RHINO panhel presentation on "Achieving Universal Health Coverage: The Role of Routine Health Information Systems" (HSR2018)

1. Welcome to the RHINO Panel
ACHIEVING UNIVERSAL HEALTH
COVERAGE:
The Role of Routine Health
Information Systems
10 October 2018, Liverpool
@RHISNetwork
www.rhinonet.org
The_rhino@jsi.com
Routine Health Information Network

2. RHINO
Routine Health Information
Network
• Network of organizations and professionals concerned
with improving the quality and sustainability of RHIS in
developing countries
• Created in 2001 with funding mainly through USAID
(MEASURE Evaluation)
• Independent NGO with 501-C-3 status since 2007
• Currently 1,000 + members from 60+ countries
– Ministries of Health
– Bilateral and multilateral donor agencies
– Consulting agencies and NGOs
• Website: www.rhinonet.org
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3. RHINO: summary of activities
(2001-2010)
• Networking:
– International Workshops
• Potomac, USA, 2001 – Mpekweni, South Africa, 2003 – Chiang Rai, Thailand,
2006 – Guanajuato, Mexico, 2010 – Vancouver, Canada, 2016
– Website with moderated listserv
– Collaboration with HDC/USAID/WHO/World Bank
– Recently: regional networks with WAHO and AeHIN
• Capacity building
– International PRISM courses in Africa and Asia
– Newly designed standardized RHIS course
– RHINO forums on SOTA topics
• Knowledge management
– Annotated bibliography on RHIS
– Publications
– Consultants database
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4. Routine Health Information Network
Creation of an
Information Culture
Theo Lippeveld, MD, MPH
Senior HIS Adviser
John Snow Inc
Liverpool, October 10, 2018
Health System Research
Symposium

5. The role and importance of decentralized
Routine Health Information System (RHIS)
 Facility-based and ideally also community-based
 Main source of information for (daily) planning and
management of quality health services at district
level and below
 Coverage and quality of health interventions
 Disease surveillance
 Commodity security
 Human resource management
 Financial information systems
 Eventually also feeding information into national
and global levels (but not its primary role)
 Ideal support to integrated management of health
interventions

6. Administrative
records systems
(NHA etc.)
Services
records
systems
Individual
Records
systems
Pop based
surveys
Vital
registration
Census
Population-based
data sources
Health Institution
(including community) based
data sources (RHIS)
Routine Health Information System (RHIS)

7. Unfortunately...
Routine health information systems in most
developing countries are woefully
inadequate to provide the needed
information support ...

8. What is wrong with existing routine health information systems?
• Irrelevance, plethora, and poor quality of the data
collected
• Fragmentation into “program- oriented”
information systems: duplication and waste
• Poor and inadequately used HIS and ICT
infrastructure and resources
MOST OF ALL
• Absence of information culture where data are
valued for decision making

9. RHIS Reform and
strengthening: Achievements
and Way Forward Advocacy: growing demand in the past decade for
strong RHIS in the global health community
 RHIS performance has improved in many countries
thanks to technical interventions such as
 Better measurement of RHIS performance: PRISM
tools
 Data quality assurance systems
 eHealth Architecture establishment
 Improved data visualization
 But use of information for DM lagging behind
Need for broader “system” thinking : PRISM framework
Need for behavioral interventions at individual and
organizational level

10. Behavioral
Determinants
Knowledge/ skills, attitudes,
values, motivation
2008: PRISM Logical Framework for Understanding
Routine Health Information System (RHIS) Performance
Improved Health System
Performance
Improved Health
Outcomes
Technical
Determinants
Data generation architecture
Information/communication
technology
Desired Outputs
= RHIS performance
•good quality information
•appropriate use of information
Inputs
RHIS assessment,
RHIS strategies
RHIS interventions
Organizational
Determinants
Information culture, health system
structure, roles & responsibilities,
resources

11. Need to Establish a “Culture of
Information”
Operational definition
“The capacity and control to promote values and
beliefs among members of an organization for
collection, analysis and use of information to
accomplish its goals and mission.”

12. What drives Culture of Data Use? (JLN,
2018)
​ Enabling environment with a decentralized organizational
structure
​ Robust data feedback loops throughout the health system
​ Clear roles and responsibilities around decision making
​ No-blame environment with respect and promotion of
transparency
​ Mutual accountability and shared ownership within the
health system, and between the health system and the community
​ Encouragement and incentives to motivate behavioral
change

13. Illustrative Interventions to Promote Data
Culture
​ Role modeling by senior management for using collected
information
​ Human Centered Design (HCD) involving users at the RHIS design
stage (Data Use Partnership projects in Ethiopia, Tanzania, Malawi)
​ Dissemination of success stories on use of HIS
information
 Publication of district level indicators through media (Uganda)
 Allocation of resources based on HMIS indicators (Brazil)
​ Institutionalizing use of RHIS information
 Use of information as a criteria for annual performance appraisal
​ Health Services Performance Review meetings
 with focus on using RHIS data (problem solving methodology)
​ Creating data use incentives

14. ​ “Two years ago, we were the least performing
woreda in the zone. The training we received on
how to use our performance data to make
decisions and take action was an eye opener.
We knew very little about using our own data to
identify our own gaps and propose solutions.
​ Now, we are completely data-driven. Soro
Woreda health office has witnessed a growing
interest in use of performance data for DM,
making it a cliché in the hearts and minds of
health workers and managers in the woreda.
​ Abenezer Bekele, Head of Soro Woreda HO.
Case Study: Creating an
information culture in Soro woreda
in SNNPR/Ethiopia
(IHFP, Selected Stories from the Field, 2016)

15. Challenges and the way forward
 Creating an information culture is a behavioral
intervention: it will take time to see results!
 Measure information culture based on PRISM
assessments
 RHIS capacity building to improve data analysis,
problem solving and advocacy skills of district
and facility staff
 Can you share a good story on gradual
introduction of use of information for decision
making?

