International Journal of Medical Informatics (2005) 74 , 733—744
Evaluation of existing District Health ManagementInformation SystemsA case study of the District Health Systemsin Kenya
George W. Odhiambo-Otieno
Department of Health Management, Faculty of Health Sciences, Moi University,P.O. Box 6142, Eldoret, Kenya
Received 9 May 2005; accepted 10 May 2005
KEYWORDSEvaluation;District Health
ManagementInformation System;District Health System
SummaryIntroduction: This paper discusses some of the issues and challenges of implement-ing appropriate and coordinated District Health Management Information System
(DHMIS) in environments dependent on external support especially when insufcientattention has been given to the sustainability of systems. It also discusses fundamen-tal issues which affect the usability of DHMIS to support District Health System (DHS),including meeting user needs and user education in the use of information for man-agement; and the need for integration of data from all health-providing and relatedorganizations in the district.Methods: This descriptive cross-sectional study was carried out in three DHSs inKenya. Data was collected through use of questionnaires, focus group discussions andreview of relevant literature, reports and operational manuals of the studied DHMISs.Results: Key personnel at the DHS level were not involved in the development andimplementation of the established systems. The DHMISs were fragmented to theextent that their information products were bypassing the very levels they werecreated to serve. None of the DHMISs was computerized. Key resources for DHMISoperation were inadequate. The adequacy of personnel was 47%, working space 40%,storage space 34%, stationery 20%, 73% of DHMIS staff were not trained, manage-ment support was 13%. Information produced was 30% accurate, 19% complete, 26%timely, 72% relevant; the level of condentiality and use of information at the pointof collection stood at 32% and 22% respectively and information security at 48%.Basic DHMIS equipment for information processing was not available. This inhibitedeffective and efcient provision of information services.
Conclusions: An effective DHMIS is essential for DHS planning, implementation, mon-itoring and evaluation activities. Without accurate, timely, relevant and completeinformation the existing information systems are not capable of facilitating the DHSmanagers in their day-today operational management. TheexistingDHMISs were foundnot supportive of the DHS managers’ strategic and operational management functions.Consequently DHMISs were found to be plagued by numerous designs, operational,resources and managerial problems. There is an urgent need to explore the possibili-
Health Management Information Systems (HMISs)are important support tools in the managementof health care services delivery [1]. In 1983, theGovernment of Kenya (GoK), decentralized theMinistry of Health’s (MoH) decision-making pro-cess to the districts [2]. This was in line withWorld Health Organization (WHO) resolution callingon all WHO member states to strengthen DistrictHealth Systems (DHS) [3]. For this decentraliza-tion to be effective, there was a need to establishinformation systems to support the DHS managersin their planning, implementation and evaluationfunctions. The establishment of effective HealthInformation Systems to support decision-making bydistrict health personnel was an essential compo-
nent of the DHS [4]. The GoK recognized that with-out an effective and appropriate information sys-tem, the MoH’s capacity to cope with its planningand management needs would be severely compro-mised [5].
These information systems were to provide theDHS managers who were members of District HealthManagement Team (DHMT) and District Health Man-agement Board (DHMB) with the information theyrequire. The DHMT members including among oth-ers the District Medical Ofcer of Health (DMOH)as Chairman, the District Health AdministrativeOfcer (DHAO), the District Public Health Nurse(DPHN), the District Public Health Ofcer (DPHO,)and the Medical Records Ofcer, were responsiblefor among other things, developing a strategy forthe district health service, monitoring the healthproblems that occurred in the district, and coordi-nating the activities of all health care providers inthe district. The DHMB on the other hand, whichconsisted of the area DMOH, local community andNon-Governmental Organization (NGO) representa-tives, among others, played an advisory role in rela-tion to DHMT and worked with DHMT to coordinateand monitor the implementation of government and
non-government health programs in the district [5].The DHMIS was to provide both the DHMT and DHMBwith accurate, reliable and up-to-date informationfor the management of the DHS.
