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Given the complexity and diversity of the NHIS components within the health sector, a comprehensive assessment could not be always possible. According to the extension of the planned NHIS improvement, the assessment could cover the whole nationwide system or focus on its specific components (administrative, technological and functional), or some specific information systems (such as the environmental information system).

For each information system, the focus should be placed on the key components, relevant phases of the management and operation (specially the productive process). In case of a nationwide HIS covering different regions with similar structure and performance, then a geographical area can be

explored (a conventional samples); this option assumes that the NHIS has similar characteristics and critical problems in all areas of the country (Sapirie, 2000).

The assessment should be guided by its primary purpose: to provide a descriptive analysis of the level of organization, structure and performance of the NHIS, followed by the analysis of critical aspects, gaps and needs, to produce a diagnostic of the situation, with conclusions and recommendations aimed to orient the NHIS planning and improvement.

Publication of guidelines for integral NHIS assessment is not frequent in the literature, as the use of pre-defined methodologies and successful methods is not usually disseminated (Gissler at al, 2006). However starting in 2005, the Health

Metrics Network Initiative (HMN, WHO 2005) has been supporting countries with framework and analytical tools for NHIS broad assessment.

The preparation of the assessment includes the development of the methodology and tools (if no method is available), the plan and the necessary organization and training to carry out the assessment. The assessment should include a descriptive NHIS diagnostic, followed by the measurement on the availability and quality of organization, resources, processes and results. This will provide elements for the analysis, interpretation and recommendations.

Main phases of the assessment process are:

x Defining the NHIS components and specific elements or systems to be assessed;

x Planning and preparing the assessment, with the instruments for collecting and measuring information;

x Collecting the information: x Document and data collection x Observation

x Fact finding interviews

x Accreditation review (tracking)

x Documenting clinical and administrative procedures

x Information workflow guide; x Gap analysis

x Overall analysis and interpretation;

x Consolidation and validation of initial conclusions and recommendations.

x Development of assessment report (M. Courneene, 2007)

Some tools can be prepared and used (if available) to support the assessment:

x HMN situation analysis tool (HMN, 2005b) and document and data analysis guides (to explore state of HIS-related documents, data and sources of information);

x Interview templates (for fact finding);

x Use cases guide and workflow templates, for tracking clinical, administrative and documentation processes;

x Gap analysis guides and templates

Periodical repetition of the NHIS assessment will provide the basis for monitoring and evaluation, to ensure a successful improvement process.

Planning and preparing the assessment includes: x Preparing the methods, guides and tools, through

using, adapting or creating suitable assessment instruments;

x Defining the expected results or objectives, components to be assessed, resources, steps, budgets and timetable;

x Establishing the terms of reference of key participants and contracts (in case that hiring external support is needed);

x Defining the details of the process;

x Getting resources, financial, political and institutional support;

x Organizing and training the personnel who will participate.

Collecting information is a critical phase and depends from the structure ands processes to be assessed. Instruments for collecting information could include templates, questionnaires (as based on the orienting questions suggested in this chapter), tables providing categorical values to critical aspects to be observed (such as a scale between 0 and 5 for the level of training observed in specific staff).

Collection of information could involve internal or external staff in places where data will be collected. Costs and efforts will depend on the extension of geographical areas, components and units that will be under assessment.

In the assessment of the functional component (management and production of information), it is important to involve key staff and representatives of the various groups of personnel participating in the management and production of information, at

different levels, offices and specific information systems. Also, it should be important to have the perspective of the users, specially the personnel in decision-making positions.

The analysis and interpretation of finding is supported by the material and information collected. Findings provided by the description and measurement of the NHIS components can be analyzed in terms of organization, structure, performance, gaps and needs for improvement. The answers to the orienting questions suggested below in this chapter should provide an analytical view of the NHIS and critical aspects to be developed or improved.

Final interpretation of results implies the comprehensive analysis of the NHIS findings, with plausible explanations for internal or external causes of limited development, performance or integration of the NHIS, including causes of gaps and needs detected.

Initial conclusions and recommendations, based on antecedents collected as well as observation and interviews, can be validated trough consultative meetings to discuss initial report, with concurrence of all those who either provided key information or will apply the assessment recommendations to further NHIS improvement. It is important to have the feedback and opinion of decision-makers, as key users of information.

The conclusions, based on main findings, and the recommendations should become a practical orientation for planning, developing and improving the NHIS.