RHIS3rd year regular generic HI (1).pptx

Routine Health
Information system

Course Information
Course name: RHIS
Course code:HeIn3023
Course credit hours: 4credit hours
Target: 3rd Year generic BSc. Health Informatics Students
Academic year: 2015E.C (2023) Semester I
Course Instructor: Sisay Maru Email: sisay419@gmail.com
2

Course contents
Chapter 1: Introduction to Health Information Systems
Chapter 2: Health Information system resources
Chapter 3: Health indicators
Chapter 4: Data sources of health information system
Chapter 5:Community Health Information System
Chapter 6:Disease Surveillance and response data management
Chapter 7: RHIS Data management and use
Chapter 8: District Health Information System (DHIS-2)
3

Chapter 1:
Health Information Systems
Learning outcomes
At the end of this lecture, students will expected to:
Define Health system
Identify building blocks of health system
Define Health Information system(HIS)
Identify the components of Health Information System
Identify the data sources of HIS
4

Definition of terms
 Health: Is a state of complete physical, mental and social well-
being and not merely the absence of disease or infirmity.
 System: Is an arrangement of parts and their interconnections that
come together for a purpose.
Health system: A health system is the sum total of all organizations,
people, resources and all activities whose primary purpose is to
promote health, to restore or maintain health.
RHIS: is any system of data collection, aggregation, analysis,
interpretation, communication and use that provides information at
regular intervals.
5

Continued…
Today, three types of definition of health seem to be possible and
are used.
Health is the absence of any disease or impairment.
health is a state that allows the individual to adequately cope with
all demands of daily life (implying also the absence of disease and
impairment).
Health is a state of balance, an equilibrium that an individual has
established within himself and between himself and his social and
physical environment.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2080455/
6

Health systems have three objectives
 Improving the health of the population they serve
 Providing financial protection against the costs of ill-health (Risk
Protection)…sharing risk and providing financial protection => Fairness in
financial contribution
 Responding to people’s expectations (Responsiveness)…reflects the
importance of respecting people’s dignity, autonomy & the confidentiality of
information
Health System con…
7

Health System Building blocks
The 6 building blocks of the health system are:
1. Service delivery
2. Leadership and governance
3. Health workforce
4. Health Information systems
5. Medical products, vaccines and technologies
6. Health Financing
8

Health System building blocks
9

Health Information system (HIS)
It refers to any system that captures, stores, manages or transmits
information related to the health of individuals, which will improve
health care management decisions at all levels of the health system.
Sound and reliable information is the foundation of decision-making
across all health system building blocks.
It 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.
10

Key Functions of HIS
1.Data generation
2.Compilation
3.Analysis and synthesis
4.Communication and use
11

Components of Health Information System(HIS)
1. HIS Resources
 HIS coordination and leadership
 HIS information policies
 HIS financial and human resources
 HIS infrastructure
2. Indicators
3. Data Source
 Censuses
 Civil registration
 Population surveys
 Individual records
 Service records
 Resource records
4. Data management
 Data storage
 Ensuring data quality
 Data processing and compilation
5. Information Products
 Data transformed in to
information
6. Dissemination and use
12

Data requirement is a continuum from patient care to strategic
management level & this implies that not everything needs to be
known at every level of the system.
The quantity and detail of data needed is generally greater at lower
levels of the system, where decisions on the care of individuals are
made, than at higher levels where broader policy-making takes place
with different data sources.
Sources of data
13

Health Information Data Sources
Administrative
records
Services
records
Individual
records
Pop based
surveys
Vital
registration
Population-based Institution-based
Census
14

Data sources can also be classified as
routine and non-routine
A. Routine data sources
 Routine HIS data source is an information system that allows routine data
 Are collected continuously at various times periods (daily, monthly etc.)
 Come from the HIS and its subsystems that are collected as part of an ongoing system
B. Non-routine HIS data source
 Are collected at certain periods of time, or over a specific period of time
 Come from special studies or surveys carried out for specific purposes
15

Data sources of the Ethiopian HIS:
 Community level: CHIS, surveys and different household studies
 Facility level (HCs, Hosp. Private Facilities): Routine HMIS report &
surveillance report (PHEM), facility based researches and surveys
 Woreda, Zonal and Regional levels: HMIS, Surveillance data,
administrative data, surveys
 National level: HMIS, Census, demographic and health surveys (DHS),
national household surveys, different national level researches, modeling
and estimates
Sources of data…
16

RHIS/HMIS
RHIS: is any system of data collection, aggregation, analysis,
interpretation, communication and use that provides information at
regular intervals.
It is produced through routine mechanisms and comprises data
collected at regular intervals at public, private and community level
heath facilities and institutions.
It includes HMIS, CHIS, LMIS, HRIS and LIS.
In Ethiopian context usually RHIS is equivalent with HMIS.
17

Health Management Information System (HMIS)
Is a system for collection, compilation and analysis of routine health
service data.
It is the processing of data from various health components into
information that enables health workers & managers, planners, policy
makers and other stakeholders to make informed decisions.
18

Purposes of HMIS
To routinely generate quality health information
To use that information at each level of the health system for
management decisions to improve the performance of health services
delivery.
19

Components of HMIS
HMIS has two main components:
1. Information management component
2. Use of information for management purpose.
20

Components of HMIS cont…
1. Information management
 Data collection
 Data processing
 Data analysis and presentation
2. Using information for management
purposes
 Problem identification
 Prioritizing problems
 Decision making
 Action taking
 Monitoring
 Evaluation
21

Historical development of RHIS/HMIS
 1596 to 1634 Simon Forman and Richard Napier
 1920s
 As healthcare advanced, physicians realized that the best way to continue
improving diagnosing and treating illnesses was to carefully document
observations and actions while treating patients – and share this information
as a way to teach other health professionals.
 Standardization of medical records and growth of complete record-keeping
continued from the 1920s through the 1960s, but records were paper-based.
American Association of Record Librarians (AARL)
 1960s and then
22

Historical development of RHIS/HMIS
Information systems are increasingly important for measuring and
improving the quality and coverage of health services.
The global shift from
curative to preventive care,
hospital care to community and public health care,
centralized to decentralized health care,
a specific project approach to a comprehensive sectoral approach,
has necessitated the restructuring of fragmented health information
systems into single comprehensive HMIS.
23

RHIS/HMIS in Ethiopia
FMOH adopted the three ones of harmonization principles; i.e. one
plan, one report and one budget principles across the health system
The Ethiopian HMIS is designed in a way that can capture data from
the different level of health institutions (health facilities and
administrative health units) in the country.
24

Milestones of HMIS development in Ethiopia
Before 2008 G. C
 There was a huge data burden on health care providers due to Collection of many data
elements that cannot be used for decision making
 The health sector didn’t have a standardized HMIS: There were no standardized set of core
indicators, and no standardized recording and reporting tools and procedures
 The HMIS was not fully institutionalized
 Unintegrated data flow where different program units and institutions parallelly transmit
reports.
 Poor information use at all levels
 Very Limited resources for HMIS
• Limited application of information technology
25

2008 to 2013 G.C
A set of 108 core indicators were selected to monitor and evaluate the
performance of the health sector.
Standardized data recording and reporting tools were developed for
each level of the health system
Huge investment on capacity building and HMIS infrastructure
Health information technician (HIT) curriculum was developed
26

2014-2016 G.C.
The HMIS was revised for the first time since 2008 to address the
requirements of the changes in the health sector
A total of 122 core HMIS indicators were selected.
The recording and reporting procedures and tools were revised
Since then some improvements have been observed with regards to
data quality and information use for evidence-based decision making.
27

2017 till now
 The HMIS indicators were revised due to a number of driving forces that have
resulted in the need for indicator revision.
 A set of 131 core indicators were selected
 The recording and reporting procedures and tools were revised
 Information revolution roadmap development with a focus on pillars of cultural
transformation in information use and digitalization
 There has been observed improvements with regards to data quality and
information use for evidence-based decision making.
28

The driving forces for HMIS revision at
different periods include:
Gaps in monitoring the health sectors strategic and annual programs.
Due to the introduction of new health initiatives.
Requirements to align with international indicators and other factors.
Example: Need to align with WHO, SDG,
Feasibility of data collection (cost, time, data burden, ...)
Focus on quality, equity and universal health coverage
29

HMIS reform guiding principles
1. Standardization
Common definitions throughout the health sector
Define standardized recording and reporting instruments & procedures
2. Integration
One report and one reporting channel
3. Simplicity
Reduce number of data items, limited to those required by indicators
selected
Develop user friendly forms and procedures
30

HMIS reporting hierarchy/channel
31

Types of HMIS reports by content
o Service reports
o OPD morbidity report
o IPD morbidity and mortality report
o PHEM reports
33

HMIS reporting formats
o By Type:
Service delivery report forms
Disease (Morbidity & Mortality) report form
PHEM reports
o By Health institution:
Health post, Health center ,Hospital, clinics and
WorHO/ZHD/RHB
o By reporting Period:
Immediate/ Weekly report
Monthly /Quarterly/annual administrative report
34