Following this decentralization, Health Informa-tion Systems (HISs) at the district level in Kenyahave undergone fundamental changes that haveresulted in the introduction of different types of information systems. A quick survey of Kenya’s MoHreveals that it operates different versions of DistrictHealth Management Information Systems (DHMISs)at the DHS level [5]. The rst DHMIS was intro-duced in Murang’a DHS in 1988 and was funded byUNICEF. This system introduced a total of 26 datacollection forms, 11 of which were for collectinghealth service data and 15 for collecting adminis-trative/management data [6].
Subsequent to the introduction of the Murang’aDHMIS, the following DHSs introduced various ver-sions of DHMISs: Kitui, Embu, Baringo, Nakuru,Nyandarua, Nyamira, Kisumu, Kwale, Uasin Gishu,Bungoma and Mombasa [5]. Reasons advanced forthe introduction of these systems were: (a) healthfacilities collected information haphazardly andirregularly; (b) information collected was incom-plete and unreliable with limited analysis and useat the point of collection; (c) too much datawas collected rendering analysis impossible. Theobjective of this system was to facilitate theuse of selected existing information to supportoperational decision-making and planning.Relevantinformation compiled at the District HIS Ofce wasto be extracted, processed and made available reg-ularly to the DHMT and DHMB for action planning,supervision and impact assessment [6]. These sys-tems operated along side with the routine HISswhich are operational in all DHSs in Kenya.
All these systems within the DHSs in Kenya arecharacterized by a lack of integration, and are dis-jointed and widely dispersed, with no effectivecentral co-ordination to ensure that the informa-tion which they contain is readily available to those
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who need it [5]. To-date, there has been no formalcomprehensive evaluation of these systems by theirdesigners to determine their strengths and weak-nesses ever since their introduction in the DHSs inKenya. The research question is: To what extentare the information systems in the DHSs in Kenya
supportive of the operational management of thehealth services? This paper attempts to provide ananswer to this question and at the same time iden-ties and discusses some of the obstacles to thesmooth operation of the existing systems.
2. Objective of the study
The broad objective is to evaluate the extent towhich existing information systems have supportedthe operational management of health services atthe district level in Kenya.
The specic objectives are to:
• identify the processes undertaken in designingand implementing the existing DHMISs;
• identify DHMIS operation and resource require-ments;
• identify DHMIS users and their informationrequirements.
3. Methodology
This exploratory and descriptive, cross-sectionalstudy was undertaken to unearth the real problemsfaced by existing DHMISs in the MoH, Kenya. Bothqualitative and quantitative approaches were usedto explore, describe and explain why things hap-pened the way they did [7]. The qualitative methodpermitted the researcher to study selected issuesin depth and detail thereby producing a wealthof detailed information from a small sample [8].These methods permitted subjects full opportu-nity to express themselves and behave in a nat-uralistic way [9]. In-depth studies of 3 of the 13DHMISs introduced in the Kenya’s DHSs were made.Interviews were conducted with system designers,DHMIS operators (staff) and users (health workers).These interviews were conducted on an individualbasis. In addition, document analysis of literatureon these systems was carried out. Finally, day-to-day observation of the operations of these systemswas conducted. As a result, a set of constraints tothe operations of these systems was evident.
This study used a combination of purpose-ful/judgmental and snowball/chain sampling pro-cedures [10]. The logic and power of purposefulsampling lies in selecting information-rich cases for
study in depth [8]. Since DHMISs were implementedin 13 selected DHSs in Kenya, this study used pur-poseful sampling procedures for selecting the threeDHSs of study, namely, Murang’a, Uasin Gishu andBungoma. Murang’a was selected because it wasthe rst DHS to pilot and implement a DHMIS. The
Murang’a design was supposed to be used as ablueprint for other DHSs, hence the justication tostudy in detail the original system and assess howit was actually operating in comparison with thosein other DHSs.
