The HIS in Rwanda included a variety of computer based systems. The country had deployed functioning computer systems for the health sector
nation wide, and were developing their computer HIS further every day. Network coverage was country wide, allowing for Internet based systems in even the most remote regions.
Most systems performed their own specific task, and the people working with them usually only used one of the systems, especially if it was on the lower levels of the health sector. Most of the time the systems were self-contained, and performed its specific task without connecting to other systems. The systems were implemented using a variety of softwares, most of which were generic Open Source tools which allowed you to design and make use of the functionality you needed. The softwares were specialist in each their particular area like for example aggregate data collection and analysis, individual patient records, human resources, or registry functionality.
DHIS 2 was the main software being used for aggregate data collection and was also covering individual records in the field of tuberculosis treatment. Data managers in local areas entered data directly into DHIS 2, making the data immediately available for others to analyze. Health workers also used other computer systems in other programs, in which some of the data from the other systems was entered into the DHIS 2 Data warehouse which stored the most important statistical data for the country. The DHIS 2 Data warehouse can be seen as a central database for the whole country which could be used to generate forms and charts, which could then enable easier decision making based on live data.
Even though the systems were designed with particular tasks in mind, data was sometimes duplicated or relevant across systems and caused redundant work in synchronization efforts as it was explained in the previous chapters. When data was transferred from one system to the other it was often done manually. If these processes were automated it would save time and enable more work to be done more efficiently.
The MoH were working every day to improve their HIS. They imple- mented new reporting forms and new analysis charts based on decisions made by programs and managers, in addition to trying to automate pro- cesses that had to be manually performed.
Furthermore it is important not to forget that an important part of the HIS are the people working in it. The information itself is invaluable but if there were no one to use it, it would be useless. There were often training workshops where MoH staff taught health workers how to use the systems in their local areas. It varied from teaching new functionality introduced in systems for data managers who had already been using the software, to basic training of new health personnel.
7.3.1 Capacity building and sustainability
As it was mentioned in the introduction, a big question in the context of HIS in developing countries is the one of capacity and sustainability. At the moment, many of the projects rely on funding coming from foreign aid organizations who work with improving the HIS. However, an ultimate goal is that it will be self-sustainable in the future, without the help of
foreign aid[7, Introduction]. For that to be possible, the HIS needs to be run without the need of financial and other support from foreign agencies. There is however often a lack of resources and capable people able to maintain HIS efforts, which makes building of capacity with training and knowledge an important part of HIS development. The systems should preferably be run and maintained by local staff, which is explained by the authors in [23] where they argue that the success of a sustainable large scale HIS depends on it. At the moment, the majority of staff were in fact locals, but were often supported by foreign organizations.
The fact that the use of DHIS 2 is encouraging local capacity building is a move in the right direction. The authors of [6] explain how capacity is developed within the HISP network, where one particular area is “DHIS- related IT capacity”. The staff that is being trained become valuable resources as the number of people capable of performing the required tasks are limited. Both in special training workshops, and by using the system they are becoming more skilled every day, and are able to train others using their own acquired knowledge. The main administrative HMIS staff participated in training sessions conducted by the HISP, where they learned how they could implement and improve the system in their own country, and train staff on their own. In [42] these training sessions for the administrative staff are presented, and called workshops, and are run under what is called the DHIS Academy.
In Rwanda they were also further improving their systems every day by implementing more features, reporting forms, while having their database grow through data collection. Since the local staff were maintaining and administrating their own servers and databases it means that they owned everything that they were reliant on, including the computers that hosted the systems. This is further contributing to their local capacity, rather than them being dependent on outside actors owning and maintaining their systems.
Training workshop in Kayonza
An example of such capacity building is a training workshop I attended, where data managers were trained by the main HMIS staff on the use of DHIS 2.
At the time of arriving the team responsible for DHIS 2 in Rwanda were conducting a training session in the Kayonza district in the Eastern Province. The training lasted for a week, and was about training community health workers and data managers at Health Facilities on the analytical functionality of DHIS 2. Rwanda had been using DHIS 2 and entering data for about two years when we arrived, and were now ready to start using the data through generating various types of graphs, reports and pivot tables. The training took part in a hotel, and they had invited all of the attendants (roughly 250 people) to stay there for the week. To conduct the training they had brought with them a computer with an installed instance of DHIS 2 acting as a server with a wireless router connected to it. This allowed everyone to connect and work without the need for an internet connection,
and without having to interfere with the live DHIS 2 instances running in the country. The hosts of the training were most of the administrators responsible for DHIS 2 working at the MoH.
Training workshops like this happened quite often, meaning that the capacity of available people capable of using DHIS 2 within the country grew rapidly. The staff were commonly local Rwandans who worked in their respective districts, effectively creating local capacity. During my stay of five weeks, two such week-long training sessions were held.
The capacity of users of DHIS 2 grew rapidly, but the fact that the main HMIS staff at the MoH frequently spent a whole week at local training sessions away from their actual MoH offices shows how important and willing these few key people were. What it also shows is how busy they were, and how diverse their work tasks were. The data managers and the other users would not be able to use their skills in the system were it not for the administrators, which means that they were all relying on these 8 people. Building capacity in the form of normal users such as data managers is important, but training of administrative staff and super users is perhaps even more important since one cannot exist without the other.