Presented for an AeHIN webinar by MEASURE Evaluation's Theo Lippeveld and Hemali Kulatilaka.

1. Strengthening Country Routine
Health Information Systems (RHIS):
Strategicapproachesby
theMEASUREEvaluationProject
Theo Lippeveld, MD, MPH
MEASURE Evaluation / JSI
tlippeveld@jsi.com
October29, 2015
AeHIN Conference, Bali

2. Presentation overview
• Routine Health Information
Systems (RHIS)
 Importance in current health
system strengthening
• MEASURE Evaluation and RHIS
strengthening: Strategic
approaches
• AeHIN and RHIS: the way forward

3. Why are routine health
information systems so
important?

4. The Good News:
New Opportunities in Global Health
• Consensus building on Global Health strategies and health
system strengthening by Initiatives such as the International
Health Partnership (IHP+) and the Sustainable Development
Goals (SGDs)
• Recently spectacular increases in money flows (GFAMT,
PEPFAR, Gates, etc.) to address priority infectious diseases
(HIV/AIDS, TB, malaria, etc.)

5. The Bad News:
OLD Constraints in Global Health
• The human resources crisis
• Limited absorptive (financial) capacity of most LMIC health
systems
• Bureaucratic sclerosis versus corruption
But most of all:
• Fragmentation of the health system at various levels
continues to threaten sustainable improvements…

6. Fragmentation:
Example from SCM/Kenya

7. Parallel or “Stove-pipe” Health
Systems
• Most “stove-pipe” systems are disease-based and donor
driven (visibility)
 Presidents Emergency Plan for AIDS Relief (PEPFAR)
 Roll Back Malaria (RBM)
 Stop TB
 Global Polio Eradication Initiative
 Global Alliance for the Elimination of Lymphatic Filariasis
 Etc.
 Setting up parallel management systems (for HR, for supply
chain, for service delivery, for health information, etc.

8. As a Result:
Inefficient Service Delivery Systems
• Co-coverage study of 8 essential interventions by Cesar
Victora et al (Lancet, 2005) in 8 countries (DHS data)
 DTP, BCG, Measles, TT, Vit A, ANC, skilled delivery, safe
water supply
• Showed that in low-income countries less than 5% of
households have access to all these interventions at the
same time

9. Looking Forward
How do you build integrated health systems?
• Conditions for building integrated health systems (“Towards
Unity for Health”, Phuket, 1999)
 Organizational models for supporting coordination and
integration processes
 Focus on a reference population and a defined
geographical area in the context of a decentralized
health services system
 Need for a comprehensive health
information system

10. How to Build a Comprehensive HIS…
• Develop and reinforce a National Long Term Strategic Plan
for the development of integrated HIS, including all data
sources
 Health Metrics Network (HMN) framework and tools
(2005)
• Focus on performing district-managed and denominator-
based routine health information systems (RHIS)
 PRISM framework and tools (2008)

12. Country Health Information System (HIS)
Administrative
records systems
(NHA etc.)
Services
records
systems
Individual
Records
systems
Pop based
surveys
Vital
registration
Census
Population-based
data sources
Health Institution
based data sources
* HMN Framework

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

15. RHIS subsystems (jargon)
Individual Record Systems (facility and community-based)
Paper based records
Electronic Medical Records (EMR)
Service Record Systems
Health Management Information Systems (HMIS)
 facility and community-based (CBIS)
Disease Surveillance Information Systems (IDSIS)
Health facility assessments (HFA) = hybrid
Administrative Record Systems
Financial Management Information Systems (FMIS such as National
Health Accounts - NHA)
Human Resource Information Systems (HRIS such as iHRIS)
Logistics Management Information Systems (LMIS)

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

17. Unfortunately……
Routinehealthinformationsystemsinmost
developingcountriesarewoefullyinadequate
toprovidetheneededinformationsupport...

18. What is wrong with existing routine health
information systems?
• Irrelevance, plethora, and poor quality of the data collected
• Centralization of information management without
feedback to district and service delivery levels
• Fragmentation into “program- oriented” information
systems: duplication and waste
• Poor and inadequately used HIS and ICT infrastructure and
resources

19. As a result…
• Poor use of information by users at all levels: care providers
as well as managers
• Reliance on more expensive survey data collection methods,
but the findings are relevant only to national and global
levels

20. So the question is not…
Where can we find other data sources (since
RHIS cannot provide the information)?
But rather…
How can we improve the RHIS performance in
support of planning and management of
quality district health systems?