HMIS reporting period
S.No
.
Type of Health
care facility
Reporting level Latest date
report should
be submitted
Frequency of
reporting
1 Health facilities Sub-city/woreda/town
health offices
26th of the
month
Monthly,
Quarterly &
Annual
2 Woreda Health
Offices
Zonal Health Departments
(Sub-cities)
2nd of the next
month
Monthly,
Quarterly &
Annual
3 ZHDs/Sub-cities Regional Health Bureaus 7thof the next
month
Monthly,
Quarterly &
Annual
4 Regional Health
Bureaus
FMOH 15thof the next
month
Monthly,
Quarterly &
Annual
35

HMIS implementation challenges
Lack of reliable data and Misuse of available information in
planning and management of health services were two main
weaknesses of the health information systems.
The reason for non-use and under-use of information includes:-
Leadership
Working environment
Accountability
Resource constraint
Lack of management training, skills and personality
Inadequate dissemination
36

Activity 2
• Read HSTP of Ethiopia
37

Chapter 2
recording and reporting tool

Objectives
At the end of this chapter, you are expected to:-
1. Define recording and reporting
2. Identify the different types of registers
3. Identify the different types of tally sheets
4. Identify the different types of reporting formats
5. Identify reporting Periodicity in Ethiopia
6. Know and practice data entry in DHIS-2
39

Recap of yesterday class
Building blocks of health system
Health information system components
Classification of health information sources
40

Brain storming
What is recording ?
What is reporting ?
41

What is recording
Is a clinical, scientific, administrative and legal
document relating to the health care given to the
individual family or community
42

Introduction
Good health care administration depends upon good
reports and records. Reports and records are good tool
and vehicle for transmitting information from
downward to upward to downward communication.
All health care provider or health team member
require the some information about client so that can
plan and organized comprehensive care plan.
43

Purpose of recording
 Records provide data for program planning and evaluation.
 Records are the tools of communication between the health
workers, the family and other development personnel.
 Records indicate plans for future.
 Records provide baseline data to estimate the long-term
changes related to the services.
 Records provide an opportunity for evaluating the services.
 Records help in the research for improvement of medical and
health care.
44

Reporting
• Is an oral written of information shared between caregivers or
workers in number of ways , and its usually written daily ,
weekly monthly or yearly.
• A report is a document created to communicate essential information. That
information can be a written or oral account of a specific situation like a
project status report. It can also be a spreadsheet or dashboard that focuses
on quantitative information like sales numbers or budget reports.
•
45

Why do we report
• To show the kind and amount of services rendered
over a specified period
• To illustrate progress in reaching goals .As an aid in
studying health conditions
• As an aid in planning .
• To interpret the services to the public and to other
interested agencies.
46

Types of recording tools
Medical record documentation
Register
Tally sheet
Logbook
47

1. Registers
Register: is a form/tool that is used to record the abstract information
from each service/ department required by indicators
48

Registers cont.…
Every register has columns & rows
Each row contains information for one patient
The column contains information about that patient , and one piece
of information per column is available
Contains reportable and non-reportable data elements
Are data sources for computation of HMIS indicators
Most registers have tally sheet , those registers which don’t have
tally sheet have a box for computation of reportable data elements
49

Types of registers
Serial (Case) Registers:
Each subsequent visit is registered as a new entry. E.g. OPD,
VCT, Abortion registers...
Longitudinal Registers:
Each client is stayed in the register so long as s/he is in the
service. E.g. EPI, ANC, FP, ART , TB...
50

Common Elements of ALL Registers
Identification:
Registration Number: sequential number.
Medical Record Number (MRN): Card number
Name: clients’ full name
Age: age in years/ in months
Sex: M for Male and F for Female
 Address:
Region, Woreda, Kebele, Gott and House number
Date: All dates are written in the EC as Date/Month/Year (DD/MM/YY)
51

2. Tally Sheet
Tally Sheet: is a piece of paper that is used to mark the number
of clients that use specific services
 A sole purpose of tally is to ease reporting
 each stroke represents single unit to be counted in
service; client/patient, dose
Example:
 Immunization tally,
 VCT tally
52

quiz
1. write the objective of health system
2. List all Health system building blocks
3.List at list four Health information system components
4. Write all HMIS reform guiding principles
5.Differenciate recording and reporting
53

Group discussion(30minutes)
MCH Register (Group one)
Disease prevention and control registers (group two)
Medical service registers (group three)
Tally sheets (group four)
54

Registers and tally sheets…
There are
57+ Registers including logbook
21+ tally sheets
55

MCH Register
.
56
S/No MCH Register HC Hospital
1 Family Planning Register  
2 Long acting FP Removal Register  
3 ANC Register  
4 Delivery register  
5 PNC Register  
6 PMTCT Register  
7 Abortion care Register  
8 Infant Immunization & growth Monitoring  
9 TT Register  
10 Human Papilloma Virus (HPV) immunization Register  
11 Pregnant and Lactating Women (PLW) Nutrition
Screening register
 
12 Therapeutic Food Program (TFP) Register  
13 Neonatal and Intensive Care Unit (NICU) Register 
 

Disease registers
• .
57
15 VCT register  
16 Pre-ART  
17 ART  
18 PEP register  
19 Unit TB Register  
20 TB Contact screening & LTBI treatment follow
up register
 
21 DR TB Register  
22 DR TB follow up Register  
23 Leprosy Register  
24 Leprosy register for care after completion of
treatment
 

Medical service registers
• .
58
25 OPD abstract register  
26 Emergency register  
27 IPD/Admission/Discharge/ register  
28 ICU Register 
29 Referral register  
30 Ambulance Service Register  
31 Dispensing Register  
32 Central patient register  
33 Visceral Leishmaniasis Treatment and Follow up
Register
 
34 Cervical Cancer screening Register  
35 Trachomatous Trichiasis(TT) surgery register  
36 OR register  
37 HPV immunization register 

Tally sheets
• .
59
S/No Tally Sheets HC Hospital
1 Family Planning Service Tally  
2 Family Planning Methods Dispensed Count Tally  
3 ANC Tally  
4 PMTCT tally  
5 Pregnancy testing tally  
6 Abortion Tally  
7 Immunization tally  
8 Comprehensive and Integrated Nutrition Service
(CINUS) Tally
 
9 Tracer drug availability Tally sheet  
10 IPD Service tally sheet  
11 PITC tally:  
12 NCoD summary tall sheet  
 

Family Planning Register
A longitudinal register used to record FP information for one year
for a single client
 After the fiscal year is completed, the client is registered again in the
same registration book
kept in the FP Room
The information required to complete the FP register is obtained
from woman’s card
60

FP Register cont…
New acceptors
A client who has not received a contraceptive from a recognized FP program
previously at the time of registration
Repeat acceptors
A client who has received a contraceptive method from a recognized FP program
in previous year (EFY).
Note: A client is counted only once as new or repeat in one fiscal year
61

Tallies used for Family planning service:
1. Family planning service tally
 Count the total number of new & repeat client, disaggregated by age
and type of method
2. Family Planning Methods Dispensed count tally sheet
 Collect the total amount of contraceptives distributed, by type of
method
62

Long Acting FP (LAFP) removal register
 LAFP register is used to document the number of long acting family
planning methods removed
 It is used for women who came for removal of Long Acting Family
Planning methods
 The LAFP methods are disaggregated by method and period of removal
since insertion (< 6 months and >= 6 months)
63

Antenatal Care register
It is a longitudinal register
One row is used to document follow up data for one pregnancy
Enables to follow the expectant mother throughout her
pregnancy
The information required to complete this register is from
integrated RH card
64

ANC tally sheet
 Used for collecting 1st ANC disaggregated by Trimester
and age, 4th ANC visits disaggregated by age
65

Delivery Register
It is a case register
lists all clients who gave birth at the facility
The information required to complete this register is found on
the clients’ integrated RH card
Placed in the delivery room
66

Postnatal (PNC) Register
Lists all clients receiving postnatal services at the health facility
Each row has 5 sub rows; each sub row is used for one visit
Information for this register is collected from the integrated RH card
67

PMTCT Register
A longitudinal register.
Used to follow HIV positive pregnant and lactating
women and the new born
The register is kept in PMTCT service room.
The register is completed by the PMTCT care provider
PMTCT Tally
 This is used to capture reportable data elements
68

Comprehensive Abortion Care Register
It is a serial register
Used to document Post abortion and Safe abortion care services
Completed by service providers
Kept in a room where abortion care service is provided
69

Abortion tally
Abortion tally is used to tally data elements related to abortion
care services
Abortion tally simplify reporting of the disaggregated data
elements
70

Infant Immunization & Growth Monitoring
Register
A longitudinal register
Each row is used to document all the required immunization
services data of one child
completed by the service provider at time of service
kept in the immunization room
71

EPI Immunization tally
 collects all infant vaccination and TT vaccine to women
 Immunization tally is filled at the end of each service
72

Human Papilloma Virus (HPV)
immunization Register
Each row is used to document HPV vaccine for 9 years old girl
73

TT (Tetanus Toxoid) Immunization Register
each row is used to document all 5 doses of TT vaccine
provided for pregnant and non-pregnant
74

Neonatal Intensive Care Unit (NICU) Register
It is a Case register where each row is used only for one visit
It is used to record information about neonates who have been
treated in the NICU
It should be completed by service providers after the service is
provided
75

