HEALTH INFORMATION MANAGEMENT STRATEGIC PLAN 2007 TO 2011

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BACKGROUND Introduction Information management in the health sector has been the subject of several reviews, development and improvement programmes in recent years. One of the key reasons for these programmes is because the Ministry of Health has a responsibility for health services situation analysis, monitoring and evaluation at all levels. Of the various attempts to improve the information system the UNDP supported Maternal and Child Health Information System (1987- 1993) stands out as the most extensive with a trial conducted in three out of the ten regions in the country. A major finding of the trial was that establishing a system that required each level to organise their data, discuss these as a team and prepare one composite report for the next level greatly facilitated the analysis and use of data. It also enhanced supervision and offered a greater scope for support activities from higher levels. The trial also showed that developing an information system from a programme perspective data collection could not extend beyond the programme needs even when information from other programmes were incorporated. Data analysis and interpretation was always tilted in favour of the programme activities with little scope for other areas of health care. The trail made it clear that for the development of a comprehensive information system, a special unit with the responsibility for coordinating the collection of data and converting these into relevant information for management was required. At the inception of the health sector reforms there was a strong recognition of the need for quality information as an essential part of the health planning, management and policy development processes that were being introduced. With the focus on performance, establishing an integrated and properly functioning health information system was seen as a priority. However investments in building capacity for health information management remained limited, uncoordinated with continuing emphasis on programmes and projects. In recent years there have been rigorous activities in the area of health information management in Ghana. This is partly in response to the overall changes in the development-planning arena. The current Poverty Reduction Strategy (GPRS II), which represents the Government’s development agenda, aims at transforming Ghana into a Middle Income Country by 2015. Within this framework, health care as well as protection of the vulnerable within a decentralised, democratic environment has been given a new impetus. The Monitoring and Evaluation framework demands information on diverse areas of health care delivery and systems development. The strategic objectives of the GPRS II are also anchored in the Millennium Development Goals and thus demands specific reporting on health sector activities aimed at meeting the targets set. This document is a strategic plan for health information management in the health sector in Ghana. It is a compass to guide the activities of the Ministry of Health and its agencies

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and its purpose is to define how health information management can help achieve the health system’s goals and objectives in the medium term. It is based on the recognition that a modern health system needs accurate and instantly accessible information. It is vital for improving care for patients, improving the performance of the health care system and the health of Ghanaians. The shift toward community based care, the need for improved accountability, efficiency, equity, access, and quality, as well as the desire of Ghanaians to be more directly involved in decisions about their health care all represent significant challenges in information needs. Advancements in technology and the increasing value of integrated health data, as well as the management of that data also represent a vital thrust underpinning information management in the health sector. It is about improving the very nature of care itself through enhanced knowledge and understanding by means of supportive information systems. It is also about providing decision-makers with accurate information so that they can make informed decisions. Most important, it is about increasing value for all users of the health care system. The plan begins by reviewing the status of health information development within the last few years and outlines a vision and the guiding principles for health information management in Ghana. It identifies four strategic activities to achieve the goal. Key Constraints to HMIS in Ghana Although several attempts have been made at reviewing and improving the health management information systems, the lack of information continues to be the frequent complaint of decisions makers. A quick review of the information scene shows that the health sector currently lacks adequately organised repositories of information as well as information processing capacity at all levels. While this may be viewed as a legacy of the old civil service system where managers collect information for the purpose of transmission, the reasons for poor quality health information also stems out of several other factors. The following outlines some of the main problem areas:

The inadequate perception of health workers of the usefulness of their information collection activities contributes a great deal to an exceptionally low level commitment to the information organisation process.

Low level use of locally collected routine data on both clinical and management activities for local planning purposes. In almost all cases these are forwarded to the central level.

Although some management data is collected at all levels, including budget, personnel, transport, drugs and other supplies, systematic analysis largely ignores these and concentrates on health status and health care utilisation data. Thus information support for planning is usually very weak. Again management information collected is not always relevant to the day to day information needs of managers.

Data collection systems in place collect input and output information differently thus giving very little scope for performance assessment. Without this there is very little incentive to collect and analyse data meaningfully.

Cooperation and information sharing between different programmes within the health sector and with different agencies is very minimal because of the different

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priorities, the multiplicity of indicators and data collection procedures in use. Though this may be a reflection of the planning process it is important to view it as an indication of the existence of vertical programme management systems still in place.

