Health Management Information Systems (HMIS) using ICT

Group 2:

Arul Murugan 1404001

Babu Venkatesh 1403003

Praveen R 1403019

Senthil Nathan Velu 1403024

1

Introduction

HMIS aims to consistently reduce the healthcare cost of institutions, country and private

companies’ trough an ICT based approach which involves the following stages in building a

robust health care system:

Increasing public expenditure on health

Reducing regional imbalance in health infrastructure

Pooling resources

Integration of organizational structures

Optimization of health manpower

Decentralization and District management of health programmers

Community participation and ownership of assets

Induction of management and financial personnel into District health systems

Operationalizing Community Health Centers into functional hospitals in each Block

across the country that meets international standards.

Deploying a HMIS increases the demand for data on population and health for use in both micro-

level planning and programme implementation. At the same time, understanding the synergy

between availability of services, cost involved in provision of public health care. In response,

healthcare services expenditure and pattern of utilization among various sections of population,

including vulnerable sections of the society, are important aspects that influence decision

making. A continuous flow of good quality information on inputs, outputs and outcome

indicators facilitates monitoring of the objectives critical CSF of HMIS.

In the underdeveloped countries like Tanzania, Mali, Zambia and Uganda Health Management

Information Systems are being introduced in hospitals to assess health system performance

which is of high importance to the government, development agencies and multilateral

institutions. The international Institute for Communication and Development (IICD) has been

working with countries in Africa since 1998 by introducing Information Communication

Technology (ICT) to gather experiences and lessons learnt and identify challenges for

introducing and using information system (IS) in healthcare. During the same time in India due

to the telecommunication evolution HMIS was growing in a rapid phase. In this study we would

focus on the implementation of ICT in India and Tanzania in the health care sector.

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Critical Success Factors for HMIS Implementation

Many CSF impact the implementation of healthcare service using ICT. Management\agencies

should focus on CSF’s before any major implementation exercise is undertaken. The CSF’s in

healthcare service falls under three major categories: User characteristics, System design

characteristics, organizational characteristics.

User Characteristics

System Design Characteristics

Organizational Characteristics

Cognitive Style

Personality Demograph

ics Situational

Variables Attitude Expectation

s

Hardware and software performance

Learning

Decision Making Support

Ease of use

Graphical user interface

Organizational Structure

Hierarchy of Authority

Management Support

Commitment

Involvement

User Characteristics

These are the study of people problems which should be extensively studied: example – learning

style, behavior, user attitude. The recognition of the dysfunctional user behavior is a first step

toward successful implementation. User orientation, training, education, running awareness

programmes are some ways to minimize the behavioral problems.

3

Implementation Steps

System Design Characteristics

These characteristics play an important role in determining the HMIS acceptability: example –

hardware – software performance issues, user acceptance testing. For an HMIS to have a

seamless flow of data communication system requirements should be articulated during the

planning phase of HMIS. Some thoughts that should go into consideration of system design

characteristics are from nurses who interact with the patient and they would have historical

issues in the hospital management, incorporate favorable factors such as proper use of colours

and graphics to practice uniformity.

Organizational Characteristics

Organizational characteristics can also influence HMIS implementation success. Examples of

variables include organizational structure and power, organizational culture, and other

managerial factors, such as top management support, commitment, and involvement. Key

strategies to achieve successful HMIS implementation include a realistic situational assessment,

accurate identification of necessary resources, and development of an action plan. It is therefore

critical to encourage top management involvement in many areas, and there should be a disctrict

level authority, programme authorities, regional level authorities or another knowledgeable

senior member of the management team taking charge of HMIS implementation.

Data Sources & Data Flow

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In the diagram shown above the straight lines represents upward flow of information and the

dotted lines represents downward flow of information (feedback report). Private facilities report

either at Block level or directly to the District Headquarter.