Pregnant and Lactating women(PLW) Nutrition
screening register
It is a longitudinal register
It is used to record information regarding screening of pregnant
and lactating women for acute malnutrition
It is kept at a department where the service is provided
76

Comprehensive & Integrated Nutrition Services
(CINuS) Register
 It is a longitudinal register, where each row can be used for one child for one
year in repeated visits.
 It is used to record the following services:
Growth monitoring for children under 2 years of age
Nutritional screening for children under 5 years of age
De-worming and Vitamin A supplementation
 It is kept at a department where the service is provided.
 The information is completed by service provider after delivering the service.
77

Comprehensive and Integrated Nutrition
Service tally sheet
It is used to simplify reporting of CINuS related reportable data
elements
The tally is used to tally GMP, nutritional screening and Vitamin A
& de-worming services, disaggregated by age and nutritional status
category.
78

Therapeutic Food Program Register
 It is kept at a department where the service is provided
 It is used to record therapeutic feeding that is provided for Children < 5 years
of age with Severe Acute Malnutrition (SAM)
 The information is completed by service provider after delivering the service.
 Data related to admission and treatment outcome of children who have been
admitted to TFP centers will be recorded in this register
79

VCT Register
• It is a case register
• Each row is used for one client only
• The register is kept in VCT service room
• VCT service provider (counselor) completes the register
VCT Tally sheet
• It is used to capture reportable data element from VCT service
• The tally is completed by the care provider
• Kept at the VCT room
81

PITC Tally
 Help to tally information about all patients/ clients who are tested for
HIV
 It should be available to all Service outlets except VCT
 The required information is tallied from OPD, IPD, FP, ANC, Delivery, PNC ,
safe abortion care, and TB registers …..
82

Pre ART Register
Pre-ART register is a longitudinal register.
 It is used to follow PLWHIV until they start ART.
The register is kept in HIV chronic care service unit.
The register is completed by the care provider
83

ART register
 ART register is a longitudinal register.
 It is used to follow PLWHIV who are on ART.
 The register is kept in ART service room and is completed by the ART
care provider/ART data clerks
 The data is abstracted from ART follow up card
84

ART Tally
 ART clinical care and ART regimen tallies
 They are used to capture reportable data element from ART service provided.
PEP register
 PEP register is a longitudinal register.
 It is used to follow people who received PEP for occupational and non-
occupational exposure for HIV.
 The register is kept in ART service room and is completed by the ART care
provider.
85

Unit TB register
Used to record data for patients who are on TB treatment
It is a longitudinal register where patients are followed for the whole
period of treatment once they are registered
Completed by the health service provider and kept at TB treatment
room
87

TB Contact screening & LTBI treatment
follow up register
It is a longitudinal register where screened contacts are followed .
Used to record data for TB patient contacts screening and follow up
for LTBI treatment..
Completed by the health service provider and kept at TB treatment
room
88

DR TB Register
It is a longitudinal register where patients are followed for the whole
period of treatment once they are registered
It is used for facilities which started drug resistant tuberculosis
treatment.
 It is used to record data for patients who are on DR TB treatment.
89

DR TB follow up Register
It is a longitudinal register where DR TB patients are followed
for the whole period of treatment once they are registered.
The Register includes information for clinical monitoring for
the health facility.
90

Leprosy Register
A longitudinal register where a patient registered is followed
until the end of the treatment period.
The register is kept in leprosy treatment room and is
completed by the leprosy care provider
91

Leprosy referral and transfer form
This form used for leprosy cases
Which is referred to your health facility for registration and starting
Leprosy treatment:
Which is transferred out to your health facility to continue and
complete Leprosy treatment
To refer the cases for further investigation and managements with
other health facility.
92

Leprosy register for care after completion of
treatment
Used to follow leprosy patients after completion of treatment
– For any disability or medical care
93

Clinical Service, Emergency and
Health system (Others)
94

OPD Abstract Register
It lists all patients who received outpatient services at the facility.
It is used for outpatient patients 5 years & older.
Under five year children will be recorded in the IMNCI register.
Data will be abstracted from the patient form
The patient form and register are both completed by the service provider at
the time of OPD service.
The register is kept at all out patient department
95

New Vs repeat visits at OPD
Definitions:
New Visit
 A patient who visit for a new episode of illness
Repeat Visit
 A patient who visits the health facility for the same episode
of illness and or for follow up etc
96

IPD/Admission/Discharge/ register
It is a case register and is used to abstract data from the inpatient
departments
Each row is used for one admitted patient.
The same row is completed by the service provider on admission
and upon discharge.
97

Tally sheets used in IPD;
1. IPD Service tally sheet
 completed at the time of discharge of admitted patients
2. PITC tally:
3. NCoD summary sheet
– Help to capture morbidity and Mortality cases at time of admission
and discharge.
98

Trachomatous Trichiasis(TT) surgery register
It is a case based follow up register used to capture basic information
of patients who have TT surgery.
 Each row used for one patient.
Kept at department where the procedure is done at HC or at Eye clinic
if available
99

Cervical Cancer screening Register
 It is longitudinal register helps to capture basic personal and service
related information of clients who are screened for cervical Cancer
 Helps to follow clients with suspicious cervical ca treatment.
 Each row used for one client.
 Register kept where the service provided
100

Visceral Leishmaniasis Treatment and Follow up
Register
 It is case register helps to capture basic personal and service related with
Visceral Leishmaniasis
 Helps to follow clients with Visceral Leishmaniasis Treatment and
Follow up
 Each row used for one client.
 Register kept where the service provided
101

ICU Register
A case register covering each row for a single client
It is used to record information about patients who are treated in the
Intensive Care Unit (ICU).
The Register should be placed in the intensive care unit room
It is filled by service providers after service is provided
102

Emergency Register
A case register that is prepared for use in the emergency
department
each row covers for a single client
lists all clients who arrive with emergency case at facility
It should be placed in the emergency unit/department
It filled by service providers after service is provided
103

Referral register
 It is used to document patients who are referred to or referred in
– The referral out can be to higher health facilities (for better care) or to lower health
facilities for continuity of care.
– The Referral in can be from other health facilities or from the community
 This register is kept at Liaison department for Hospital and Outpatient Department for HC
 The information required to complete this register is found on the clients’ referral paper
104

Ambulance Service Register
It is used to record information about community ambulance
request and service provided.
Register is to be placed in ambulance dispatch center
105

Tracer drug availability Tally sheet
This Tally sheet is kept at Pharmacy unit/Department
It is used to follow the availability of tracer drugs in each day of the
month
Dispensing Register
 This register is kept at Dispensing unit
 It is used to record information about clients who received prescription and
came to dispensary
 Information in the register is filled by dispenser after service is provided
106

Dispensing Register
 This register is kept at Dispensing unit
 It is used to record information about clients who received prescription and
came to dispensary
 Information in the register is filled by dispenser after service is provided
Supplier fill Card
 This Card is kept at Pharmacy unit/Department
 It is used to record the request and received line items by supply category and by
Supplier
107

Central patient register
It is a serial type of register
It is kept at card room and completed by card room providers.
Data quality and performance monitoring logbook
It is a log book kept at HMIS/M&E unit at HF and Administrative health unit
This log book help to track report timeliness, completeness, LQAS score,
RDQA Data verification, Performance Discussion and...
108

Reporting formats
By Type:
 Service delivery report forms
 Disease (Morbidity & Mortality) report form
 PHEM reports
By Health institution:
 Health post, Health center ,Hospital , clinics and WorHO/ZHD/RHB
By reporting Period:
 Immediate/ Weekly report
 Monthly /Quarterly/annual administrative report
109

Activity 3
• Practice the revised 2021 HMIS recording and reporting tools
in Ethiopia
110

Summary
• Basic concepts recording
• Different types of recording tools for health care
system
–Registers
–Tally sheets
• Definition, purpose of reporting and types of reporting
111

Quiz
• Define recording
• List and describe at least five MCH registers
• List and describe at least five medical service registers
• List and describe at least five tally sheets
• Discuss the benefits of recording
• Discuss the benefits of reporting
112

Unit 3
Health indicators
4/1/2024 115

Learning outline
At the end of this chapter, you are expected to:-
Define terms related to health indicators like
indicator, data element
Describe how to formulate indicators
Classify types of indicators
Explain indicator selection criteria
Define KPIs
Identify KPIs
116

Definition of Terms
Indicator
 Indicator is a variable that evaluates status and permits
measurement of changes over time.
 An indicator does not always describe the situation in its entirety,
but sometimes only gives an indication of what the situation
might be and acts as a proxy.
 Indicators are the basis of effective M&E system.
 Indicators are warning signals
117

Definition cont.…
Data element:- refers to the name of an ‘event’ that can be counted.
•It is an input in calculating indicators.
Targets: Are a subset of objectives that state exactly what has to be
achieved, by whom and when.
118

Definition cont.…
Health Indicator: Is a variable that is used to measure change of
health service status over time.
e.g., life expectancy, mortality, disease incidence or prevalence)
Health Related Indicators: are indicators that are used to
measure/assess the necessary requirements/inputs for the
healthcare delivery like the human resource for health, the budget
allocation and utilization etc.
119

purpose of HMIS indicators
 Availing accurate, timely and complete data
 Routine collection and aggregation of quality health
information
 Provide specific information that support health decision
making process
 Strengthening the use of locally and national generated data
for evidence-based decision
120