In addition to these broad constraints, information management in the ministry suffers from other specific set backs. The first is the poor communication between users and producers of health statistics. The health statistics does not support planning activities but operates as a unit which produce statistical information as an ends in itself. The information produced for instance relates very little to the current priorities and focus of the sector. This has led to a situation where information is largely organised within departments and programmes in the bid to satisfy specific programme requirements. Data collection reporting and analysis is thus uncoordinated. The shortage of information management manpower at each level also makes for the lack of an integrated health information system. In addition to this most of the statistical forms are either outdated, irrelevant or are duplications and the forms are hardly reviewed in view of current changes. A review of reporting formats within the ministry shows that health facilities are required to complete between 36 and 40 different forms from 15 different units and programmes for submission to higher levels. Medical care requires that 8 reporting formats should be completed, while disease control requires 14. There are no forms for reporting on Environmental health, health education and supplies (excluding drugs) and information on about 90% of these forms are submitted as raw data. The current information system does not collect data from traditional and private practitioners and institutions outside the Ministry of Health. Again data on populations without access to public health facilities or who use private sector are not reported on in the public sector. These omissions do not only create a problem for policy formulation and development of strategies but also provides inadequate basis for planning and resource allocation. Another basic problem of the information system is the low rate of data and report submission from the periphery. While this may be linked to the lack of capacity at the lower levels, the real reason may be due to the excessive demand for data recording and reporting on service staff much of which are not used for tasks performed at their level. For instance very little information on disease conditions and situations at the periphery are collected, organised and analysed for local action in prevention and control. Most of these are collected for the purpose of onward transmission to the District, Regional and sometimes directly to the national level. Commitment and validity are sacrificed under such circumstances. To worsen the problem, health research activities do not involve the main stream data collectors thus opportunities for development and training are missed. Current Developments in HMIS The strategy to improve information management within the last ten years has progressed along three main lines. The first has been to improve the human resource available for

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data collection and analysis at the district and regional level. In this direction steps have been taken to set up and support the training of health information officers at the Kintampo Rural Health Training School. These include the development of the curriculum, the provision of a computer laboratory, supporting staff to teach specific courses and the organization of orientation programmes. Initial reports indicate that the products are increasingly becoming significant resource in data management at the regional level. The second major strategy was to improve central level capacity for collation and analysis to support decision-making. The focus has been on building the capacity at the Centre for Health Information Management to be able to produce the kind of analysed data required by the sector. While significant success has been achieved in the development of the infrastructure and systems for data capture, storage and analysis a lot still remains particularly in the area of human resources with the requisite skills in statistics and information technology. The strengthening of data collection and analysis at the district level was also taken as a priority. Steps were therefore taken to study and understand the health information needs and demands at the district level and to design systems that will improve data collection and reporting, enhance the use of data and to facilitate self-assessment at the district level. The most significant problem encountered at the district level is the multiple reporting requirements through the sub districts. It was noted that several programmes and divisions continue to make specific reporting demands on the sub districts leading to considerable sacrifice in data quality. There was no central information management focus at the district level and the manual systems available lend themselves to duplications and serious under reporting and errors in calculations. It was also observed that the scope of data collection at the district level was not optimised leading to a very low contribution of the routinely collected data at the district level in determining the performance of the sector. To improve the situation a “platform” for the collation of reports at the district level was introduced through the District Health Management Information System. It was also to enhance the management of data generated and the reports required to be produced by the districts. It also looks at improving the scope of use of the information generated as a result for decision-making. Two key tools have been developed for the purpose. A “Decision Support Manual” to guide the interpretation and presentation of the routinely collected data at the district level and a “District-Wide Computer Assisted Information Management System” to facilitate the management of reports to the districts and reports required of the districts. Twenty districts (two from each region) were selected to pilot the system. As part of the efforts to develop the systems for data collection, a study was conducted to map out the architecture of a comprehensive health information system in Ghana. The study provided a comprehensive picture of the structure of the health sector information system and described the linkages and processes in health information management in the health sector. Although this study provided a clear picture of the components and layers

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of the health information system, it did not provide insight into the challenges related to the content and processes for information management. What the study made clear, however, was the scope of work required for a functional comprehensive information system. The Health Metrics Network Assessment In 2007 a further assessment of the health information system was undertaken using an assessment tool developed by the Health Metrics Network. The comprehensive assessment covered the six components of the HMN framework, which are Resources, Indicators, Data Sources, Data Management, Information Product and Dissemination and use. The following were the main findings: 1. Multiple information systems exist in the health sector. These systems do not

communicate with each other in data redundancy, duplications and inconsistencies amongst the various information sources. Access to information remains inadequate as a result of the lack of coordination.

2. The Ministry of Health has not established formal links to sources of information

outside the health sector. There are regular and irregular communications between MOH, GHS, donors, academia and GSS, but there is no inter-agency coordinating mechanism for health information. Overall performance of HIS is dependent on abilities of individual managers rather than corporate needs.

3. The policy and legal framework for the health information system is weak, there

is no national plan for health information and no national data repository. 4. Human resources availability and capacity at all levels are low. People with

advanced skills in health information are very few and Districts do not have formally designated health information officers.