Sample size in this study depended mainlyon what could be done with available time andresources [8]. There were two categories of sam-ples for this study whose sizes were: study areasn = 3 (based on purposeful/judgmental samplingprocedures) and, respondents n = 30 (based on out-come of snowball sampling procedures). Snowballsampling was used for locating information-rich keyinformants (interviewees). The process began byidentifying the rst key informant who then helpedin identifying subsequent key informants for thestudy [7,8,10] . Rationale for using this strategy wasto get information-rich respondents; those who hadactually been involved in one way or another ineither the design or implementation of the DHMISsthat were being evaluated. This strategy enabledthe researcher to identify information-rich respon-dents whose knowledge of the system helped in pro-viding the crucial information sought by the study.
4. Results and discussions
4.1. The processes undertaken in designingand Implementing existing DHMISs
The study revealed that the DHMISs studied weredesigned at the MoH headquarters and imple-mented in the DHSs with no participation of thosewho were to ultimately operate them. Neither wasthere involvement of those who were to use theinformation generated by these systems. Anotherfeature common to all of them was that they wereall donor driven. This had implication for theireventual operation upon donor pullout. There was aconsiderable variation in the degree to which DHSsstudied and their information support evolved.Whereas the Murang’a system used a total of 26report forms for collecting data, Bungoma andUasin Gishu systems used a total of 17 and 49 reportforms respectively. The study indicated that theseDHMIS were highly fragmented with no linkages withother health care providers at various levels. Thedesign and implementation of these DHMIS did not
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Fig. 1 A fragmented District Health Management Information System: NGO HQ: Non-Govermental Organization Head-quaters; PHMT : Provincial Health Management Team; DHMB: District Health Management Board; DHMT: District HealthManagement Team; HCMT: Health Centre Management Team; HCDC: Health Centre Development; Committee; VHC:Village Health Committee; ( → ) current information channel; ( ) bypassed points (levels).
facilitate integration of different sources of healthinformation within the DHSs studied.
Consequently, there was no sharing of informa-tion among health care providers in the DHSs stud-ied ( Fig. 1). The basic premise to be adopted inthe development of any information system modelis that a DHMIS should be designed with a focuson improving the health status of the community.Meaningful improvements can only come about asa result of provision of information generated by allhealth care providers in the DHS. Only health inter-ventions based on such information stand a chanceof having desired effects on improving the healthstatus of the DHS community.
4.2. The DHMISs operations and resourcerequirements
The DHMISs in the studied DHSs were mainlyconcerned with the collection of health ser-vice (patient) data with none of them collectingmanagement/administrative data. This needed tochange as these systems must concentrate also onmanagerial aspects for the better use of healthcare resources. DHMISs should strive to collect bothhealth service (patient) data and administrativedata. The information required by both DHMTs andDHMBs to plan and manage the DHS ranges fromthe broad and qualitative data, which is often
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in the realm of general knowledge, to specicdemographic, epidemiological and administrativedata. Not a single information system studied wasfound to be computerized. The existing manual sys-tems for collection, storage and retrieval were notfacilitating timely availability of information for
decision-making. Despite coming up with their ownunique designs, none of the DHMISs were found tobe operating as designed. The inability to imple-ment the systems in Bungoma and Uasin Gishu DHSsas per the Murang’a DHS design which was supposedto be the blueprint for all other DHSs in Kenya,resulted in the variations in the type and quantityof information collected. Each of the DHMIS stud-ied was found to be using its own unique set of forms which varied in numbers from one system tothe other. Given the fact that some of these formswere to be lled by the already overburdened clin-ical staff and nurses in the facilities, it resulted inmost data not being captured as these staff sawtheir rst priority as being the provision of medicalcare to the patient and only turning to the formswhen there was time to spare for this activity. Thisvariation in the data collection tools (forms) did notfacilitate meaningful comparison with other DHSs interms of performance. One of the major complaintsby DHMIS personnel interviewed was that the num-ber of forms used in data collection was too large.They felt that there was an urgent need to reducethe number of forms to a reasonable number. Someof the forms were found to be redundant in that