Benefits of health and health related indicators
Indicators are powerful tools for monitoring population health.
Indicators are used to support planning (identify priorities,
develop and target resources, identify benchmarks) and track
progress toward broad community objectives.
Inform policy and policy makers, and can be used to promote
accountability among governmental and non-governmental
agencies.
121

Who should develop indicators?
Indictors should be developed in a consultative
process that includes all those who have a stake in the
development of the program/project.
Once agreed upon, indicators give all parties, program
managers and personnel, researchers and key
stakeholders, a common framework against which to
measure the progress and success of the program over
time. 122

When should indicators be developed?
 Indicators should be developed at the beginning of programs
and can help researchers and program managers track
program progress over the life of the program as well as
measuring the results of the program at the end.
123

Steps in formulating indicators
1. Setting criteria for indicator formulation
2. Listing down possible indicators
3. Selecting indicators as per the agreed criteria: Documenting
rationale for selection
4. Defining the selected indicators: Numerator and denominator
5. Defining data source & frequency of data collection for the selected
indicators
6. Defining possible interpretation & use of the indicators
7. Setting benchmarks and targets for the indicators
124

The following criteria can be considered during indicator formulation:
 Relevance: There should be a clear relationship between the indicator and
program
 Accuracy: The indicator measures what it needs to measure
 Importance: The measurement captures something that "makes a difference"
in program effectiveness;
 Feasibility: Data can be obtained with reasonable and affordable effort;
 Credibility: The indicator should be aligned with national and international
standards like WHO, UNAIDS, USAID etc.
 Validity: The indicator has been field-tested or used in practice;
 Distinctiveness: The indicator lacks redundancy and does not measure
something already captured under other indicators.
125

Common Indicator Metrics
1. Count: describes the number of persons who received a particular service
or who have a particular disease
1. Number of service providers trained
2. Number of condoms distributed
2. Ratio: It expresses a relationships in the form of X:Y.
It is a measure for which numerator is not included in denominator (e.g : sex
ratio per 100 , Maternal mortality ratio)
1. Proportion: Is a ratio in which the numerator is part of the denominator
2. Rate: Frequency of occurrence of an event during a specific time, usually
expressed per “k” population (k=1000, 10000, etc.).
e.g. Total fertility rate
126

Types of indicators
There are different classifications for indicators.
Health indicators can be classified as
–Input
–Process
–output and
–outcome indicators
127

#1 Input indicators
Monitors affordability of resources
Measures availability of resources
It measure resources devoted to a particular program or activity
(e.g., number of hospital beds, number of health workers,
vaccination doses purchased).
It can include, among other items, buildings, equipment,
supplies, and personnel.
Input indicators can also include measures of characteristics of
a target population (e.g., number of persons eligible for a
diagnostic trial).
128

#2 Process indicators
 Monitors activities that are carried out
 Measures accessibility of services coverage & quality
It looks at the ways services are provided.
They often measure the consistency or timeliness of
activities carried out in assessing and treating service
recipients (e.g., diagnosis error rates, order fill rates,
stock wastage due to expiration or damage).
129

#3 Output indicators
Monitors results of activities
 Measures acceptability - use, change, performance, coverage &
quality
 It measures the quantity services produced from the results of
process activities, or the efficiency of those activities (e.g., live
births per caesarean deliveries performed, post-surgical
infection rate).
130

#4 Outcome and Impact Indicators
 Measures long term results of a program. Includes changes in
knowledge, attitudes, behavior, effects in the health status of the
population, morbidity, mortality etc.
 Measures appropriateness - effectiveness, efficiency, equity and
sustainability
 Outcome and impact indicators measure the broader results achieved
through the provision of services.
E.g.. rate of stunting or wasting in children under the age of 5
131

Selection of indicators
Indicators should be feasible
Indicators should be comprehensive, valid (sensitive),
standardized, meet quality criteria, and be flexible (never
fixed and final) to support evolving health strategies and
policies.
Indicators should consider the long-term as well as the short-
term objectives and how each will be measured.
Indicators should be SMART
132

Characteristics of Indicators
Indicators should be SMART
Specific:- It should be able to measure a specific disease, service
provided, practice or task.
Measurable:- consistently measurable in the same way by
different observers
Achievable:- Does the indicator measure something within the
program? The target level should be a challenge, but not
impossible to reach.
Relevance:- Does the indicator measure the most important
result of the activity?
Time-bound: There is a clear deadline for when the target must
be achieved.
133

Overview of the national HMIS indicators
The revision of Ethiopian HMIS in 2021 has resulted in the
selection of 177 HMIS indicators
These are categorized into 4 major perspectives during the
development of the HSTP.
1. Community Perspective :- “C”
2. Internal Process :- “P”
3. Financial stewardship:- “F”
4. Capacity building:- “CB”
134

Indicator revision process in Ethiopia HIS
.
135

Indicators revised in 2021
 177 indicators in different perspectives was selected in 2021
indicator revision process
 Indicators may revised as needed
 There are different types of indicators in Ethiopia health care
system, mainly HMIS indicators and Ethiopian hospitals
reform indicators
136

Reasons for indicators revision
 Gap in monitoring HSTP and annual health sector
performance using the existing indicators
 Emerging of new initiatives and programs in the health
sector.
 Focus on new priorities in health system (Emerging
diseases and expansion of control programs (NCDs and
NTD)
• Focus of Quality, equity and universal health coverage
etc.
137

HMIS indicator data source, formula and
interpretation
The national core HMIS indicators are described in an indicator
reference sheet, a table that includes their definition, formula,
interpretation and disaggregation, source of data and frequency
of reporting by level.
This standardized sheet allows us to have a standard guide to
measure the performance of the health sector from routine
health information system.
139

Data sources
In order to compute each HMIS indicator, it is essential to
identify the data elements and data sources that are used to
calculate the indicator.
The data sources for each data element can be register or
tally sheets.
Data sources: This includes population based or facility based
sources for the health information system.
 A facility based sources of health information includes
registers and tally sheets.
Reportable data elements: These are the important elements
to be reported on regular basis from the source documents like
registers.
140

A. Maternal and Child Health
Program Indicators
141

Family Planning Program Indicators
1. Contraceptive acceptance rate (CAR)
Formula Number of new and repeat acceptors *100
Total number of women of reproductive age (15-49) who are
not pregnant
Interpret
ation
CAR is directly related to operations and measures the number of
new and repeat contraceptive acceptors in one fiscal year. In order to
increase contraceptive utilization (and hence Prevalence), the
numbers of both new and repeat acceptors should increase. Each
acceptor is counted only once, during the first visit when s/he
receives contraceptive services in the specified Ethiopian fiscal year.
142

New and repeat acceptors
New acceptor: a client who has not received a contraceptive from a
recognized FP program previously at the time of registration
Repeat acceptor: a client who has received a contraceptive method
from a recognized FP program in previous year (EFY).
Note: A client is counted only once as new or repeat in one fiscal year
143

Data source for CAR
• Family Planning Register
• FP register is a longitudinal register used to record FP information
for one year for a single client
• After the fiscal year is completed, the client is registered again in
the same registration book
• kept in the FP Room
• The information required to complete the FP register is obtained
from woman’s card
144

Reportable data element in FP registers
frequency and level of reporting
No. Reportable data element Disaggregation Frequency Level of
Reporting
Type of
tally used
1 Number of new acceptors, Age, Method Monthly HP, HC, clinic,
Hospital
FP tally
2 Number of repeat acceptors Age, Method Monthly HP, HC, clinic,
Hospital
FP tally
3 Number of clients tested for
HIV
Age, Sex Monthly HC, clinic,
Hospital
PITC
4 Clients testing positive for
HIV (at PITC)
Age, Sex Monthly HC, clinic,
Hospital
PITC
5 Number of Family planning
methods issued/dispensed
Method Annual HP, HC, clinic,
Hospital
FP methods
dispensed
145

Antenatal Care Program Indicators
1. ANC coverage – first visit
Formula Number of pregnant women that received antenatal care at least once X100
Total number of expected pregnancies
Interpretation  Antenatal care coverage is an indicator of access and use of health care services during
pregnancy.
 ANC first visit coverage is categorized into two as:- early ANC (< 16 weeks) and those
>16 weeks so that ANC initiation period (Early Vs late) can be determined and
monitored.
 Early ANC often detected if the woman exactly knows her LNMP, and or in Ultrasound
detection.
 Pregnant women who begin ANC visit before 16 weeks play crucial role in early
detection of complications that may affect the outcome of the pregnancy.
Data source  ANC Register
146

2. ANC coverage – four visits
Formula Number of pregnant women that received antenatal care at least four visits X100
Total number of expected pregnancies
Interpretation
 The fourth antenatal care visit is an indicator of quality and continued
use of health care during pregnancy.
 The antenatal period presents opportunities for reaching pregnant
women with interventions that may be vital to their health and
wellbeing and to their infants.
 Receiving four focused antenatal care visits increases the likelihood of
receiving effective maternal health interventions during antenatal
visits.
Data
source
 ANC register
147