The assessment also highlighted the limited capacity for effective HIS planning, implementation, monitoring and evaluation. It was observed that the absence of an updated strategic plan to guide the overall development and implementation of a sector-wide health information was a major contributory factor to the slow progress in developing systems for managing health information in the sector. The culture of information use throughout the health sector stood out as a major challenge. Although capacity for core health information science exists, these are mainly found in the tertiary institutions and their services are not easily available to the health sector. This is as reflection of the lack of collaboration between the health sector and the training institutions, an issue that needs to be addressed from a strategic point of view. Although several steps have been taken to improve the quality and use of information through the annual performance hearing and review systems. The need to improve compliance to provisions for data reporting across board and for a medium to long-term strategy to build capacity and to strengthen systems for information was seen as urgent.

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The chart below summarises the key findings of the assessment.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Dissemination & use

Information products

Data management

Data sources

Indicators

Resources

Not functional Not adequate at all Present but not adequate Adequate Highly adequate

Summary of HMIS Assessment using HMN Assessment Tool (2007) The findings show that the information system in the health sector has responded to demands of the annual review processes agreed on between health development partners and the Ministry of Health. It therefore showed significant strengths in the use of indicators and information products. It also showed that there were weaknesses in the policy environment and the capacity to manage data at all levels. A detailed analysis of the strengths, weaknesses, opportunities and threats will be found in annex one. Summary of HMIS challenges In all the reviews undertaken there are clear indications of specific constraints to Health Information Management in Ghana. Key among them are the following: Lack of a clear policy and legal framework for health information and health data

reporting. This has contributed to the incomplete reporting in the health sector and the lack of data management structures within the private health sector.

The proliferation of data collection tools most of which are not used at the point of

collection and hence are perceived as not very relevant. Lack of systematic investment in the development of data management capabilities

within the health sector. Most investments continue to be programme focused and centred around the development of reporting systems based on specific indicators.

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The lack of requisite skills at the lower levels specifically the district in data analysis. An uncoordinated information collection system, which is overwhelmed by data

demands from higher levels with virtually no feedback and with poor linkages between the various systems for data collection leading to duplications.

The very little priority given to Data for planning and decision making at the lower

levels. New and Emerging Demands With the introduction of the National Health Insurance Scheme, a new demand is being made on the Health Information System. The nature of health information and medical records allows details of individual records to be captured as part of the overall statistics. The need to protect individual privacy as prescribed by the ethic of health care delivery becomes more challenging especially with third party involvement and the demands by schemes for mechanisms to prevent fraud. The challenge boarders on avoiding inaccuracies in the information or its improper disclosure as this can lead to problems in the contractual arrangements for service delivery. The proposed use of citizens’ identification numbers that will be used for all individual transactions raise concerns about patient privacy since it has the potential to facilitate linkage of a wide variety of personal identifiable information. Data demands in response to changing health partner funding mechanism have become very significant. There has been the need to show more precisely commensurate achievements and benefits to vulnerable groups in particular based on partner investments in the health sector. The Ministry of Health is also under severe pressure to demonstrate progress towards the achievement of the MDGs and to ensure that both multilateral and bilateral donors can show how their contribution to the health sector has helped in health development. However despite these demands, performance is grossly under reported with notable exclusion of key providers in the private and quasi government sectors. Developments to improve information management also lag behind other sector improvement activities and the whole culture of information generation and use remain under developed. The new health policy also makes new demands on health information management. With its focus on health outside the hospitals and clinics, new ways must be found to capture health and health related data to demonstrate progress being made in meeting the objectives of the policy. This requires a reclassification of what constitutes health care structures and activities and mechanisms to assess cross sectoral involvement in health. It also requires that efforts must be made to enhance behavioral change strategies through more targeted information dissemination activities.

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The Purpose of this Plan The purpose of this strategic plan is to guide address the guiding principles outlined in the collection, storage, analysis and dissemination of health information in Ghana. It is also to provide strategic directions and, at a high level set out a systems implementation and integration plan that will be required to support clinical and management decision-making. The strategic directions relevant for the medium term are:

Improving access to health information by ensuring that the right information

is available to authorized users at the time and place where it is needed to enable effective clinical and management decision-making.

Improving quality of health information by providing information that has a

high degree of consistency, accuracy, timeliness and completeness. Supporting decision making by providing appropriate information that

facilitates knowledge-based decisions in order to effect change in individual behaviour, patient care, administration, research and education and to monitor and measure health outcomes.