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The levels of reporting in computerized HMIS can be Districts, Blocks, and Facilities. Each

level of reporting has its own benefits but it is always better to have facility-wise data entry and

reporting. Facility-wise data entry would help in:

• Assessing performance of each facility with respect to other facilities in a District.

• Identifying which facility has low or high coverage and this is very useful to identify

underserved population in a community.

• Assessing how many facilities are reporting data on time (not possible in consolidated

reporting such as Block or District).

• Probing further question related to data quality and services coverage: example - if a

District has reported ‘full immunization=106%’, facility-wise data helps in identification

of those facilities which have reported very high coverage and this can be due to

duplication or over reporting. Also, if the District has reported ‘home deliveries=50%’

facility-wise data will help find facilities that have highest burden of home delivery, so

that decisions can be made accordingly.

• To ensure continuous and seamless data flow and reporting, these guidelines on data

reporting, entry and aggregation should be followed.

Data Reporting and Data Entry

As a team we have studied various HMIS models and we suggested to have facilities including

health sub-Centre (Hub and Spoke Model) which could report their data to Block in the format

prescribed for their facility. At the Block level, Block would consolidate these data to prepare the

‘Block Consolidated Report’. Block Consolidated Report would be sent to the District

Programme Management Unit (DPMU). Then DPMU would consolidate all Block data and

include stock details of Districts to make the ‘District Monthly Consolidated Report’, which

would be then uploaded on Web Portal. If the State decides to have a functional State specific

HMIS application, facility-wise data could be entered at Block and at the District level. District

stock details would be entered in HMIS application at District level. Once data entry is complete,

Districts can generate ‘District Monthly Consolidated Report’ to upload on Web Portal. Formats

required to generate a ‘District Monthly Consolidated Report’. The reports could be generated

quarterly, half yearly; the more frequent the data are reported the more approximate would be

precision of the data.

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Information And Communication Technology (ICT) in HMIS

Globalisation is about the transformation of traditional systems, it is about innovations and

competition in a global market, at intensified pace, facilitated very significantly by or through the

use of Information and Communication Technologies (ICT). Effort to strengthen the HMIS in

developing countries goes back to only a decade ago. As a result of these efforts enormous

amount of data has been generated in many of these countries to the extent that in some of these

countries data has become a source of problem. This is because often managers are overwhelmed

with lots of data that they cannot analyse effectively and use it for decision-making. The

collection, compilation and analyses of data become an end rather than the means of improving

health care services.4 In addition, data produced continued to be of doubtful quality and

untimely, thus ending up being not adequately used for decision-making.5 This paper aims at

highlighting some of the opportunities and challenges offered by ICT in the strengthening HMIS

in the wake of globalisation.

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Type of business\service Change in Indian HMIS Type of business\service Change in Tanzanian HMIS

Do New Things Do Things Better Stop Doing Things Do New Things Do Things Better Stop Doing Things

Degree Of

Explicit-ness

Financial Benefits

Quantifiable Benefits

District HMIS could intrun be integrated with the HMIS operated by WHO

Robust data analytics tools should be implemented and HMIS users needs to be trained in the tools

Measurable Benefits

Rapid Real time monitoring of HMIS dashboards: Could lead to better handling of inventory of health care by both private organizations, as well as by government agencies

Data collected from frontline HMIS users could be done using PDA devices: Field data with very accurate metrics would be available to HMIS

Manual data collection by district HMIS workers

New application for collating field data: People from rural villages come to district level care centre’s to attend to their health needs which could capture and mine the data to give a meaningful information of field data

Better handling of resources: Becomes an enabler to implement the ICT and other allied systems to the government

Observable Benefits

Usage of Cloud computing for duplex data interaction between the application and end HMIS users

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Strategic Impact Grid – India HMIS

Indian HMIS is a monopolistic service catered by Indian government through PPP, though the IT strategic grid is done to understand the

competitiveness of a companies IT strategy since HMIS is a nationwide service offering the below mentioned grid shows the state of Indian

HMIS which was leaping towards improvement. The ICT based HMIS is currently in Support mode and is moving towards Turnaround

mode using the concept of functional IT.