3. Percentage of pregnant women attending antenatal care clinics
tested for syphilis:
Definition Proportion of pregnant women attending antenatal care tested for syphilis
Formula Number of pregnant women tested for syphilis
X100
Number of pregnant women that received 1st ANC
Interpretation  Syphilis affects the health of pregnant mothers and their fetus.
 It may cause abortion, still birth, premature birth and congenital anomalies.
 Performing syphilis screening test for all pregnant mothers helps to detect the
disease early so that appropriate treatment can be provided to protect the mother
and the fetus from complications
Data source  ANC register
148

ANC coverage – four visits
149

Reportable data element in ANC register, frequency and level
of reporting
No. Reportable data element Disaggregation Frequenc
y
Level of
Reporting
Type of
tally used
1 Number of pregnant women that received ANC
first visit
Age, Gestational
week
Monthly HP, HC, clinic,
Hospital
ANC tally
2 Total number of pregnant women that received
four ANC visits
Age Monthly HP, HC, clinic,
Hospital
3 Total number of pregnant women tested for
syphilis
Test result Monthly HC, clinic,
Hospital
4 Total No. of reactive pregnant women treated
for syphilis
None Monthly HC, clinic,
Hospital
5 No. of pregnant women tested for hepatitis Test result Monthly HC, clinic,
Hospital
6 Total number of reactive pregnant mother
treated for hepatitis
Hospital
7 Number of pregnant women tested for HIV and
know their result during pregnancy
Age Monthly HC, clinic,
Hospital
PITC tally
8 Total Number of partners of pregnant ,laboring
and lactating women tested and know their
results
Hospital
150

Delivery Program Indicators
1. Proportion of births attended by skilled personnel
Formula The number of births attended by skilled health personnel
X 100
Total number of expected deliveries
Interpretat
ion
 All women should have access to skilled care during pregnancy and childbirth to ensure
prevention, early detection and management of complications.
 Assistance by properly trained health personnel with adequate equipment is key to reducing
maternal deaths.
151

Other delivery indicators
Caesarean section rate
Proportion of institutional maternal death
Still birth rate
Early neonatal death rate (institutional)
Percentage of Low birth weight
Proportion of asphyxiated neonates who were resuscitated (with
bag & mask) and survived
Data source for delivery program indicators: delivery register
152

Reportable data element in delivery register,
frequency and level of reporting
No. Reportable data element Disaggr
egation
Frequenc
y
Level of
Reporting
Type of
tally used
1 Number of births attended by skilled
Health personnel
None Monthly HC, clinic, Hospital
None
2 Number of deliveries by cesarean
section
3 Number of institutional maternal
deaths
4 Number of live births None Monthly HP, HC, clinic,
Hospital
5 Number of still births None Monthly HP, HC, clinic,
Hospital
153

Cont.….
No. Reportable data element Disaggregati
on
Frequenc
y
Level of
Reporting
Type of
tally used
6 Total number of newborns weighed None Monthly HP, HC, clinic,
Hospital
None
7 Number of newborns whose weight is less
than 2500gms
None Monthly HP, HC, clinic,
Hospital
8 Number of early neonatal deaths None Monthly HC, clinic,
Hospital
9 Number of women who received HIV test Age Monthly HC, clinic,
Hospital
10 Number of women who tested HIV positive Age Monthly HP, HC, clinic,
Hospital
11 Total IPPFP acceptors Age
&Method
Monthly HC, clinic,
Hospital
12 Number of neonates treated for birth asphyxia
& survived
Hospital
154

Postnatal (PNC) Care Program Indicators
Early postnatal care coverage
Institutional maternal death
Percentage of pregnant women who were tested for HIV and who know
their results during pregnancy, labor and delivery and post-partum period
Early institutional neonatal death rate
Proportion of Sick Young infants treated for sepsis/VSD (Very Severe
Disease)
Proportion of low birth weight or premature newborns for whom KMC was
initiated after delivery
Proportion of asphyxiated neonates who were resuscitated (with bag &
mask) and survived
Data source for PNC Program indicators: Postnatal (PNC) Register
155

Reportable data element in PNC registers frequency and level of
reporting
No. Reportable data element Disaggregatio
n
Frequency Level of
Reporting
Type of
tally
used
1 Number of postnatal visits within 7 days of
delivery
Period Monthly HC, clinic,
Hospital
None
2 Number of institutional maternal death None Monthly HC, clinic,
Hospital
3 Number of pregnant women who were tested
for HIV and who know their results during
post-partum period
Hospital
4 Number of women tested positive for HIV None Monthly HP, HC, clinic,
Hospital
5 Number of neonatal deaths in the first 24
hrs of life/institutional/
Hospital
156

Cont.…
No. Reportable data element Disaggregati
on
Frequency Level of
Reporting
Type of
tally used
6 Number of neonatal deaths between
1-7 days of life/institutional/
Period Monthly HC, clinic,
Hospital
None
7 Number of sick young infants 0-2
months treated for sepsis
None Monthly HC, clinic
Hospital
8 Total IPPFP acceptors Age
Method
Monthly HC, clinic
Hospital
9 Number of Newborn weighing
<2000gm and premature newborns for
which KMC initiated
Hospital
10 Number of neonates treated for birth
asphyxia & survived
None Monthly HP,HC, clinic
Hospital
157

Comprehensive Abortion Care indicators
Number of women receiving comprehensive abortion care
service
• Data source: Comprehensive Abortion Care registers
158

Reportable data element from comprehensive abortion care register
No. Reportable data element Disaggregat
ion
Frequency Level of Reporting Type of
tally used
1 Number of safe abortions performed age Monthly HC, clinic Hospital
and above
Comprehensive
Abortion
Tally
sheet
2 Number of post abortions performed age Monthly HC, clinic Hospital
and above
3 Number of women receiving comprehensive
abortion care
Trimester Monthly HC, clinic Hospital
and above
4 Number of women who were tested for HIV Age Monthly HC, clinic Hospital
and above
5 Number of Positive HIV tests Age Monthly HC, clinic Hospital
and above
6 Number of maternal deaths (institutional) None Monthly HC, clinic Hospital
and above
7 Number of new and repeat family planning
acceptors
Age
,Method
Monthly HC, clinic Hospital
and above
159

Group discussion(30 minute)
Child health indicators
HIV prevention and control
EPI
Health extension and primary health care and malaria
prevention and control
 Informed decision making and innovations and human
resource and development
160

Key Performance Indicators (KPIs)
 KPIs are a core set of indicators that provide all the
necessary information related with to ensure that the
health facility provides effective, efficient and quality
services with minimal cost and effort.
 KPIs are measures that a sector or organization uses to
define success and track progress in meeting its
strategic goals.
161

KEY PERFORMANCE INDICATORS
KPIs
162

Well-designed KPIs should help health sector decision makers
to:
Establish baseline information
Set performance standards and targets
Measure and report improvements over time
Compare performance across geographic locations
Benchmark performance against regional and international peers or
norms
Allow stakeholders to independently judge health sector
performance.
163

 There are 36 National Key Performance Indicators for
Hospitals and 18 for Health center.
164

KPIs (1/1)
Ser no Characteristics Target Weight Source
1 Contraceptive acceptance rate 70% 5 HMIS
2 Antenatal care mothers tested for Syphilis 100% 5 HMIS
3 Skilled delivery care 95% 8 HMIS
4 Early postnatal care coverage within 7 days 95% 6 HMIS
5 Neonates treated for sepsis 95% 5 HMIS
6 Proportion of HIV positive pregnant and
lactating women who received ART at ANC
+L&D + PNC for the fist time and linked from
ART
95% 5 HMIS
7 Immunization dropout rate from penta 1 to
penta 3
5% 5 HMIS
8 Fully immunization coverage for under one
year children
95% 6 HMIS
9 Iron and folic acid supplementation 95% 4 HMIS

KPIs (1/2)
Ser no Characteristics Target Weight Source
10 Children attended Growth Monitoring and
Promotion sessions
80% 5 HMIS
11 All forms Tuberculosis case detection rate 87% 5 HMIS
12 TB case detection contributed by community 87% 5 HMIS
13 Malaria cases per 1,000 population (<5 cases per
1000 pop)
5/1000 5 HMIS
14 Currently on ART 90% 6 HMIS
15 Viral load suppression 90% 6 HMIS
16 Essential drug availability 100% 6 HMIS
17 Average community score card 100% 5 Assessmen
t
18 Functional Health Development Army (HDA) 100% 6 HMIS

Some of key performance indicators for hospitals
 Percent of Non-Functional Model Medical Equipment
 Outpatient waiting time to Consultation
 Outpatients not seen on same day
 Emergency room patients triaged within 5 minutes of arrival
 Emergency room attendances with length of stay > 24 hours
 Delay for elective surgical admission
 Pressure ulcer incidence
 Surgical site infection
 Completeness of inpatient medical records
 Peri-operative Mortality
 Rate of safe surgery checklist utilization
 Mean duration of in-hospital pre-elective operative stay
 Surgical volume
 Anesthetic adverse outcome
167

Some of key performance indicators for hospitals
 Births by surgical, instrumental or assisted vaginal delivery
 Percentage of Clients with 100% prescribed drugs filled
 Essential laboratory tests availability
 Blood unavailability ratio for surgical patients
 Outpatient clinical care productivity for physicians
 Staff satisfaction
 Raised revenue as a proportion of total operating revenue
 Patient satisfaction
168