Key Stakeholders Individuals, families patients and all those who receive health care services in Ghana and advocates for better health and healthier living are the primary stakeholders in the efforts to develop the health information system. For them the need to provide information to empower them to make the choice for healthy lifestyles and to seek the right services at the right time will be central. Communities, District Assemblies, Corporate entities and agencies within the health sector as well as outside the health sector are seen as major consumers of health information in the bid to facilitate collaboration in meeting the general health needs of the society. In this context, the important role of women’s groups and other community structures will be the target for health promotion and prevention information while corporate entities will be used to expand the scope of health care services in the country. Health care providers, health managers and allied practitioners and service providers will drive the content of health information and will be the main users for health care and management decision making decision. As stakeholders they will be critical in the standards for good quality and reliable health information and for ensuring better health outcomes as a result of available evidence for decision-making. Health development partners will play a role by using information generated by the sector as the basis for advocacy, resource mobilisation and sector support. By improving the sector’s capacity to demonstrate performance in more precise terms it is expected that the position of partners will be strengthened in their role as donors as well as ensuring that their core principles and objectives are met.

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The Vision All decision making in the health sector at all levels are informed by information resources that are accurate, timely, relevant, complete, concise and readily accessible. This vision will be realized when:

District Health Management Teams are able to assess the health needs of the target population and efficiently allocate resources to meet those needs, manage and monitor the use of the resources including human resources, set targets and monitor achievements in the area of service coverage and quality of care.

Reporting mechanism provides relevant sector wide information on time to assist

decision-making, demonstrate sector wide performance to support resource mobilisation.

The health sector can measure precisely the state of health of the population,

utilisation of health services and performance of the health sector towards meeting the MDGS.

The realization of this vision will also help the Ministry of Health and its agencies to contribute to the improvement of the health status of Ghanaians by improving capacity to plan and implement health interventions, reduce ineffectiveness and negligence in health services thereby improving quality and maintain credibility in the health sector by rationalising inputs into the sector and service output resulting from them. The Ministry of Health will also be able to obtain or renew funding for the health sector by providing the rationale and the basis for financial requests, motivate staff through feedback, encourage community participation by analysing performance in the context of user perspective and contribute explicit measures of performance to programme and policy reviews. Guiding principles The key principles guide the pursuit of the vision and to define how information in the health sector in Ghana will be gathered, managed and shared are:

Content and systems for managing health information will be people centred and driven by the health needs of the country.

Personal privacy and confidentiality will be ensured through legal and procedural

mechanisms that ensure clear distinction between medical records and health data. Information collection activities will be structured to support front line health

workers.

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Information security will be guaranteed through data and information protection and accountability for personal health information.

Access to health information will be assured through a seamless and secure flow

of information between authorized users in the health sector. Information will be collected once and used across the health system.

Information management principles of accountability, competency, value for

money, economy, integrity, sharing, exchangeability, compliance, business continuity, privacy, copyright and intellectual property will remain fundamental to HMIS initiatives and operations

HMIS Goals and Strategies The overall goal is to make reliable health information available for decision-making. Embedded in this goal is the need to enable evidence-based decision-making in clinical and management settings by information resources that are accurate, timely, relevant and complete, concise and readily accessible Strategic Objectives All the initiatives planned for the medium term are aimed at four specific objectives. These are to: 1. Improve the environment for health information management 2. Improve capacity for managing health information at all levels 3. Improve quality of information generated by the health sector and 4. Improve the use of information for decision-making These objectives are based on the weaknesses identified in the assessment of the health information system and related to the recommendations of other reviews that have taken place in the area of health information management in the health sector. Improving the Environment for Health Information Management

The Problem Of all the HMIS challenges in the health sector what stands out as a major issue is the lack of premium placed on information gathering and management activities. The nature of health information and medical records allows details of individual records to be captured as part of the overall statistics. The management of this primary source of information is a challenge since issues of privacy and reporting obligations need to be spelt out clearly. Particularly under the National Health Insurance Scheme, rights of patients and rights of schemes to information will need to be balances in such a way that the guiding principles outlined are observed.

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Information in the health sector is scattered. This is due to the way in which the sector functions. There are several service delivery points and management setups each with several transaction points. These are found at different levels and may belong to the public, quasi government or privately owned. The diagram below provides a bird’s eye view of the architecture and systems components.

Other agencies & organizations

Pharmacy councilNurses & Midwives council

Agencies and relevant organization system

Medical & Dental council

Quasi-Gov. hospitalsPrivate facilities

CHAG institutionsTeaching hospitals

Hospitals / clinics system

Public facilities

GHS DHA

Centralized health service support system

GHS RHA

Centralized health service support system

GHS HQ

HMIS ARCHITECTURE AND COMPONENTS

System component System function

Drugs and supplies logistics

Health sector administration and management systemPolicy planning, monitoring, evaluation

(Information analysis, performancemonitoring, policy formulation)

Resource management(HR, Finance, Estate,

Transport and Equipment)

Agency / organizationoperations

Local administration& management

Clinical service

Monitoring & evaluation

Public health & outreach services

Information management

Surveillance

Resource mgmt. (HR, finance, others)Information management

Local administration& management

Information management

Sector wide health information management systemVerification

Health information exchange network platform (electronic transmission / manual submission)

Dissemination

MOH administration andmanagement system

Local administration& management

Informationmanagement

Validation

Each of the components and layers outlined above generates information that supports decision making at that level as well as contributing to the sector-wide information management system. The challenge is that in almost all cases the information produced is incomplete because one component or another fails to contribute. This is especially so with respect to private and quasi government providers. As the diagram portrays, there are multiple entities that play an important role in defining the health information landscape in Ghana. The diversity of participants in the healthcare industry and the complexity of their relationships with each other have frustrated the voluntary adoption of common standard across the sector to help in the collation of data relevant to the health development.