they were collecting information already collectedby other forms.Inadequacies in access to and availability of
information call for the creation of partnership andshared vision in health information management.The lack of common vision and of coherent poli-cies within the MoH arise partly because of thelack of adequate and shared information. The goalis for all partners in health care to share theirinformation. The DHSs studied were based on theWHO Model, with the district as the main opera-tional unit that supports the Primary Health Care(PHC) strategy [3]. The most important PHC strate-gies are intersectoral co-ordination and commu-nity involvement, coupled with bringing togetherall relevant parties (including government, pri-vate health providers, NGOs and traditional heal-ers) as partners in work related to health. TheDHS through the PHC is inherently multidisciplinary.Findings indicated that these DHMISs neither col-lected nor received data or information from otherhealth care providers like the private hospitals,local authority facilities or NGOs providing healthcare in their respective DHSs ( Fig. 1). Particularattention needs to be paid to collecting informa-
tion from non-governmental sources with a viewto strengthening co-ordination and collaborationto improve health in the DHS. To complement thefacility-based sources of information, surveys couldbe used to collect information from the communityin the facility’s catchment area. Data for a dis-
trict health prole, for example, could be obtainedthrough routine reporting. These two sources wouldthen enable the DHS managers to have a more com-plete and comprehensive picture of the health sit-uation in the DHS and would help them to come upwith appropriate interventions. All institutions in aDHS should be seen to be having an important con-tribution to make to the DHMIS and to improvinghealth in the DHS.
The partnership between information users andcollectors helps to avoid embarrassing errors andgreatly reduces external criticism of the DHMIS.Making information users partners in the design andimplementation of a DHMIS has the opportunity tounify its goals with users’ goals. Ideally, the part-nership between information producers and infor-mation users should be formed as early as possiblein the data collection process. Successful designand implementation of a DHMIS requires the fulland active participation of all stakeholders (DHMISdesigners, donors, operators and users) during allthe stages of developing a DHMIS. Institutionaliza-tion, ownership and commitment can only comeabout as a result of active involvement of all stake-holders. There is need for integration of data from
all health-providing and related organizations in theDHS.Health care workers in the studied DHMISs stud-
ied spend a signicant proportion of their workingtime collecting large amounts of patient data thatwas rarely analyzed and used at the point of col-lection. They were found to be merely collecting,aggregating and dutifully passing over this data tothe next level. This information is rarely ever usedto guide local action at the level at which the datais collected [11] . Data collected was not compiledand presented into summaries useful for decision-making. There were no wall charts or graphs sum-marizing information collected in any of the sys-tems studied.
Very little collected information reached theDHSmanagers, the DHMTs and DHMBs (Fig. 1). This wasdespite the fact that the DHMIS was introduced tofacilitate the operations of these two bodies. Infor-mation produced by these systems rarely matchedthe requirements of the DHS managers. This couldpossibly be explained by lack of involving informa-tion users in the design of these systems. Giventhe manual nature of these systems, their informa-tion was not delivered in time as it was not easily
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physically accessible mainly due to type of storagesystem used.
The most frequent problem is the lack of feed-back to local districts and health care workers[11] . When feedback was nally received from theheadquarters in the form of MoH Annual Report, it
inevitably came too late, sometimes after 2 years,to impact on operational management decisions. Atthe grassroots level, thehealth centre developmentcommittees (HCDCs), health centre managementteams (HCMTs) and the village health committees(VHCs), where they existed, were usually isolatedfrom their health centres and dispensaries ( Fig. 1).They were rarely provided with processed informa-tion from these facilities or from the district healthcommittees that were supposed to assist them inbetter understanding the health problems of theirlocalities.