Introduction to vital statistics and civil registration
• The vital statistics is study of human population. It is the numerical records
pertaining to events connected with the study of human population. It exclusively
deals with birth, marriage, divorce, and, deaths of human population. In Ethiopia
vital statistics are collected under civil registration
• Identifying vital statistics and data elements for Health facility and community
• The most common way of collecting information on these events is through civil
registration, an administrative system used by governments to record vital
events which occur in their populations. Efforts to improve the quality of vital
statistics will therefore be closely related to the development of civil registration
systems in countries.
170

Uses of Vital statistics
1. They are great use in planning evaluation of economic development of a country.
2. They are useful to government agencies to administrative purposes
3. They very much useful in medical research
4. Very essential in demographic research
5. Highly useful to an individual record by the way of recording birth, marriage, death
and divorce during his/her life time.
6. Great use to the government to accesses the impact of family welfare in the country.
171

Methods of obtaining vital statistics
• Different method obtaining vital statistics are:
a) Civil registration method:
 Under this method’s vital events such as births, marriage, deaths, divorce, migration etc. are continually recorded.
 The government authorities like kebele, woreda, sub cities, offices maintain the record of vital events.
 In the case of birth, the information regarding:
o Date of birth.
o Name of parents
o Sex of the new born baby
o Nationality
o Religion and etc… are recorded.
 In the case of death, the information regarding:
o Date of death
o Name of diseased (clinical DX)
o Parent name (husband or wife)
o Address
o Causes of death and etc… are recorded.
• NB: This method is continuous and compulsory.
172

Census Enumeration method
• It is a process of complete enumeration of population in a country. Population census
is conducting usually once in every 10 years. Census Enumeration method covers data
includes: Sex, Marital status, Educational status, Occupational status, Health status,
Religion etc. which are needed vital statistics. The information is available for the
census year only. Three censuses have been taken in Ethiopia: 1984, 1994 and in 2007.
The responsible institution is the Central Statistical Agency.
173

Techniques of census
• There are two Techniques of conducting census.
a. Dejure
• This type of technique is counting people according to the permanent place of location or residence. Advantages;-it gives
permanent picture of a community and provides more realistic and useful statistics. Disadvantages; some person may be omitted
from the count.
a. Defacto
• This type of technique is counting persons where they are present at the time of the census period. Advantages: there is less
chance for the omission of persons from the count.
• Disadvantages: Difficult to obtain information regarding persons in transit.
174

• Assigning appropriate indicator formula
• Vital statistics refer to the data collected concerning the progression of human life,
from birth through death. This data is often used to calculate population related data for
municipalities, states, nations or regions of the world. Vital statistics are also collected
on an individual level, in which case they are often used to gauge the well-being of the
person for whom the data has been collected.
• Computing and interpreting vital statistics
• In order to compute and interpret vital statics you will expected to understand the
following terms.
• Count, Ratio, Proportion and Rate
175

Unit 4
Data source of Health Information
system

Routine source of information
 Individual record
 Service record
 Administrative record
177

Overview of Census
1. Population census
 Definition of census(UN): The total process of collecting,
compiling and publishing demographic, economic and
social data pertaining at specific time, to ALL persons in a
country or delimited territory.
 Census is the enumeration of the entire population of a
country at a particular time
 Refers to nation-wide counting of population
 Census is taken in most countries of the world at regular
intervals
180

2. Housing census
• It is the total process of collecting, classifying, evaluating,
analyzing and publishing or distribution of statistical data related
on housing and their residents in the country during a certain
period of time.
• The census provides information on the existing housing units and
information about the characteristics and constructions that have
an impact on maintaining the particularity, health and to create
normal living conditions for the household.
181

Essential characteristics of a
population census
 Individual enumeration
 Universality with in a defined territory
 Simultaneity
 Defined periodicity
182

Individual Enumeration
• A census implies that each individual is separately, but only once,
enumerated and that some important characteristics of each
person are separately recorded.
These include:
Sex
Age
Religion
Marital status
Literacy
Occupation
Educational attainment
Economic activity etc 183

Universality with in a defined territory
 Ideally, a national census should cover the countries
entire territory and all people resident places.
 A census must cover every individual or housing unit
present with in the defined census area
 Simultaneity
 Each person and housing unit must be campaigned
with in a defined point in time
 Ideally, census is taken of a given day. To avoid
omissions and duplications in census, it should be
taken in a given day.
184

Defined periodicity
There should be a defined time gap between
censuses. Mostly 10 years
Census should be taken at regular intervals, so that
comparable information is made available in a fixed
sequence.
A series of censuses make it possible to:
Appraise the past
Accurately describe the present
Estimate the future
185

Types of Census
1. De Jure
• The enumeration is done according to the usual or legal
place of residence
2. De Facto
• The enumeration is done according to the actual place
of residence on the day of the census
186

Advantages and disadvantages of De Jure
 Advantage:
 Unaffected by seasonal and temporary movements
 Disadvantage:
 Some omitted and some counted twice
 Information regarding people away from home is
incomplete or inaccurate
187

Advantages and disadvantages of De Facto
Advantage:
•Less chance of double counting
•Less chance of omission
Disadvantage:
•Affected by tourists and other travellers
•Distorted in areas where there is high migration
188

Uses of the census
 Population census is the primary source of basic
national population data.
 Required for administrative purpose, planning and
policy making
 For many aspects of economic and social
planning and research.
 Aids in the decision-making processes of the
private sector.
189

Use of census cont.…
• Population censuses also constitute the principal source of
records for use as a sampling frame for the household surveys
during the years between censuses.
• It provides us with information on
Trends in population growth
Change in the age and sex structure of the population
The course of mortality and fertility, migration and urbanization
etc
190

Population registers
Population registers are accounts of residents within a country.
Population registers are continuous records of the residential
context, socioeconomic status, and demographic behavior of the
members of a community
They are typically maintained via the legal requirement that both
nationals and foreigners residing in the country must register with
the local authorities.
Aggregation of these local accounts results in a record of
population and population movement at the national level
191

Basic characteristics that may be included in a
population register
–date and place of birth
–Sex
–date and place of death
– date of arrival/departure,
–citizenship(s) and marital status.
In order to be useful, any additional information must
be kept up to date.
If complete, population registers can produce data on
both internal and international migration through the
recording of changes of residence as well as the
recording of international arrivals and departures. 192

Main uses of the population register
To provide reliable information for the governments
administrative purposes, mainly for programme planning,
budgeting and taxation.
Useful for establishing personal identification, voting, education
and military service, social insurance and welfare, and for police
and court reference.
Utilized for issuing documents needed for the admission of
children to nurseries, kindergartens and schools and the
assignment of residents to health clinics
193

Census Instruments
 Questionnaires
 Different forms
 Maps
 Manuals
 Stationary
194

Census in Ethiopia
 Conducted every 10 years according to article 103 (5)
of the 1995 Constitution of the FDRE.
 Ethiopia has so far conducted 3 censuses
 1984, 1994 and 2007
 It includes population and housing census
195

Scope
• The 2007 Ethiopia Population and Housing Census covered the
following topics:
- Type of residence and housing identification
- Details of persons in the household
- Deaths in the household during the last 12 months
- Information on housing unit
Coverage of 2007 Ethiopian census
• National coverage
196

Universality of 2007 census
• The census has counted people on dejure and defacto basis.
• The dejure population comprises all the persons who belong to a given
area at a given time by virtue of usual residence, while defacto approach
people were counted as the residents of the place where they found.
• Homeless persons were enumerated in the place where they spent the
night on the enumeration day.
• The 2007 census counted foreign nationals who were residing in the city
administration. On the other hand all Ethiopians living abroad were not
counted.
197

Use of the Population and Housing Census
• Gives a complete and comprehensive picture of the size,
composition and distribution of the population.
• Provides basic data for demographic, social and economic
analysis of the population, including population estimates and
projections.
• Provides the basic data required for allocating government funds
• Provide data for delineating electoral districts at every
administrative sites.
• The housing census provides characteristics of the living quarters
of the population.
• Provide a sampling frame for household surveys
198

Phases of census in Ethiopia
• Pre enumeration phase
• Enumeration phase
• Post enumeration phase
199

Pre enumeration phase
Legal basis for a census
Budget and cost control
Census calendar or time table
Administrative organization
Consultations with users
 Questionnaire preparation
Census test
Staff recruitment and training
Mapping work on Enumeration Area
Listing of living quarters and household
Plans for various phases of census operations such as field operation,
tabulation, quality control, data processing, data dissemination
200

Enumeration phase
Basic determinants for enumeration
 Timing, population to be enumerated, units of enumeration,
census moment, duration of numeration, etc.
 Field operations
preliminary field work, carrying out the enumeration,
supervision
Public relations
201

Post-Enumeration phase
 Data processing: ---(Coding, Data capture, Data editing,
Tabulation)
 Dissemination: --- (publication of printed tables and reports,
dissemination on computer media, on-line dissemination)
 Evaluation : --- (demographic analysis for census evaluation,
post-enumeration survey)
 Analysis of the results
 Publication of census results-----(descriptive reports, basic statistical
reports)
202