Developments to date A number of individual policies have been developed in this direction. In collaboration with the Ministry of Information and Communication a policy on Information and Communication Technology for the health sector has been developed to guide investments in ICT in the health sector. The law establishing the National Health Insurance Scheme also makes specific demands on reporting in the context of the claims management.

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Under the SWAPs the sector has been under continuing pressure to report on performance based on the Sector-wide Indicators. The Five Year Programme of Work and the Annual Programmes make a clear demand on each management unit to report. However this largely excludes the Private Sector, NGOs in Health and other quasi government institutions generating health information. The existing problems are therefore summarised as:

Incomplete reporting making it difficult for precise measurement of performance Lack of investments and organized structures for information management within

the private sector Weak coordination mechanisms in support of data collection and health

information management at the district level leading to weak data/information audit trails

Strategy for the Medium Term 1. Enhance the policy and legislative environment for the development of Health

Information Systems in the country through: a. The development of a policy and legislative framework for health and health

data reporting. This will include guidelines for: Organisation of data collection systems and components at the district,

regional and national levels Minimum infrastructure requirements for the establishment of information

management units in health facilities and other health care providing organizations.

Specific reporting requirements by type of health care organization Guidelines on reporting and disclosure of health information Third party responsibility for health information management

b. Review laws on statutory reporting in accordance with the Commonwealth Privacy Act, 1988 and other emerging demands specific to Ghana.

2. Development of standards for guiding the content of health information which

will include : a. The developing a Medical Records Policy as a standard for all sectors

including the private sector b. Development of Manual for Medical Records Management

3. Improve the coordinating mechanisms for health information management by: a. Transforming the Information, Monitoring and Evaluation working group of

the Ministry of Health into a more functional and formalized inter-agency working group on Health Information that includes representatives from the Ghana Statistical Service, Births and Deaths Registry of the Ministry of Local Government and other relevant stakeholders.

b. Strengthening interagency coordinating framework by enhancing role of interagency working groups to provide oversight responsibility for information management in specific areas.

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Expected Results The implementation of these strategies will lead to the development laws on health reporting with clear responsibility for the establishment of structures for health data collection, reporting linkages and sanctions for non-reporting. it will also improve the completeness of reported data in the health sector. Improve Capacity for Managing Health Information at All Levels

The Problem Capacity in Health Information Management encompasses the skilled manpower and the technology support needed to facilitate the collection, storage, analysis and dissemination of health information. It deals with the resources, devices and methods required to optimize the acquisition, storage, retrieval and use of information in health. It includes include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems. Over the years the investments in this area have been uncoordinated, sparse, lacking a strategic approach in its implementation and in most cases focusing on the procurement and deployment of computers. The absence of key standards such as manual for data management and a systematic development information management capacity has contributed in large measure to the weak capacities available particularly at the district level and below. In many instances grossly unqualified personnel are made responsible for the management of data in health facilities. Most Medical Records Assistants have not received formal training in data management and yet are responsible for the collation of health statistics. The end result is that capacity for generating good health information has remained weak.

Developments to Date Development in capacity building has focused on the establishment of the training programme for middle level health information officers. However at the current rate it will take about eighteen years to produce the required numbers for effective management of health information. Consequently some steps have been taken to recruit HND graduates from the polytechnics. Although this approach has a number of institutional challenges it has provided encouraging results for now. Investments in technology have however seen no strategic improvement apart from the deployment of hardware. The current drive by the National Health Insurance Scheme to deploy Information Technology to support the operation of the schemes at the district level is seen as a promising development and will provide the spine for launching an enhanced electronic reporting capacity between districts and the regional and national levels. These developments notwithstanding there are some existing challenges to be met. These are:

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Low human resources availability and capacity for information management at all levels.

Very limited capacity in terms of people with advanced skills in health information.

No establishment for the placement of district health information officers. Low computer and information technology density Non availability of standards and formalized procedures for information

management Strategy for the Medium Term

1. Develop a human resource management strategy for Health Information Manager

by building information management skills and promoting career development and education.

a. Review systems for production by reviewing training plan and intake for the production of Health Information Officers at the KRHTI

b. Design and implement top-up programme for polytechnic graduates c. Create establishment and define career progression for Health Information

Officers 2. Foster a consistent and coordinated approach to information management in the

by establishing corporate standards, practices and tools that reflect the diverse needs of information management units and communities.