Defensive Offensive

Low to high need for reliable

information technology

Factory Mode Strategic Mode

Support Mode

* With the advent of mobile technology Indian HMIS saw enormous growth in the past 10 years

* As a overall ICT growth, there were new internet kiosks, web based reporting

* E-governance/Government plans were introduced to widen the scope of HMIS

*Parts of rural India are still not have robust supply of electricity

Turnaround Mode

Low to high need for new information technology

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Strategic Impact Grid – Tanzania HMIS

Compared to India; Tanzania lacked the very level of resources required to run an ICT based HMIS across the country. Compared to India;

Tanzania had high PPP to implement the programme. The ICT based HMIS is currently in Support mode and is slowly moving towards

mode and is moving towards Turnaround mode using the concept of functional IT.

Defensive Offensive

Low to high need for reliable

information technology

Factory Mode Strategic Mode

Support Mode

* Web based centralized database system enhancing data mining, telemedicine

*Open source applications were initially used and then later on moved to a more customized suite for customized data warehousing purposes

Turnaround Mode

Low to high need for new information technology

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ICT - HMIS in India

India has been witnessing ICT in HMIS since November 2009 were 543 million phone

subscribers (landline and mobile) in India, and the overall telephone density was 46 percent. The

growth in mobile phone ownership is also reflected in large-scale national and state-specific

health surveys. The increased penetration and use of ICTs presents unprecedented opportunities

to communicate with rural audiences, and may soon be the largest communication media in rural

India. . By November 2009, 57,599 rural internet kiosks (common service centers - CSC) were

established in India.

The development of an integrated, national web-based reporting system for the Ministry of

Health and Family Welfare (MoHFW), commonly referred as the NRHM HMIS, has been a

significant step in recent years. In order to make the NRHM HMIS a single point of reference for

all health-related information, the system is being expanded to include sub-district level

information, and integrated with an advanced Geographical Information System (GIS) and other

national health programs. Data collection by frontline health workers have demonstrated faster

data transfer and communication though the use of ICTs. Some ICT projects also report better

data quality as compared to paper-based data collection systems. In all the projects reviewed, the

pace of data transfer was directly associated with the quality of service delivery – monitoring in

realtime for supervision and follow-up with field workers. For example, Rapid SMS, an SMS

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based data collection tool that uses any mobile phone, was used for supply chain management in

were field reports and alerts could be sent through SMS to a web portal, thus reducing the time

taken for reporting and allowing for quicker response from the management.

The review identified projects that used ICTs to collect beneficiary data in rural communities in

India including the Community Accessible and Sustainable Health System (Ca:Sh) project being

implemented in Ballabhgarh; the mCARE project being pilot tested with healthworkers at 120

sub-centers in Tirur (Kerala); the Beneficiary Tracking System (BTS) being implemented in 206

sub-centers in Gujarat; and the Catholic Relief Services program on maternal and neo-natal

health monitoring being implemented in UP. Results show that in the Ca:SH project the use of

mobile devices resulted in greater accuracy in data collection, a reduction in data entry time for

ANMs and use of data. Community feedback is relevant for both public and private sector health

service providers, but is particularly important for the provision of public sector services as these

are largely outside the monitoring influence of market forces. A review of projects in India

shows that with the rapid growth of telephones (landlines and mobiles) and the internet, ICTs

have the potential to develop an effective community feedback system. For example, Lokvani, an

e-governance initiative in Sitapur district, UP, was launched in 2004 by the district

administration and the National Informatics Centre.

Lokvani has a website in Hindi and includes an online public grievance redressal service. As part

of the project, existing computer training institutes and cyber cafes have been designated as

Lokvani centers. As of June 2008, 115 Lokvani kiosks were operational in Sitapur district.