Activity 3
Discuss the detail activities done in each phase of census in
Ethiopia?
Compare the 3 Ethiopian censuses and with other countries
203

Civil registration and vital Statistics
204

Overview of civil registration and vital statistics system
Civil registration (CR)
• Civil registration is defined by the UN as “the continuous, permanent,
compulsory and universal recording of the occurrence and characteristics
of vital events (live births, deaths, fetal deaths, marriages, and divorces)
and other civil status events pertaining to the population as provided by
decree, law or regulation, in accordance with the legal requirements in
each country.”
• It is the recording of vital events in a person’s life (e.g., birth, death) and is
a fundamental function of the national government.
• Birth registration establishes an individual’s legal identity at birth
205

Overview of CRVS Cont.…
Vital statistics (VS)
• UN definition of a vital statistics system as the total process of:
1. collecting information by civil registration or enumeration on the
frequency or occurrence of specified and defined vital events, as
well as relevant characteristics of the events themselves and the
person or persons concerned; and
2. compiling, processing, analyzing, evaluating, presenting and
disseminating these data in statistical form
• Vital statistics (VS) are statistics on vital events and of the persons
concerned.
206

Types of Vital Records
1. Birth–a live born infant
2. Death–the disappearance of life
3. Fetal Death–a dead born fetus
4. Marriage–the legal relationship of a husband and wife
5. Divorce–the legal termination of a marriage with the right of the
parties to remarry
6. Annulment of Marriage–the invalidation or voiding of marriage
7. Judicial Separation of Marriage–the parting of married persons
without the right to remarry
8. Adoption–the legal taking of a child of other parents as one’s own
9. Legitimation–legally giving a person the rights of a person born in
wedlock
10.Recognition–legal acknowledgement of paternity of a child born out
of wedlock
207

Uses of Civil registration system
Birth
• Legal proof of identity for an individual
• Individual proof of age, date of birth, place of birth, parentage and
citizenship
• Maintaining population registries and identity card systems
• National security and issuance of passports
• Creating and maintaining election rolls
• Administering social service programs
• Public health programs and registries
• Natality rates and trends
• Maternal and infant health studies
• Population estimates and predictions
• Sampling frames for research studies
• Identify populations at risk for medical problems
• Fertility data for family planning studies
208

Death
• Evidence of death for inheritors
• Mortality rates and trends
• Study specific disease patterns and causes of death
• Examine differences in mortality by age, sex, ethnicity,
geographic areas, etc.
• Infant and maternal mortality studies
• Creation of life tables
• Population estimates and predictions
• Monitor infectious diseases
209

Marriages and Divorces
• Legal proof of marriage or divorce
• Administering social and family benefit programs
• Genealogical research
• Marriage and divorce rates and trends
• Demographic studies
• Sampling frames for research studies
210

characteristics of civil registration system
Legal framework
Full coverage of population
Continuous and permanent
Confidentiality of personal information
211

structure of civil registration system
• Can be centralized or decentralized.
• Decentralized or regionally organized civil registration
structures are more prevalent in countries with a federal
governing structure.
• In a centrally organized structure, the national civil
registration organization controls all activities of the
system down to the lowest level
212

process of civil registration system
• Place of registration:-
 Can be by place occurrence or place of residence
• Person Responsible for Registering Event
• Time to Register Vital Event
213

process of civil registration system
cont..
• Storage of Vital Records:
Since records of vital events are official government documents
that have legal value, they must be kept in a secure, permanent
way
• Issuance of Copies:
Issuance of certified copies of vital records is a key function of civil
registration.
214

Registered records processing
• Numbering
• Coding Data
• Computerizing
• Editing
• Querying
• Correcting errors
215

Birth and death records
Definition birth and death records
• A live birth is the delivery of a child that breathes or shows signs of life
regardless of the length of the pregnancy.
• A country’s official definition for a live birth should be specified in the civil
registration law for consistency in reporting of birth events.
WHO defined live birth as : the complete expulsion or extraction from its
mother of a product of conception, irrespective of the duration of pregnancy,
which after such separation, breathes or shows any other evidence of life, such
as beating of the heart, pulsation of the umbilical cord or definite movement of
voluntary muscles, whether or not the umbilical cord has been cut or the
placenta is attached.
216

Definition birth and death records
• The death of a person is defined as the permanent
disappearance of all evidence of life at any time after live birth
has taken place.
217

Information collected from birth records
 full name and sex of the child
 mother’s and father’s name
 marital status of mother
 place of residence of mother or family,
 duration of residence
 type of place of residence
 attendant at birth
 date and place of registration
 name and relationship of informant
 birth registration number etc.
 Characteristics of the father
 Medical information related to the birth
218

Problems with Data
• Source and accuracy of information
• Missing records
• Missing information
• Errors in preparation and processing
• About 48 million infants are not registered each year (~ 40%)
• About 38 million deaths are not registered (2/3 of all deaths
globally)
• A total 85 countries have zero or unreliable cause of death
information, an additional 52 countries have low-quality data
219

Fetal deaths
• Any death of a fetus after a certain period of pregnancy (28
weeks in many countries) is termed as fetal death or still birth
220

Analysis of vital statistics data
Vital statistics are the basis for public health and epidemiologic
monitoring, evaluation, and planning.
Vital statistics data systems should have clear, explicit and simple
definitions; continuity; and flexibility to adapt.
For international comparison, WHO standards for classification of
diseases and definitions for a variety of terms used in tabulating
vital statistics data should be followed.
221

 Types of vital statistics measures include percentages, ratios, and rates.
 A time reference (date of occurrence or date of registration) and a geographic
reference (place of occurrence or place of residence) must be considered in
preparing vital statistics tabulations.
 Some common measures used to analyze natality data are crude birth rate, sex
ratio at birth, percent low birth weight, percent preterm births, age-specific birth
rate, general fertility rate, and total fertility rate.
222

Some common measures used to analyze mortality data are:
• crude death rate,
• age-specific death rate,
• cause-specific death rate,
• infant mortality rate,
• maternal mortality rate,
• pregnancy-related mortality rate,
• life expectancy at birth, and years of potential life lost
223

WHO has developed standard Tabulation Lists consisting of groups
of ICD codes to be used in presentation of cause of death data.
WHO has also made recommendations for age categories and size
of geographic area to use for mortality tabulations.
Linking of birth and/or death records is done for both
administrative and research purposes
224

Vital event registration in Ethiopia
• nearly 50 years since legal ground was established
• The 1960 Civil Code of Ethiopia “every member of the
society must register births and deaths.”
225

Birth registration in Ethiopia
• Legal framework for birth registration: proclamation No. 760/2012 and
proclamation No. 1049/2017
• Authority- vital events registration agency
• Organizational structure: Decentralized
• There is a legal obligation to register the birth of a child
• Birth certificate issued immediately
• Legal informant to register a child
 Parents
 In the default of the parents, by the guardian of the child
 In default of the guardian, by the person who has taken care of the child
226

Birth registration in Ethiopia cont.…
• Time allowed for registration- 90 days
• Fee for birth registration- No
• Fee for birth certificate- Yes
• Penalty for late registration- Punishable by imprisonment up to
six months (up to 5000 Ethiopian Birr);
• Requirements for birth registration: Identification card of the
mother and father, Name of the child, Physical presence of both
parents
• Processing: Manually
227

Birth registration in Ethiopia cont.…
Place of registration
• Civil registration office (nearest administrative office to the principal
residence of the parents)
• Nearest Agency for Refugee & Returnee Affairs (ARRA) office for
refugees
• Ethiopian Ships for registration of births and deaths occurring at sea
• Ethiopian Embassies for Ethiopian residing in foreign countries
• Ministry of National Defense for registration of birth and death
occurring on active duty
228

Death registration in Ethiopia
• Legal framework for death registration: proclamation No. 760/2012 and
proclamation No. 1049/2017
• There is a legal obligation to register the death
• Death certificate issued immediately
• Legal informant to register a death
 Any person who lived with the deceased
Any police officer receiving a report of a death
229

Death registration in Ethiopia cont.…
• Fee for death registration- No
• Fee for death certificate- Yes
• Penalty for late registration- Yes
• Requirements for death registration: Medical death certificate, Police
report for accidental deaths (if available but not mandatory)
• Place of registration:- Civil registration office
230

Marriage registration in Ethiopia
• Legal framework for marriage registration: proclamation No. 760/2012
• Legal age for marriage: 18 years old for both sexes;
• There is a legal obligation to register the marriage
• Marriage certificate issued immediately
• Legal informant to register a marriage
 Officer of civil status who observed the marriage ceremony, Spouses (if
celebrated by religious or customary ceremony)
231

Marriage registration in Ethiopia cont.…
• Fee for marriage registration- No
• Fee for marriage certificate- Yes
• Penalty for late registration- No
• Requirements for marriage registration: Husband’s and wife’s
presence at registration, Proof of wife’s and husband’s age
• Place of registration:- Civil registration office
232

Why CRVS Systems Don’t Work
233
Lack of priority by government
Poor quality systems
Inadequate systems outside of urban areas
A passive system doesn’t work in a developing setting
Majority of events occur at home
Population doesn’t feel need to register
Barriers to registering (distance, cost, time, lack of
awareness, etc.)