3. Build awareness and understanding of and commitment for information management by staff at all levels.

4. Enhance knowledge management by providing information on best practices and information that will improve health care knowledge.

5. Effectively leverage technology for the delivery of health care and the management of health services through the intense application of ICT in the rural and peripheral areas and systematic improvement in investments to improve IT density in the health sector.

6. At the central level apply strategic resource planning for analyzing and reporting trends and predicting future system requirements, tactical resource management for maximum return on IT investment and quality reporting for service verification.

Expected Results It is expected that these strategies will lead to a marked improvement in the numbers and skills of officers responsible for managing health information at the district and regional levels while national level will have the services of highly skilled managers with the requisite analytical capacity. The information technology density will be increased and the deployment of IT will follow a systematic and incremental path, which will augment existing capacities in human resource and make them more efficient. Eventually agencies in the health sector

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will be using IT to move from post-processing of health care related transactions to on-line processing which actively intervenes in the health care process. Ultimately quality, timeliness and relevance of information provided will improve. Improve Quality of Information Generated by the Health Sector

The Problem Quality in this context is defined as improvements in the accuracy, validity and reliability of health information. This is essential in ensuring that information generated and analyses conducted actually describe in very precise terms the performance of the health sector and the observations being put forward. Under the National Health insurance Scheme, these attributes are essential in building credibility as it relates directly to the issue of claims and reimbursements. In almost all reviews the quality of health information has been questioned. The concerns raised usually have to do with duplications, inconsistencies and unclear standards for computation. In recent times the issue of population figures as the basis for calculating coverage raised several concerns. This can be seen as the result of the multiple information systems that do not communicate with each other. It is a common phenomenon to have different performance figures for the preceding year every month during the first half of the year. The problems has been identified as the lack of coordination in the information gathering processes, non adherence to standards and in many cases the absence of standards, lack of a platform for collation and obsolete data capture tools in some cases. There are also clear indications that some very robust systems exist but are not used in the mainstream performance analysis. Some districts for instance are collection and continuously updating data at Demographic Surveillance Sites but are not used for performance assessment while vital registration using community based registers remain under utilized as indicated by the low score on content and coverage of vital registration by the HMN assessment. Birth and death registration remains a challenge especially in the rural and peri-urban areas. The recent population census figures continue to give inconsistent coverage figures within some districts based on errors in growth rates and the numbers of expected pregnancies. This has led to wide variations in coverage figures based on routine data and that of coverage surveys. The assessment also showed some weaknesses in the use of geographic information system as a means of presenting analysed data on the health sector.

Developments to date Several initiatives have been introduced to help improve the quality of data and the information generated. The most important being the introduction of the annual

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performance hearing sessions, which allow managers to present and defend their performance in a peer review context. The concept of authentic sources of information was also introduced to ensure that one source was used to report on selected indicators. This was mainly linked to programmes and specific units with responsibility for such programmes. Within the last three years, a computer assisted district information system has been introduced to manage all reports that come to the district as well as generate all reports required of the DHMT. The system is currently being scaled up and will be the only means by which districts and regions will report on service performance. These developments notwithstanding, several challenges exist in the bid to improve the quality of health information generated. These are summarised as follows:

The role of the Centre for Health Management as an engine for health sector data

management is still weak as a result of limited manpower, weak infrastructure and weak systems.

There is no functioning repository for data and health information. Standards for data collection, storage and analysis do not exist Although the performance hearings are conducted annually, the peer review

context remains weak and its use as a means of validating data has not been realised.

Strategy for the Medium Term

1. Strengthen mechanisms for data management through: a. The establishment of a Central Health Data Repository that consolidates

health data from all the sources and creates a platform for sharing of health data and other relevant data for decision-making.

b. Improvement of health information infrastructure to ensure that systems within the Ministry of Health and across agencies communicate with each other.

c. Review of existing reporting tools as part of the DHIM scale up and to limit paper based record repositories

d. Develop standards and level specific manuals for data management to improve the quality and consistencies of health information.

2. Review mechanisms for validating and improving data reliability by: a. Reviewing the performance hearing system and transform it into a

performance validation exercise 3. Explore more strategic use of Demographic Surveillance Sites for reporting on

selected and multidimensional indicators. 4. Strengthen Vital Registration as part of the CHPS programme and adopt it as part

of the routine reporting system. 5. Determine and agree on a more structured use of District Coverage Surveys as a

means of validating coverage of selected interventions 6. Introduce the concept of benchmark reporting

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Expected Results It is expected that the implementation of these strategies will lead to a vast improvement in the accuracy, reliability and timeliness of health information generated in the sector. Ti will also clarify the mechanisms for validating data and hence remove problems of duplication and inconsistencies. A marked improvement in access to data at the central level is expected and support for in-depth analysis will be facilitated. Improve the use of information for decision-making