Data captured varied from one system to anotherdepending on the design and number of forms intro-duced in each system, which eventually determinedthe type and amount of data collected by eachDHMIS. These DHMISs had no information on accessto and coverage of health services. None of thesesystems studied had management/administrativeinformation about such resources as personnel,nances, physical facilities, equipment and trans-port. To get any of this information it has to bespecically collected for the purpose as it is neitherroutinely collected nor stored by the studied sys-tems. Only Uasin Gishu DHS had information on the
size of the catchment population it was attempt-ing to serve. In the absence of such information it
becomes very difcult to relate health resources topopulations. Without such population-based infor-mation, it is impossible to do even the most basictypes of monitoring of DHS activities. All the sys-tems studied had adequate information on commoncauses of morbidity and mortality. However, these
systems could be improved by collecting data onimportant underlying factors inuencing health sta-tus such as food availability, housing, water supplyand sanitary facilities. Knowledge of occupationalgroups at high risk of diseases such as malnutri-tion may point to areas of promotive and preventiveaction.
The information systems studied were found tobe lacking key resources necessary for informationprocessing, reecting low managerial priority.These DHMISs were handicapped in all their workby the lack of basic typing, duplicating, andling equipment. All Health Information Systemsrequire resources and adequate long-term fundingfor such necessities as trained staff, computers,stationery, communication equipment, systemsand staff development, reports and communi-cation costs ( Table 1 ). The three DHMISs wereall initially developed with considerable supportfrom international donor agencies. All the sys-tems collapsed as soon as the donor agencieswithdrew their nancial and technical support.For purposes of sustainability, there is need forprovision of adequate funding by beneciaryDHSs. This will ensure that these systems are
provided with adequate resources for their oper-ations. Sustainability can be enhanced by active
Table 1 Status and quantity of data processing equipment
using calculators donated by KFPHCPDesk calculator — 2 — These belong to the MoHTypewriter — 1 — Hardly used due to stationery problemsComputer 1 — — Not used for data entry as there was no
printer available. Observed staff playingcomputer games instead of entering data
Printer — — — Not available even where there is acomputer like in Uasin Gishu
Photocopier — — — All photocopying done commerciallyoutside the facilities
Duplicating machine — — — Despite its usefulness no single systemhad one in place
Telephone — 1 1 Extension of the hospital’s main lineFiling cabinets — 3 1 The available cabinets were far from
adequate. Data storage in Uasin Gishuwas pathetic. Most data was found lyingon the oor
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involvement of all parties at all stages of DHMISdevelopment.
Data collection in the wards was not co-ordinated as the nurses and medical records clerksin the same ward collected information from thesame patients for different persons and purposes.Both categories of staff (nurses and clerks) had notreceived adequate training on information activi-ties. In one of the DHSs studied, data was beingcollected by mainly untrained and temporarilyhired workers. The number of DHMIS personnelwas found to be inadequate, the majority of themwere untrained in DHMIS operations ( Table 2 ). Thedeployment of untrained staff in information activ-ities is likely to compromise the quality of infor-mation produced. Lack of a co-ordinated data col-lection strategy was a recurrent problem in theDHMISs studied which led to duplication of effortand competition among data collecting units and
health care providers.The poor quality, incompleteness and lack of timeliness of much of the data being generated byexisting institutional record-based Health Informa-tion Systems were found to be the main problems.Information produced was 30% accurate, 19% com-plete, 26% timely, 72% relevant; the level of con-dentiality and use of information at the point of col-lection stood at 32% and 22% respectively and infor-mation security at 48%. Condentiality and securityof the information was compromised by the natureof storage as most records were found lying on someoors due to either inadequate storage facilities orlack of space.
The study revealed that almost all of the keyresources needed for the functioning of the DHMISswere in inadequate supply. Information systemspersonnel interviewed on adequacy of resourcesproduced the following results: The number of per-sonnel was found adequate by 47% of the inter-viewed persons, working space 38%, storage space32% and stationery 18%. Findings also revealed thata dismal 13% of the interviewed persons foundmanagement support for information activities tobe adequate. Management follow-up/supervision
Fig. 2 Resources and managerial support.
stood at 7% and feedback from above was 13%. Allthe respondents interviewed indicated that all thestudied systems seriously lacked nances, transportand equipment ( Fig. 2).