Overview of Demographic Health Survey (DHS)
• DHS is nationally-representative household survey that provide
data for a wide range of monitoring and impact evaluation
indicators in the areas of population, health, and nutrition.
• Since 1984, the DHS Program has provided technical assistance to
more than 300 demographic and health surveys in over 90
countries.
• The strategic objective of the DHS Program is to improve and
institutionalize the collection and use of data by host countries.
235

The DHS Program supports the following data
collection options:
• Demographic and Health Surveys (DHS)
• AIDS Indicator Surveys (AIS)
• Service Provision Assessment (SPA) Surveys
• Malaria Indicators Surveys (MIS)
• Key Indicators Survey (KIS)
• Other Quantitative Data
• Biomarker Collection
• Qualitative Research
236

survey methodology
It includes
• Survey instruments
• Sample design
• Data tabulation plan
• Survey timeline
237

Survey instruments
1. Questionnaire
• A Household Questionnaire,
• A Woman’s Questionnaire
• A Man's Questionnaire
• A Bio-marker Questionnaire
2. Bio-markers
3. Geographic information
238

Sample Design
• The sample is generally representative:
• The sample is usually based on a stratified two-stage cluster design:
• First stage: Enumeration Areas (EA) are generally drawn from Census
files
• Second stage: in each EA selected, a sample of households is drawn
from an updated list of households
239

Data Tabulation Plan
• The DHS Tabulation Plan complements the 2012 versions of the DHS
Model Survey Questionnaires.
• The DHS Tabulation Plan consists of over 175 tables contained in 15
substantive chapters.
• These chapters provide information on
the demographic and socioeconomic characteristics of the population
Levels of fertility and childhood mortality
Family planning
Women’s status
Malaria
orphanhood, etc
240

Survey timeline
• DHS Surveys are normally conducted over a period of 18–20 months. The
following timeline represents a typical standard DHS Survey.
Timeline Topic Timeline Topic
Month 1 Survey design visit Month 9-
12
Data entry and editing
Month 2 Sample Design Month 13 Preparation of the Key Indicators
Report
Month 3 Questionnaire design Month 14-
16
Tabulation, analysis and preparation
of the Final Report
Month 3-4 Household listing Month 17 First draft of the report
Month 5 Pretest Month 18 Review and revision of report
Month 6 Revision of questionnaires and manuals Month 19 Printing of the final report
Month 7 Training of field personnel Month 20 National seminar
Month 8 Data processing set up Month 20 Further analysis and/or data
dissemination activities
Month 8-11 Fieldwork
241

Information generated from the DHS
• fertility and total fertility rate
• Reproductive health
• Maternal health,
• Child health,
• Immunization and survival
• HIV/AIDS
• Maternal mortality
• Child mortality
• Malaria and nutrition among women and children stunted.
242

Service Provision Assessment Surveys (SPA)
SPA is a sample survey of formal sector health facilities
Objective: to provide a “snap-shot” of the service environment “on any
given day”
Availability of different services
Facility preparedness to provide high-priority services
Evidence of functioning support systems for maintaining or improving the services
Adherence to standards in service delivery
Information on issues that clients and providers consider as important to their
satisfaction with service delivery
243

What questions can a SPA survey answer?
 What is the availability of different health services in a country?
e.g., what proportion of facilities offer child health services? family planning services?
 To what extent are facilities prepared to provide these services?
Do facilities have the necessary infrastructure, resources and support systems
available,
e.g.regular electricity and water supply, service guidelines, management practices,
trained staff
 To what extent does the service delivery process follow generally accepted standards of
care?
Does the process in service delivery meets standards of acceptable quality and
content?
 Are clients and service providers satisfied with the service delivery environment?
Clients’ perception of service provided and providers’ satisfaction with the work
environment
244

Contents of SPA surveys
Services
Maternal & Child Health
ANC, Delivery, Newborn care
Vaccination services
Curative care for children under 5
Family planning (FP) services
HIV / AIDS
Tuberculosis (TB)
Malaria
STI
Non-Communicable Diseases
Resources
Laboratory Diagnostics
Equipment
Pharmaceuticals
Systems
 Guidelines & protocols
Referral systems
Staff training and supervision
HMIS
Infrastructure
Water
Electricity
Client latrine
Items for infection control
Infection control practices
Privacy
245

SPA Survey Questionnaires
I.Facility inventory questionnaire
II. Health worker interview questionnaire
III. Observation protocol
IV. Client exit interview questionnaire
246

Strengths and Limitations of SPA
Strengths:
• Provide a snapshot of functioning of health system
• Comparisons across different service areas, facility types, regions within a country,
across countries and regions.
Limitations:
• Does not answer “Why” questions, e.g., why equipment not functioning, supplies
inexistent
• Long/detailed questionnaire + final report
247

Service Availability and Readiness
Assessment (SARA)
SARA is designed as a systematic survey to generate a set of core
indicators of services, which can be used to measure progress in
health system strengthening over time.
The SARA focuses on service availability, general service readiness,
and service-specific readiness.
248

Cont..
• Service availability refers to the physical presence of the delivery of
services
• General service readiness is the overall capacity of health facilities to
provide general health services.
• Readiness is defined as the availability of components required to
provide services such as basic services, basic equipment, standard
precautions, laboratory tests, and medicines and commodities.
• Service-specific readiness is the ability of health facilities to offer a
specific service and the capacity to provide that service measured through
selected tracer items that include trained staff, guidelines, diagnostic
capacity etc.
249

Information generated from SARA
1. Service availability
 Health Infrastructure
• Facility density per 10 000 population
• Inpatient bed density per 10 000 population
• Maternity bed density per 1000 pregnant women
 Health workforce
• Health workforce density
 Service utilization
• Number of outpatient visits per capita per year
• Number of hospital discharges per 100 population (excluding deliveries)
250

Information generated from SARA
2. service readiness
• Improved water source inside OR within the ground of the
facility
• Room with auditory and visual privacy for patient consultations
• Access to adequate sanitation facilities for clients
• Access to electricity (power)
• Communication equipment (phone or SW radio)
• Facility has access to computer with email/internet access
• Emergency transportation
• Standard precautions for infection prevention etc.
251

Other surveys and information generated
from the survey
1. House hold survey (HH survey)
A ‘Household Survey’ is the process of collecting and analyzing data to
help us understand the general situation and specific characteristics of
individual household or all households in the population.
During a household survey, field researchers investigate and record
facts, observations and experiences from the sample households which
are representative of all households in the study area.
Tools used for collecting data include a series of questions, observation
checklists and records of discussions.
252

Why a HH survey
• Important source of socio-economic data
• Provides information to monitor development policies
• In developing countries and transition economies,
supplements or sometimes even replace other data collection
programmes and civil registration systems
253

HH survey use
Provide information about household members that are useful
for policy making, planning, monitoring and evaluation
Provide migration status of household members, and socio-
economic characteristics of household
Providing information about aspects of children’s background
that may influence household schooling decisions and
children’s participation in school
254

Data generated from HH survey
• Education
• Health and social development
• Housing
• Household access to services and facilities
• Food security
• Agriculture
255

Malaria indicator survey (MIS)
• The MIS package includes questionnaires, manuals, and guidelines
that are based on Demographic and Health Surveys materials.
• The DHS Program is also active in the implementation of the
Malaria Indicator Survey and has developed a website to provide
information about and data for Malaria Indicator
Surveys worldwide.
• Standardized malaria indicators are also available for nearly 30
countries.
256

Data generated from MIS
• Household ownership of insecticide-treated mosquito nets
and their use, especially by children under five years of age
and pregnant women
• Intermittent preventive treatment against malaria during
pregnancy
• The type and timing of treatment of high fever in children
under five years of age
• Indoor residual spraying of insecticide to kill mosquitoes
• Diagnostic blood testing of children under five with fever.
257

Indicators
• A health indicator is a measure designed to summarize
information about a given priority topic in population
health or health system performance.
• Health indicators provide comparable and actionable
information across different geographic, organizational or
administrative boundaries and/or can track progress over time.
258

Why do we need measures of population
health?
To set priorities for health services & policies
To evaluate social and health policies
To compare health of different regions
To identify pressing health needs
To draw attention to inequalities in health
Highlight balance between length and quality of life
259

Classifying population health measures by
their focus
1. Aggregate measures combine data from individual people, summarized at
regional or national levels.
E.g., rates of smoking or lung cancer.
2. Environmental health indicators record physical or social characteristics of
the place in which people live and cover factors external to the individual
E.g. Air or water quality
3. Global health indicators
E.g:- existence of healthy public policy; laws restricting smoking in public
places, or social equity in access to care
260

Measures of population health
1. Descriptive measures:
i. To record current health status;
ii. To evaluate change in health status
2. Analytic measures:
iii. Predictive methods
iv. Explanatory measures
261

Domains of health information core set of indicators
Health status indicators
E.g. Life expectancy at birth, infant mortality rate, TB mortality rate
Risk factor indicators
E.g. Children under 5 who are stunted, Anemia in children
Service coverage indicators
E.g. Antenatal care coverage, skilled birth attendant
Health system indicators
E.g. Health service access, hospital bed density
262

Demographic indicators
• Life expectancy at birth
• Crude death rate
• Crude birth rate
• Total fertility rate
• Urban population
263

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