According to project documents, in June 2008 a total of 117,179 complaints were registered on

the Lokvani website, of which 97 % were addressed. Among the services provided through the

internet kiosks that are part of this initiative, online public grievance redressal services emerged

as the most popular. Another example is the Jhansi Jan Suvidha Kendra (JJSK); through these

centers, citizens can approach the concerned government officials and register their grievances

using a mobile phone (including SMS), landline phone or the internet. This free-of-cost service is

easily accessible for registering complaints, ensures the effective tracking of complaints through

follow-up with concerned officers and intimates citizens of the status of their complaints. As of

January 2010, a total 7,379

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grievances were registered with JJSK, of which 7,007 (95 %) were attended. The provision of

diagnosis and treatment support through ICTs, including telemedicine, has been accepted by

doctors and has resulted in increased efficiency in diagnosis. In some cases, telemedicine has

been shown to be cost-effective among populations with poor access to health care. In rural UP,

Tamil Nadu and Madhya Pradesh, pilot projects provide telemedicine-based health services at

the village level.

The key challenges in this application is the need to have a dedicated pool of qualified health

practitioners who provide advice based on information received through a telemedicine center,

the possibility of misuse of potential applications such as portable ultrasonography by frontline

health workers, and operating the technology under conditions with erratic supply of electricity.

Technology in telemedicine includes sophisticated and highly priced equipment such as

satellites, video-conferencing and medical devices. However, the emergence of mobile networks

and retrofitting digital data capturing interfaced to simple diagnostic tools like a hematogram

analyzer, pulse and blood pressure unit, digital camera and weighing machine can provide data

for early diagnosis for a large number beneficiaries. Frontline health workers and trained

medical practitioners use various job-aids, flow-charts and checklists to adhere to protocols

during counseling, diagnosis and treatment provision. ICTs automate job-aids, flow-charts and

checklists using algorithms, known as decision support systems (DSS). DSS projects have shown

improved counseling, increased adherence to protocols, diagnosis and treatment provision among

frontline health workers and trained medical practitioners. These were found to have an indirect

effect on BCC strategies by providing managers with data for informed decision-making and

improving the productivity of frontline health workers, as well as the quality and timeliness of

their interaction.

Education and skill development of health care providers/frontline health

workers

Intervention studies reveal that e-learning, including m-learning, is effective in imparting

knowledge and skills. E-learning was found to be as effective as classroom learning in some

studies. Further, e-learning is consistently associated with increased motivation, independent

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learning and control over learning and recall, particularly when supplemented with direct or

classroom interaction. Successful e-learning initiatives in low resource settings indicate that

e-learning can be used to train frontline health workers at Primary Health Care Centres (PHCs) \

Community Health Care Centres (CHCs) on fixed days and at fixed times. This approach could

also be used to train village health committee members.

As some PHCs\CHCs are located in remote villages hands-on training needs to be provided:

example - If the system crashes, a redundancy needs to be in place to access the data seamlessly

to restore recent backup of data from the central database. A system crash may affect the entire

reporting process if it is not rectified immediately which makes the importance for training the

field staff. Also, staff should be trained in the software application and the usability’s.

Changing the behavior of end-users

The review identified two types of communication for end-users using SMS, telephony and the

web or email in terms of how they were designed: single interaction systems or multiple

interaction systems between the sender and each receiver. For rural and low literacy audiences,

voice calls and voice SMS have been piloted and found to be successful. Single interaction

systems: Bulk SMS services where the same message is sent to many recipients enrolled with a

provider is an example of a single interaction system. Various web-based yellow pages, customer

care services and helplines send such SMS to their subscribers. Project reports reviewed suggest

that such a system is effective in increasing awareness on a topic or issue, addressing the specific

queries of individuals interested in undertaking an action, usually regarding the location of a

service delivery point (referral) and as a reminder. In this context, in January 2010, the

Mangalore Deputy Commissioner announced a scheme for the mobile operator BSNL, by which

all its customers would be sent an SMS two days prior to the polio immunization day.