The problem Evidence based decision making is currently central to the sectoral initiatives for improving performance. The use of information generated to develop or review operational policies, review service delivery strategies and for resource mobilization have remains the focus of information generation activities in the health sector. However, as shown by the HMN assessment there is a general weakness in the use of information for planning and programme implementation at the local level. The use of information is currently largely within the context of the annual review process. Most of the development in this area can be linked directly to the annual review process. Making informed decisions requires the extensive use of information at all levels. However studies have shown that within the health sector the capacity to use information is very minimal and the current information system consist mainly of the transmission of raw data. Data collection is also flawed with inaccuracies and much of the information collected is not used even at the point of collection. In a number of cases analysis and use has been reduced to very simple manipulation of data that offers very little information for decision making.

Developments to Date The efforts to improve the use of information have been limited. In addition to the overall efforts at improving data management, some progress has been made to streamline the overall reporting and feedback system. A decision support manual and a benchmark report have been produced but this is yet to be extensively disseminated and used as the basis for improving data analysis. It is also limited to the national level and has therefore not been of much benefit to data managers at the district level. The production of health bulletin to stimulate the use of local information was also initiated however this was suspended due to sever lack of patronage in terms of contribution by health staff. Presently other methods for dissemination of information forms are being used. The Ministry of Health website has been activated and the production of policy briefs has started. Improving the use of information for decision making is still a pressing issue in the health

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sector. This is shown by the: Low level of the culture of use of information for self assessment at all levels with

managers reporting on performance as an end in itself. Continuing use of redundant indicators with very little scope for indicating

performance Lack of geographically linked reports to support health action at the local,

regional, and national levels. Strategy for the Medium Term

1. Improve skill of health managers for data analysis through continuous training in: a. Data analysis and interpretation b. Scientific writing through the organisation of writers workshops

2. Improve the use of multi-dimensional indicators to demonstrate sector performance and to encourage better appreciation of the use of data through collaboration with the School of Public Health

3. Increase access to health sector information by: a. Building on the Ministry of Health existing web presence by offering greater

opportunities for public involvement, understanding, and participation in shaping health policy.

b. Exploring mechanisms for creating public awareness to assist Ghanaians in finding health information that is trustworthy and can support in behavioural change

c. Tailoring health information using mass media to different audiences and increase efforts to reach high-risk groups.

d. Integrating health information with other health services to support the management of emerging non communicable diseases

4. Develop system-wide methodologies for the sharing of health systems planning information. a. Establish one Ministry portal where aggregate health data is collected and

reported. 5. Develop a national strategy for wider implementation of telehealth initiatives 6. Promote wider use of video conferencing for medical and health care consultation

and continuing education. 7. Develop system-wide repositories, directories and inventories for use by health

system stakeholders. 8. Promote Best Practices and explore the wider use of tools such as Internet, health

bulletins and information leaflets to support the sharing of knowledge assets and information on best practices

Expected Results The strategies above will lead to increase in volume of documents, articles and other papers developed by health workers. It will also increase access to information thereby stimulating use and encouraging information sharing. The culture of writing will improve as well as the number of health workers with minim writing skills.

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ANNEX 1 SWOTH ANALYSIS OF THE CURRENT HEALTH INFORMATION SYSTEM RESOURCES Policy and Planning Strengths

• HIS Policy has been developed and is being partially implemented • Coordination mechanisms between MOH and GSS established - meet

occasionally. • HIS monitoring system exists but needs strengthening.

Weaknesses • An outdated legislation exists • Outdated HIS strategic plan. • Poor implementation of legislation and HIS strategic plan • Non functional national committee on HIS coordination • No policy on promoting culture of information

Opportunities • Enabling environment with other stakeholders • International and national agreed targets MDGs, GPRS

Threats • Inadequate Funding • Competing priorities

HIS Institutions, Human Resources and Financing Strengths

• National capacity to meet health information needs exists. • Established systems for reporting • Availability of manuals and guidelines for data collection • Training of HIS officers is undertaken in-country.

Weaknesses • Limited availability of IT, HR and data base support • Inadequacy in numbers, limited capacity and high turnover of HIS staff • Inadequate resources

Opportunities • Evolving national ICT infrastructure • Development of a national ICT policy

Threats • High taxes on imports

HIS Infrastructure Strengths

• Regular up to date information on public/private facilities • Availability of basic communication infrastructure at most levels • Computers available for most managers at national and regional levels • Some equipment maintenance support exists

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Weaknesses • Inadequate Supplies and logistics • Poorly planned preventive maintenance

Opportunities • Evolving national ICT infrastructure • Development of national ICT policy

Threats • Power outages • High taxes • Funding

INDICATORS Strengths

• Minimum set of indicators well established and in use for the past 10 years. • Established systems for selection and review of relevant indicators for measuring

the performance of the health sector exist. • Clear manuals and procedures for reporting on core indicators by each level exist

Weaknesses • Core set of indicators not entirely comprehensive. Some programmes not reported

on as part of the annual review process • Unpopular programmes may be left out of the monitoring

Opportunities • Demands through global initiatives to report on core set of indicators periodically • National development Planning Commission (NDPC) request information on core

set of indicators periodically for planning and research purposes • Different surveys such as QUICK, MICS, SAM, recognize the need for core set of

indicators and attempt to measure some thus increasing reliable information on them.