DHMIS personnel interviewed indicated thatthese systems were faced with numerous oper-ational problems. These identied problems hadgreatly affected the smooth operations of theimplemented DHMISs to the extent that they werebarely functional. Responses of DHMIS staff mainlyfocused on the inadequacies in the supply of infor-mation system resources as shown in Table 3 . Forthe same DHMISs to produce their desired effects,personnel operating the three DHSs studied madesuggestions on what they thought needed to bedone to address the problems they identied intheir respective DHMISs ( Table 3 ).
For a DHMIS to be supportive of the DHS activ-ities, it must have access to functioning equip-ment for developing forms, communication to theeld and replies to user inquiries. Storage of col-lected data and generated information must behandled with the condentiality and security theydeserve. This calls for the provision of adequate
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Table 3 DHMIS operational problems in each DHS and suggested solutions by DHMIS personnel interviewed
DHS DHMIS operational problem Suggested solution by DHMIS personnelMurang’a Financial constraints Create a budgetary line item for DHMIS operations
Manual system Computerize for ease of analysis, storage and retrievalLack of transport Provide motor-bikes to staff for eld supervisionInadequate skills Train new staff and further train old staff Heavy workload Reduce number of forms currently usedLack of feedback Encourage feedback in both upwards and downwardsLack of working and storage space Provide adequate working and storage spaceLack of equipment Procure modern equipment — calculators and photocopiersExisting system limited to MoHfacilities activities
Expand existing system to collect information from otherhealth care providers in the DHS
Bungoma Manual operations Minimize work by computerizationReluctance by some members togive full information
Training in information systems activities for new membersof staff and refresher courses for old staff
Lack of clear understandingbetween HIS and DHMIS staff (fearof takeover)
Proper interpretation of what DHMIS is all about
Financial constraints resulting in
shortages of equipment, stationerytransport, working and storagespace
Adequate nancial support — create a budget item for
DHMIS operations
Some DHS Mangers don’t appreciatethe value information
Train DHS Mangers on the value of DHMIS and its productsand them to recognize DHMISs contribution in care delivery
Limited DHMIS personnel skills Encourage further training and refresher coursesLack of reportingguidelines/feedback
Issue clear policy guidelines for reporting
Lack of integration of informationactivities in the DHS
Modify and expand existing system to involve communityand other health care providers in the DHS
Ignoring DHMIS personnel in thedesign
Involve ultimate users in the design of such systems
Uasin Gishu Manual system Computerize to enhance DHMIS operation to facilitate dataanalysis, storage and retrieval of information
System activities too narrow Expand the system and collect information from centralgovernment and local authorities, public, mission, andprivate clinics
Lack of nances for the provision of:equipment and furniture; workingand storage space; stationery;transport; adequate staff andtraining
Provide adequate funding through creation of a budget linein the Districts budgetary allocation from the MoH for theprovision of these identied services
Lack of management support Provide the necessary nancial and moral supportLack of co-ordination Co-ordinate with other health care providers in the DHSLack of appreciation of DHMIS staff work
Demonstrate appreciation of the contribution of HMIS staff
physical storage and working space. To deliverexpected information outputs, the information sys-tems require strong central management and sup-port by major decision makers within the DHS.