16. References
Power to the people: evidence from a randomized field experiement on
community-based monitoring in Uganda, by Bjorkman M, and Svensson, J.
Q.J. Economics, 2009
Improving the use of health data for health system strengthening, by Tara
Nutley and Heidi Reynolds. Global Health Action, 2013
Routine Health Facility and Community Information Systems: Creating and
Information Use Culture. Editorial by Theo Lippeveld. Global Health:
Science and Practice, 2017
Measuring the Performance of Primary Health Care: A Toolkit for
Translating Data into Improvement. Joint Learning Network for Universal
Health Coverage, 2018.
The Art and Necessity of building a data culture. By Ben Mann in MERL
Tech, 2018

17. Routine Health Information Network
THANK YOU
Theo Lippeveld, MD, MPH
Senior HIS Adviser
John Snow Inc.
tlippeveld@jsi.com

18. Use of Community
Health Data for Shared
Accountability
Tariq Azim, MBBS, DM
MEASURE Evaluation
John Snow, Inc.
October 2018

19. Universal Health Coverage – without
community partnership
Really?
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20. Universal Health Coverage – without
community partnership
Strong partnership
requires transparency
through exchange of
information/data
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21. The Community Is Not
in the Spotlight
• Dissemination and use of data generated by the health system
are traditionally limited to the health system.
• The community is not viewed as:
o A decision maker when it comes to the health system
o A consumer or user of health data
• As a result:
o The community is disengaged and does not play an active role in
improving its own health status, let alone to universal health coverage
o The health system is not held accountable to the community it serves.
o Promotion of community involvement is externally driven.
o There is a lack of community leadership and ownership of
interventions to improve the community’s own health.
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22. Community Ownership &
Accountability
• Ownership requires:
o Taking responsibility
o With that comes accountability
• Accountability:
o Committing to decisions and/or actions and
holding oneself answerable for those actions
and their consequences
22

23. Shared Accountability to
Ensure Health
• Shared accountability is defined as a process by
which partners hold one another responsible for
the commitments that they have voluntarily made
to each other (Institute of Medicine, 2011).
• Both the community & the health system (public
and/or private) are accountable for:
o Sharing health and related information
o Taking actions to improve/maintain health
o Publicly reporting and answering questions about those
decisions and/or actions
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24. Shared Accountability for Health
at the Community Level
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Purpose:
• Create an enabling socio/political
environment of mutual trust and transparency
between the community and the health
system
• Support the taking of collective responsibility
and commitment to shared accountability to
improve health service delivery
• Contribute to the overall health of the
community

25. Basic Principles: Community Health
Data Use for Shared Accountability
• The community takes the leadership role in running the
forum/meeting
• Use an existing forum at the community level
• The community and the health system both share health
and related data/information
o Health status, service coverage, disease occurrences, service
availability, maternal & infant deaths
• Mutually decide on the health priorities and voluntarily
commit to taking responsibility for addressing health priorities
• Promote transparency and open sharing of data while
ensuring privacy and security
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26. Qualitative Monitoring of Forum
Performance
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Legend:
Green = desired performance
Yellow = acceptable performance
Red = unfavorable situation
Health System
Shared Information Took Actions
Community
Shared
Information
Box 1: Both the
health system and
the community
shared information
Box 2: Community
provided
information; health
system acted on it
(health system’s
responsiveness)
Took Actions Box 3: Health system
shared information;
community acted
on it (community
engagement in
Box 4: No information
was shared, but both
the health system
and community
acted on their own

27. Quantitative Monitoring of Forum
Performance
27

28. Shared Accountability: Cases
• Disease epidemics: sharing responsibilities and working in
tandem
o Liberia Ebola crisis
 There was widespread noncompliance with government-
imposed cremation to prevent viral spread.
 Traditional and religious leaders influenced the
development of World Health Organization guidelines on
safe burials with dignity, which became government policy
at the end of 2014.

29. Shared Accountability: Cases
• Community-based maternal death surveillance
o Accra, Ghana
 A modified survey system of community-based
reproductive age mortality using six questions was
implemented in the Bosomtwa district of Accra
o Malawi
 Community-linked maternal death review: Communities
and health facility staff worked in partnership to investigate
and respond to maternal deaths occurring in communities
and at health facilities

30. Shared Accountability: Cases
• Community-based tuberculosis directly observed treatment,
short course (TB-DOTS): accountability on both sides
o Mozambique
 Clients choose their DOTS with support from the local
volunteers, known as padrinhos
 Example of community taking responsibility for
supervising TB-DOTS
 Padrinhos make themselves accountable to the larger
community regarding adherence to DOTS by the
clients of TB services.

31. This presentation was produced with the support of the United States
Agency for International Development (USAID) under the terms of
MEASURE Evaluation cooperative agreement AID-OAA-L-14-00004.
MEASURE Evaluation is implemented by the Carolina Population
Center, University of North Carolina at Chapel Hill in partnership with
ICF International; John Snow, Inc.; Management Sciences for Health;
Palladium; and Tulane University. Views expressed are not necessarily
those of USAID or the United States government.
www.measureevaluation.org

32. Questions?
@RHISNetwork
www.rhinonet.org
The_rhino@jsi.com
Routine Health Information Network