21. Some of the lessons learned
• Need for well defined RHIS performance criteria:
 Production of relevant and quality information
 Continued use of information for DM at all levels
• Empirical evidence shows that availability of quality
information does NOT NECESSARILY mean that is it used for
decision making
 Need for broader “system” thinking
 Need for better understanding of factors influencing RHIS
performance
 PRISM framework:
Performance of Routine Information System Management

22. 2008: PRISM Framework for Understanding Routine
Health Information System Performance
Behavioral
Determinants
Knowledge/ skills, attitudes,
values, motivation
Improved Health System
Performance
Improved Health
Outcomes
Technical
Determinants
Data generation architecture
Information/communication
technology
Desired Outputs
= RHIS performance
•good quality information
•appropriate use of information
Inputs
RHIS assessment,
RHIS strategies
RHIS interventions
Organizational
Determinants
Information culture, health system
structure, roles & responsibilities,
resources

23. PRISM: Major Breakthrough in RHIS
Strengthening
• PRISM allows for measuring RHIS improvements:
baseline-endline
• PRISM allows to identify factors that can influence
RHIS performance and to develop action plans

24. Examples of Factors Influencing RHIS
Performance
Technical factors:
• Business architecture
• Information system architecture
• Information/communication technology
Organizational factors:
• Information culture
• Health system structure
• Roles and responsibilities
Behavioral factors:
• Knowledge and skills
• Attitudes, motivation
Key level system conditions:
• Availability and management of resources

25. PRISM Assessments After 10 Years of
Experience
• Widely used by more than 25 countries
• Tools downloaded > 5,000 times
• Have been the starting point of massive RHIS reform
efforts
• Have been used for evaluation of the effectiveness
and efficiency of the reform efforts
• Currently MEASURE Evaluation is revising the tools
based on lessons learned and best practices

26. To Further the Cause of RHIS and Their
Support towards Integrated Health Systems…
… need for advocacy
• System strengthening interventions take time: usually a minimum
of 3-5 years
• Lack of visibility as compared to vertical disease interventions
 Fight against the common mindset: “RHIS do not work”
 Advocacy network: RHINO

27. RHINO
Routine Health Information NetwOrk
• Global network of organizations and professionals concerned with
improving the quality and sustainability of RHIS in developing countries
• Created in 2001 with funding mainly through USAID (MEASURE
Evaluation)
• Independent NGO with 501-C-3 status since 2007
• Currently 1,000 + members from 60+ countries
 Ministries of Health
 Bilateral and multilateral donor agencies
 Consulting agencies and NGOs
 Functions: Advocacy and Knowledge Management
 Activities:
 Website
 Forums
 Bibliography
 International conferences
• Website: www.rhinonet.org

28. RHIS in the Spotlight:
M&A for Health Summit in June 2015
• Finally increased interest in strengthening RHIS
 Effect of 15 years of RHINO advocacy?
• Call for Action:
 Maximize effective use of the data revolution, based
on open standards, to rapidly improve health facility
and community health information systems, including
well-functioning disease and risk surveillance systems,
and financial and health workforce accounts

29. MEASURE Evaluation IV (2014-2019)
joined the (R)HIS battle

30. Phase IV Results Framework

31. MEASURE Evaluation TOC:
Pathways for improvement of RHIS performance

32. MEASURE Evaluation RHIS Strategic
Approaches
1. Assist countries to coordinate and collaborate in
complex multi-stakeholder RHIS initiatives
2. Strengthen RHIS governance and strategic planning
and management structures
3. Regionalize capacity building for RHIS organizations
and individuals
4. Establish regionalized RHIS advocacy and knowledge
management (KM) networks
5. Commission and/or undertake research on key RHIS
issues

33. RHIS Strategy Phase IV:
Decentralization and Regionalization
• Need for contextualization of RHIS capacity
building, advocacy, and knowledge management
• Getting RHIS users at country levels more involved
in capacity building, advocacy, and knowledge
management
• Establishment of regional networks for RHIS
advocacy and KM

34. PROPOSAL:
Creation of RHIS subgroup under AeHIN
• AeHIN has wide coverage and active participation
by Asian countries from east to west
• AeHIN is well supported by various donors and
centers of excellence in strengthening health
systems and health information systems
• AeHIN plays an important role in introducing
appropriate information and communication
technology (ICT)
• Several countries with intensive RHIS reform efforts
in the past decade: Bangladesh, Cambodia, India,
Pakistan, Philippines, etc.

35. Proposed role of AeHIN RHIS Network
• Sharing between member countries of lessons learned
and best practices on all aspects of RHIS strengthening
• Need for consensus building on RHIS and ICT standards
and strategies and on way forward
• Participate in review and revision of RHIS training
curriculum and materials
• Organize advocacy and knowledge management
interventions (mainly via virtual media)
• Revisit state-of-the-art on RHIS strengthening and
participate in RHIS research activities

36. The Way Forward
• Discussion session scheduled at the AeHIN 4th
General Meeting in Bali on October 29-30, 2015
 Vision and mission – goals and objectives
 Members and membership criteria
 Management
 Interventions: development of action plan

37. RHIS Strengthening Mission
ToundertakecarefulassessmentofRHIS…

38. RHIS Strengthening Mission
…insearchofappropriate(?)solutions

39. THANK YOU !
Questions?
Please go to:
www.measureevaluation.org

40. MEASURE Evaluation is funded by the U.S. Agency
for International Development (USAID) under terms
of Cooperative Agreement AID-OAA-L-14-00004
and implemented by the Carolina Population Center,
University of North Carolina at Chapel Hill in
partnership with Futures Group, ICF International,
John Snow, Inc., Management Sciences for Health,
and Tulane University. The views expressed in this
presentation do not necessarily reflect the views of
USAID or the United States government.
www.measureevaluation.org