4.3. DHMIS users and their informationrequirements
The health care panorama is diverse and complex.Major differences are observable among DHSs activ-ities and even among different levels of the same
DHS. No single information system will support thisdiversity of information generation and manage-ment needs. DHMIS users (health workers) com-plained about untimeliness, inaccuracies, irrele-vance and incompleteness of information produced(Table 4 ). Various DHMIS users are not getting thetype of information they need. In such a case thereis need for conducting an information audit to iden-tify user requirements. The information audit is amanagerial tool for the examination of informationused to make decisions. The information identied
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Table 4 DHMIS users and their information requirements
User Type of Information ReasonsHIS dept. personnel
(MoH Hq)Information from all other health careproviders in the DHS
Information needed for formulation of comprehensive policies and intervention
Outcome/impactDHS managers General socio-economic Information provides a district health prole
necessary for the planning and managementof the DHS
Catchment population Information needed for effective andefcient allocation of health resources
DemographicAccess and coverageResource mobilization, allocation andutilizationAdministrative information(personnel, nances, facilities)Information from all other health careproviders in the DHS
PHC providers Preventive and therapeutic strategies Need to know which strategies achieve the
best outcomesInstitutions andorganizations
Outcome and impact Need to know how best to ensure the healthand productivity of their employees
General public Environmental and socialdeterminants of health
Need to know how to avoid illnesses andimprove life expectancy
Patients Options for their on-going care For effective decision-making for bettercare
as relevant to current decision-making and to whatmight be used in some future system is ordered bypriorities according to the resources allocated on
the basis of the decisions being made.The role of the DHMIS in the DHS should not justbe routine collection of facility-based health ser-vice data and dutiful conveyance of the same tohigher levels of the health care system. The under-lying rationale for a DHMIS’s efforts is improvementin health status of the population within a DHS.Information collection, analysis and presentationshould be organized in such a way that the mostneedy groups and individuals are identied. Sub-sequent health planning should be based on suchinformation and strategies should be designed toredress any identied inequalities. It is importantthat the DHS managers have current informationon the impact of its service activities. The infor-mation on target populations is quite essential forunderstanding the impact of health services ren-dered. This information is necessary for monitor-ing the impact/outcome of DHS interventions. DHSmanagers need information on an intervention’srelevance, progress, effectiveness, impact and ef-ciency.
Information output from the systems studied isof statistical nature, inappropriate and outdatedthat only a relatively small group of health infor-
mation personnel and researchers are capable of using it. In this respect, the very format, compo-sition and availability of the information products
have become formidable barriers to the potentialusers. No DHMIS can afford to discourage the suc-cessful use of its information resources by produc-ing information products that are not aligned withthe needs of the user in the forefront. It is impor-tant forexisting DHMISs to produce information thatis user-friendly. If the DHMIS personnel are willing(and technically able) to tailor information to spe-cic user needs, then that information is likely to beutilized to a greater extent than would otherwisebe the case.
No information system should be developedwithout a careful assessment of the levels of theinformation generation and use. Information shouldbe the basis for improving the administration of health resources, as quickly and efciently as pos-sible, in the pursuit of national and district healthpriorities. DHMISs must place greater emphasison providing DHS Managers with information thatwill be genuinely useful in improving health sta-tus. The goal should be to reduce morbidity, dis-ability and premature mortality and improve ef-ciency in health care delivery. Information has thepotential to unite the health sector in the pur-suit of better community health, but studied sys-
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was collected in the DHSs studied. It was doubtfulif the DHS managers in the study areas were able tounderstand their district’s health situations in theabsence of such key information.
Measures must be implemented to ensure thatinformation is shared widely and synthesized into
forms suitable for use by various information sys-tem users. This prevailing situation raises disturbingquestions about the relevance and efciency of thestudied DHMISs’ activities. DHMIS users identiedseveral DHMIS operational problems and suggestedmeasures that needed to be taken to alleviate them(Table 5 ).
No information system should be developedwithout a careful assessment of the levels of infor-mation generation and use. DHMIS needs to provideat least some information in each of the follow-ing categories: general socio-economic and envi-ronmental information; demographic information;health status patterns and trends; access, utiliza-tion, coverage and quality of health care; resourcemobilization, allocation and utilization; and Dis-trict Health System management process. Informa-tion systems designers must also address the issuesof co-operative partnership in information activi-ties, systems compatibility and sustainability [5]. Inthe absence of this information, the DHMISs werenot able to help health managers to efcientlyand effectively allocate resources and monitor thefunctional status of resources at their disposal. Inthe way they are collecting, processing and dis-
seminating information, DHSs studied are, indeedoperating fragmented systems which are not sup-portive of the operational management of the DHS(Fig. 1).
5. Conclusions
The design of the existing DHMISs studied was doneat the ministry headquarters ignoring both thosewho were to eventually operate them and usethe systems products (information). There was amarked difference in the focus of health workersand DHMIS staff. Whereas the health workers com-plained about the quality of the information pro-duced, DHMIS staff on the other hand concentratedtheir complaints on inadequate supplies of basicresources necessary for effective operation of thesystem.