Multiple interaction systems

This system requires the beneficiaries enroll to receive ongoing messages from a service

provider and interact with this system by providing information pertaining to their health status

or behavior, asking questions and getting answers. Messages sent to recipients are customized,

based on the input they provide, and the system supports the

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recipient through the behavior change process. This system has an extensive body of evidence

showing its effectiveness in improving health status, behavior modification and increased

adherence. Reviews show that behaviors related to smoking cessation, weight management,

physical activity, HIV/AIDS prevention, adherence to medication (including tuberculosis),

diabetes management and asthma management have been modified. For example, in a

andomized controlled trial, the effectiveness of SMS and multimedia message services (MMS)

for weight loss among overweight adults was evaluated. Participants in the intervention group

received customized SMS and MMS messages, 2-5 times a day, printed materials and brief

monthly phone calls from a health counselor. SMS were generated automatically from a database

using predetermined algorithms and user profiles participants’ plans and actions. Responses to

these questions were used to customize future SMS.

BabyCenter is an interactive network targeting pregnant and newly-delivered mothers. It

provides personalized, stage-based email and SMS messages (tied to gestation / baby’s age)

addressing a wide range of topics relevant to pregnant women and new mothers. In India, the

website had 3.5 million users in December 2009 and received 2,000 discussion posts a day. The

site provides expert-vetted content and parent-to-parent advice. BabyCenter India has launched a

phone-based platform, combining daily SMS messages and pre-recorded voice content, accessed

through an Interactive Voice Response system. Users receive customized emails from pregnancy

till the child is 3 years of age. Messages focus on maternal and child health issues such as

nutrition, iron folic acid tablets and danger signs during pregnancy. The BabyCenter seeks to

adapt this platform in the long term to reach a significant proportion of the Indian market,

including rural, low literacy women, poorly trained frontline health workers, and consumers

seeking reliable information on health.

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ICT - HMIS in Tanzania

Since independence in 1964 Tanzania has struggled to improve its health services. During the

late 70’s the service level in health was relatively high. Economic problems and structural

adjustment devastated the health sector, causing falling numbers of health workers, decrease of

available materials, and a breakdown of the referral system. Also the rural- urban inequality

increased sharply. The ICT (Information Communication Technology) structure in Tanzania

was developed to a level where it is realistic to computerize some of the routine processes in

hospitals to support management in dealing with these issues. The Tanzanian government

decided to implement a HMIS to supply each level of the health sector with the necessary

information in a timely and accurate manner. Provision of support to sector performance

monitoring system was identified as a priority for health development. An array of information

sub systems already existed to generate a set of input, output, outcome, and process indicators for

gauging key sectoral performance and contribution to development. Included in this are the

health Management Information Systems (HMIS), Demographic Surveillance Systems (DSS)

and Health Systems Research under the MoHSW (Ministry of Health and Social Welfare), the

Demographic and Health Surveys (DHS), Population Census and Housing and the Household

Surveys are coordinated by the National Bureau of Statistics (NBS) in collaboration with the

MoHSW. Robhust

ICT programme in Tanzania required resources, including training and skill upgrading needs,

will be a more natural part of the planning process. Contrary to India which is a developing

country with booming scale of ICT, most of the health facilities in Tanzania are located in

remote areas where there is inadequate access to reliable electricity, telephone lines and poor

infrastructures as a whole. This has contributed to major problems in the provision of health

services to the population.

