g. for ANC visits & vaccination • Feedback – simple reports, text & calls • Communication – ‘social media’ for both health staff and community (support, chat, • Integration with DHIS data warehouse & backbone infrastructure • Support wide range of technologies Browser SMS Java Android PC/laptop/tablet

31. All devises integrated in More flexible SMS PC/laptop Lightweight Browser Android app or browser Tablet

32. Enterprise architecture: 3 Levels (each serving the level above) Patient records Institutional use of information DHIS Data warehouse Aggregate data iHRIS Open MRS Applications supporting use of information Data & indicator dictionary /standards Facility register Provider register OpenHIE Health Information Exchange ADX Data Standards and infrastructure supporting the applications

33. Indonesia Data Warehouse & Dashboard National level: Electronic data sources Dashboard BKKBN (Family Planning Board) BPJS (Social Security Provider) DHIS2 Data warehouse SITT (TB) SIHA (HIV) E-Sismal (Malaria) NCD NIHR&D Logistics

34. Integrated National HTM Dashboard

35. National TB Dashboard

36. National Malaria Dashboard

37. TB + rate 2014 By Province By District TB +Ve cases by facilities

38. Location of Hospital and Puskesmas

39. Yogyakarta Hospital and Puskesmas

40. Yogyakarta Dashboard

41. NATIONAL PROVINCE: All programs receive reports aggregated by district –from district programs KOMDATA • DISTRICT: • Each program • manage own data • Limited coordination • across programs District TB AIDS MCH IDSR Vaccine Others Malaria Data flow PUSKESMAS: Each Program Reports to Program in District TB AIDS MCH IDSR Vaccine Others Malaria Puskesmas – Health facility Dataflow – Districts with few patient records (Malang)

42. Pilotitis in Uganda: mHealth mapping Map of mHealth pilots in Uganda (Sean Blaschke , Unicef Uganda)

43. Shared Facility codes Integrating data sources Family Planning Mapping Facility codes MCH DHIS : Data warehouse Statistical data Malaria Same code EPI Komdat /HMIS MAPPING Different codes Nutrition TB Facility Codes Register BPJS Human Resource records HIV/ AIDS LMIS Dashboard Indonesia

44. Integration - District system DHIS2 PROVINCE/NATIONAL: Integrated data warehouse & dashboard used by all TB AIDS DISTRICT: Integrated data warehouse & dashboard Vaccine IDSR MCH DHIS2 Malaria Others PUSKESMAS: Programs use DHIS2, both data use and reporting TB AIDS MCH IDSR Vaccine Others Malaria Puskesmas – Health facility

45. Integration - District system DHIS2 PROVINCE/NATIONAL: Integrated data warehouse & dashboard used by all Data access & use TB AIDS DISTRICT: Integrated data warehouse & dashboard Vaccine IDSR MCH DHIS2 Malaria Others PUSKESMAS: Programs use DHIS2, both data use and reporting TB AIDS MCH IDSR Vaccine Others Malaria Puskesmas – Health facility

46. OpenHIE Architecture Design

47. OpenHIE / DHIS Architecture - Evolving through use Facility Registry Data Dictionary DHIS 2 HMIS Community

48. Dashboard projects in Indonesia • Pusdatin – University of Oslo – UGM • National data warehouse & dashboard project • Integration national programs: data by Puskesmas • Creation of health program-based dashboards (TB, HIV/AIDS, Malaria, ..) • Creation of integrated dashboards: indicators across programs TB-HIV/AIDS, .. • Yogyakarta province data warehouse • Province & district based dashboards • Applying & aligning national data warehouse with province data warehouse

49. Initial plans: HSS – Pusdatin – Oslo –UGM • Selection on 5 provinces for DHIS2 implementation • Provinces where HSS district located • Identification of data sources and reporting flows in districts and province • Applying & aligning national data warehouse with province and district data • Including selected district & province specific data • Electronic data: (semi) automate data transfer • Manual data capture • Design and develop of district and province dashboards

50. Initial plans (2) : HSS – Pusdatin – Oslo –UGM • Capacity building • Train & develop national expert DHIS2 team –Pusdatin &UGM • Train all HSS staff • Training of Trainers (TOT): Key people from provinces & districts • Training & data review and data use in districts • Continuous hands-on training and support