The information systems studied werecharacter-ized by a lack of integration, and were disjointedwith no effective central co-ordination to ensurethat the information which they contained wasreadily available to all who needed it. The DHMISs
were found to be fragmented with no mechanismsfor information ow that allowed sharing of infor-mation among stakeholders. The information sys-tems were basically data-led which routinely col-lected large amounts of data that was sent to higherlevels without analysis and use at the collection
point. The variation in data collection tools did notallow comparison in terms of performance amongDHSs.
The information requirements of the users wereneglected thereby making the systems products(information) irrelevant to potential users. Thereis need to foster partnership between informationproducers and users. Without accurate, timely, rel-evant and complete information, the existing infor-mation systems are not capable of facilitating theDHS managers in their day-to-day operational man-agement. Without people who are trained in tech-niques of both information production and use,the likelihood is small that a DHMIS will enhancethe level of health care management in the DHS.There is an urgent need to explore the possibili-ties of computerising the existing manual systemsto take advantage of the potential uses of micro-computers for DHMIS operations within the DHS.Despite the ultimate use of computers, care mustbe taken in the way data is collected manually. Thegreatest challenge facing the existing and futureDHMISs in Kenya is securing the support of theDHS managers both nancially and morally giventheir low-key perception on information activi-
ties. For long-term internal sustainability, thereshould be a gradual shift from depending exclu-sively on donors for nancial and technical sup-port for such initiatives to a fully self-supportingsituation.
To be supportive, existing systems must have acomprehensive and accurate picture of the healthsituation in the DHS. The existing DHMISs must col-lect information from other health care providerswithin their respective DHSs. Only then can DHSmanagers receive information necessary for theoperational management of the DHS. To the extentthat this is not being done, current DHMISs aretherefore not supportive of the operational man-agement of health services at the DHS level inKenya.
To improve the current situation, concrete pro-posals will be made in another publication thatwill address in more detail the issues raised in thispaper. An integrated information system model thatinvolves all district-based health providers whichalso collects key categories of information fromboth community- and facility-based sources, with acentral management information unit will be pro-posed.
7/27/2019 Evaluation of Existing Health Communication Systems in Kenya 2005
• Evaluation of DHMISs remains the weakestlink in their design, implementation andoperation.
What this study added to our body of knowl-edge:
• For effective management of the DHS, theDHMIS must facilitate the integration of datafrom all health-providing and related organi-zations in the DHS.
• Sustainability of the DHMIS requires activeparticipation of all its key stakeholders,namely, the developers, the users andthe patients whose management may beaffected by the information generated bythe DHMIS.
References
[1] M.C. Azubuike, J.E. Ehiri, Health information systems indeveloping countries: benets, problems, and prospects,Int. J. Med. Inform. 60 (2000) 21—28.
[2] Government of Kenya, District Focus Strategy forRural Development, Government Printer, Nairobi,1986.
[3] World Health Organization, Strengthening of Informa-tion Support for Management of District Health Systems:Report on an Inter-regional Meeting, Surabaya, Indone-sia, 30 October—3 November, 1989, WHO/SHS/Geneva,1989.
[4] L. Hanmer, Criteria for evaluation of the district healthinformation systems, Int. J. Med. Inform. 56 (1999)161—168.
[5] G.W. Odhiambo-Otieno, Health management informationsystems in Kenya: diagnosis and prescriptions, Moi Univer-sity, Kenya, Unpublished Ph.D. Thesis, 2000.
[6] Ministry of Health, Manual for the District Health Man-agement Information System, Health Information SystemDepartment, 1991.
[7] Earl Babbie, The Practice of Social Research, 5th ed.,Wadsworth Publishing Company, Inc., 1989.
[8] M.Q. Patton, Qualitative Evaluation and Research Methods,2nd ed., Sage Publications, 1990.