All the village health posts are staffed by village health workers primarily providing first aid

services. Dispensaries provide basic curative and Maternal and Child Health (MCH) care. They

are usually headed by a rural medical aide who is responsible for curative services, and who is

supported by a MCH aide and other less trained nursing staff, that is, staff with less training than

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nurses and/or without formal training for health care services. In addition to the basic curative

and maternal and child services, health centers offer inpatient and obstetric services. They are

physically large institutions than dispensaries and are served by a large staffing complement. The

health facilities collect data, which are then collected and aggregated at the district level where

the reports for the particular district are being generated. This is being done manually, that is,

using paper-based forms. Data from the districts are sent to the regional level, where the reports

for a particular region are being generated and sent to the national level. At the regional levels

reports generation is being done using a computer system. The HMIS includes all data collected

at all the health units in all levels.

The before implementing the ICT based HMIS the manual way of collecting data has led to various weaknesses in HMIS systems which are as follows:

Data quality and accuracy are not sufficiently assured through simple validation or verification procedures.

Information is generally not sufficiently used for local decision-making.

Data presentation, analysis, and feedback are generally very weak.

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Late reporting of health information from one level to another. •

HMIS-related activities result in higher workloads, especially for health staff at the

dispensary and health center level where data are being collected.

I n 2005, as a result of the Round Table District Health Management system (D-HMIS) was set

up in 2006. The specific objectives of the D-HMIS using ICT was to:

Train HMIS users in 14 hospitals

Raising awareness to other stakeholders and government personnel

Capacity building for project headquarters

Installing internet connectivity at the regional and district offices

Exchange date and improve the performance

Software package and modules

In 1997 the already prevailing DOS based HMIS system was decided to be enhanced further by

MoHSW. The Project was first initiated in six hospitals, but only one continued to use it after a

few years. This experience showed that there is interest, because people indicated it helped them

in their work and they have since asked for a better version of the system. But it also clearly

showed the problems that inhibit the effective use of such a system. Most problems related to:

• The integration of ICT in the workflow, processes and responsibilities

• The robustness, effectiveness and user friendliness of the system

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• The computer skills of the hospital staff

• The technical support structure

The project team compared many alternatives which were either too expensive, of poor quality

or without affordable long term support. After a careful review of available solutions with a

broad collection of stakeholders from amongst others the Ministry of Health and the University

of Dar es Salaam Computer Centre (UCC), Evangelical Lutheran Church in Tanzania (ELCT)

decided to develop a generic Tanzanian version of Care2X, an open source HMIS that is used in

several countries over the world. ELCT programmers cooperated with UCC, COSTECH and a

German software company to adapt the software to the government health registration system

Mfumo wa Taarifa za Huduma za Afya (MTUHA) , and to specific hospital requirements.

Drafting of requirements was done with hospital managers. Experiences and lessons learned

from the hospitals were continuously translated into requirements for further development of the

Care2X software which took two years.

Care2X a client/server software, which is scalable from a single computer to a big hospital

network. It is modular and health facilities can choose which modules they need or are able to

use. Modules used in this project are patient registration, billing, laboratory, pharmacy,

radiology, diagnosis and treatment, appointments, in-patient, outpatient, eye-clinic and nursing.

Strengthening the MOHSW HMIS unit and building the integrated district and

national data warehouses

The software team’s main tasks are to develop the national and district data warehouses and to

customize DHIS and additional software tools as according to the needs of the MOHSW,

Furthermore, to integrate the data warehouse with other data sources by extracting the needed

data. GIS functionality will be developed as part of the collaboration with WHO on the HMIS

project. The software team will work with, and be part of, the global network of DHIS

developers and work closely with the WHO and HMN on the developing of appropriate Open

Source tools. Capacity building MOHSW; data management, DHIS data warehouse and open

source technologies

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Capacity building MOHSW; data management, DHIS data warehouse and open

source technologies

Capacity will be developed in the MOHSW through the activities of the software team

described above but also through the building of a solid base for managing the overall

HMIS. All staff in the HMIS and ICT units will be part of this effort. As the building of the

National data warehouse and the National HMIS will take place in the HMIS unit, capacity

building will be part of every step of the process. In order to achieve capacity development in the