• The health sector has agreed on multiple data collection mechanisms such as administrative, surveys and special studies for routine collection of data thus improving the scope of indicators and the frequency of assessment

Threats • Quests/Demand for comprehensiveness may lead to an extremely tall list of

indicators • Demand and Manipulation of data sets by donors. • The indicator list can be manipulated by influential partners and donors.

DATA SOURCES Strengths

• Availability of adequate data • Capacity exists in terms of Infrastructure and human Resource • Strong Government commitment • Legislation in place for vital statistics • Incentives exist for birth registration. (Free up to 12mths)

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Weaknesses • Problem with analysis of data at locality level • Poor coverage • Inadequate personnel • Inadequate logistics • Poor coordination between DSS sites and VRS • No incentives available for registration of deaths • District level estimates are unavailable • Low private sector contribution • No legal compulsion • Lack of vertical and horizontal feedback • Lack of human resource to update database • Inaccessibility of data

Opportunities • High demand for output. (Donor, private sectors and the public at large) • Collaboration between CBVS and BDR • The evolving National Identification System • Involvement of faith-based association and traditional leaders

Threats • Non retention of qualified staff • Very costly • Funding • Lack of awareness • Cultural and religious belief and practices • Non enforcement of law • Non retention of qualified staff

DATA MANAGEMENT Strengths

• Technical Capacity for data management exists at the national and regional level. • Guidelines procedures and manuals to assist in the management of data have been

developed and tested. • Training and placement of health information officers now institutionalized • Existence of a centre for health information management

Weaknesses • Proliferation of data collection tools countrywide • Lack of data management skills at the lower level • Lack of functional data repository at national level. • Uncoordinated data collection systems due to data demands from higher level and

donors • Little use of data for planning at the lower level.

Opportunities • Increasing demand for quality data under the national health insurance scheme

and the annual review process.

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• Decreasing cost of data management equipment such as computers, leading to increase in computer density.

• Improved national communication infrastructure leading to increase use of electronic data transmission.

Threats • Excessive dependence on Information and Communication Technology without

requisite attention to working manual systems and human resource capacity building.

• Increasing external demand for data management staff. (Brain Drain) • Bureaucracy in recruitment of requisite staff for data management.

INFORMATION PRODUCT GROUP Strengths

• System in place to capture data in the public sector • Adequate trained health personnel supported by a cadre of CBSVs (Human

resource) • Regularity and Access to Demographic Health Surveys Data • Training of more Health Information Officers to fill the Information Officers gap. • Improved ICT to enhance data management and dissemination • Annual performance review system in place

Weaknesses • Poor data or information sharing and dissemination • Capacity for data analysis at the periphery is poor • Validation of Data not done • Weak coordination and collaboration among programmes and units • Lack of Programme ownership-donor support • Limited utilization of ICT facilities • Inadequate GOG funding for data collection and management • Lack of legal framework for reporting on HIS

Opportunities • Large No. of Health partners interested in Data Management • Limited utilization of ICT facilities • There is commitment to monitor the progress towards the achievement of MDGs.

This is an • Opportunity to strengthen the HIS with assistance from partners • Opportunity to Integrate resources • There are programmes with resources that can be utilized more efficiently • Political and Social stability creating enabling environment for work

Threats • Political and Social stability • Donor driven programmes and projects establishing parallel data management

systems (indicators etc) • Better job opportunities outside attract trained health workers

DISSEMINATION AND USE

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Strengths • Good reporting of set of core indicators • HIS information is largely used for annual health sector reviews • There is continual demand from health policymakers (e.g. program managers,

directors etc.) for good quality and timely health information Weaknesses

• The availability of information is untimely • The presentation of health information is not adequate ( e.g. mostly facts sheets,

presentations not adequate etc) • HR capability for analysis is weak • Inadequate information sharing to influence decision making among stakeholders • Fragmentation of data (Interoperability?). No common platform • No standard forum for information dissemination. Weak coordination

Opportunities • There is continual demand from stakeholders (DP, DA, NDPC etc) for good

quality and timely health information • Interest exists among the media and politicians regarding health information

Threats • Policy and planning not linked to HIS therefore • Resource mobilisation remains a challenge • Misinformation in the absence of dissemination

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