MOHSW, the project needs to recruit additional regular MOHSW staff, train existing staff,

allocate skilled project staff to the HIR section and engage them fully in the development of

the system and its rollout. Training of regional and zonal HMIS staff will also be part of this

effort. Both Topdown and bottom up approach were used for capacity building and application

work packages (WP). Integration with other computer based application such as Electronic

Patient Record systems in hospitals and other facilities was handled through a standardized data

interchange platform. This, of course, was depending on the use of open standards also by other

computer applications, which will be ensured through the strategic planning process. and other

computerised data sources; establishing web-based data warehouse, electronic reporting etc.

The basic principle underlying the various software applications involved in this work package is

that first a “first” customised, stable and useful application is implemented, and thereafter it is

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continuously further developed and integrated with the patient record systems such as the

Care2X, OpenHealth and other systems in place.

Capacity building scheme was carried out in stages; starting with the regional and national

levels, and about 3 months later, also with the district level staff in the test region(s) The first

objective – and stage – for this work package is to establish a training program for the “training

of trainers”; regional and national staff.

Three staff from each region, including the HMIS focal person, totaling 63, and about 12

from national and zonal level, totaling about 75. Four training sessions of 2 weeks was

conducted over 2 years. The topics of the training will address HMIS and management,

analysis and use of information for health management and health services delivery.

Assignments were given to the staffs to be completed between the training sessions which

included the use HMIS and other information for situation analysis, planning and target setting,

as well as the organisation of data use workshops at district and regional (i.e. for all districts in

the region) levels. The training was conducted using the zonal training centres where

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appropriate. The second objective is to devolve an adapted part of this training program to the

district level, starting in the test region(s). Three times one week training over about 1.5-2 years

will be carried out at the regional level for 3-4 staff from each district. With about 25 persons per

training session, some regions may be combined. The training included the same issues as for the

regional staff, but with an additional emphasis on facility supervision and the training of facility

level staff. Assignments to be completed between training sessions will include, as for the

regional level staff; use HMIS and other information for situation analysis, planning and target

setting, as well as the organisation of data use workshops at district level for district and facility

staff. Regional level staff would be responsible for conducting the training, but with support

from national level, in particular during the first session. The third objective was to devolve the

training scheme to the facility level. The test region(s) would be used to develop cost effective

methods to train facility level staff (data use workshops may be the primary methodology, linked

to supervision an additional one). Details will be developed later. For long term HMIS

sustainability, an HMIS module will be designed and integrated into pre-service training. In

addition, a diploma in Health Informatics programme will be established for HMIS cadre. The

training materials were prepared as a joint effort between MOHSW, Ifakara, UDSM and

University of Oslo.

Conclusion

Increasing penetration of computer and information communication technology to the lower

level is of primary importance if poor countries are to bridge the internal digital divide in their

countries. Participation of the private sector has been of crucial importance in the establishment,

investment and development of ICT when compared to other stakeholders. With the current

economic situation the private sector will continue to play major role in the efforts to spread ICT

technology. But currently, most investors shy away from investing in rural areas due to

unfavorable conditions such as low purchasing power and high investment costs in areas with

lack or erratic supply of electricity and shortage of telephone lines. ICT revolution will continue

to ignore and marginalize poor countries and its people. The profit motive in the private sector

cannot work unless deliberate efforts are taken to create conducive environment for investing

through the establishment of favorable Government policies and infrastructure. There is therefore

a need for poor countries to exercise strong commitment and political will to bring

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in favorable conditions for investment in the rural areas by encouraging the development of low

cost access technologies that address the need of the rural majority by reducing taxation for

solar-power equipment that can be used to run computers in remote areas where there is no

electricity an through various other schemes. Certainly in countries like India and Tanzania were

larger sector of population are still left out without electricity and telecommunication; the future

for HMIS looks bright as technology becomes affordable to all class of general public.

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