Determinaci´ on del tama˜ no de la muestra

Information is one of the principle ingredients for planning and monitoring health services. For over a decade now, there have been a series of evaluations on the information system and how to improve it, both in Dar es Salaam and at the national level. At the national level, there was recently a report on the HMIS under the Tanzania Joint Health Technical Review 2002 (HMIS evaluation team 2002), as well as a comprehsneive evaluation on the national level HMIS financed by DANIDA and conducted by HERA in 2000 (HERA 2000). At the local

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level, there have been various reports on the HMIS in Dar es Salaam, both routine annual reports (Fimbo 1999) as well as more evaluative studies (Fimbo 1998).

While there have been continuous and significant efforts to improve the HMIS in Tanzania, progress towards having a reliable and timely information system through the HMIS has been slow. A great deal of technical evaluation as well as physical resources have been thrown at the HMIS, with frustratingly disappointing results. The picture for Dar es Salaam has been more or less similar to that of the national level. The efforts to improve the HMIS have been characterised by technical problems (such as computers breaking down) as well as unrealistic solutions and expectations of the system to collect, process and report huge amounts of health information. Compilation of data involves processing some 666 data items (141 of which are quarterly and 525 are annual reports), originating from data collected at facility level and aggregated by level at the district and regions, before submission to the central HMIS Unit. The health sector review in 2002 reported that the 2001-3 Plan of Action (POA) that resulted from the HERA evaluation in 2000 was itself unrealistic in terms of the sheer number of activities expected (83 strategic and operational activities), their time lines, and the lack of guidance on how operationalisation was to be achieved (HMIS evaluation team 2002). Also, the responsibility/overview for many of the recommendations was argued by the review team to be inappropriate, such as the responsibility for capacity building within HMIS being the responsibility of the HMIS itself. More recently a national information strategy is in the process of being formulated; and surveys and censuses for monitoring health and poverty reduction indicators have been defined and planned. What follows is a brief overview of the situation for the two levels at which the information from HMIS is used: the national and sub-national levels.

5.5.2 National level information needs

At the national level, HMIS data has two major uses. The first major use is for monitoring of the health system to see whether it has achieved its goals (Ministry of Health 2002). In order to monitor the performance of the health system in Tanzania, 26 indicators have been chosen that reflect a range of inputs, processes, outputs and outcomes that are considered most key to the performance of the health system. Out of the 26, seven rely on information from the HMIS. These are:

1. Proportion of public health facilities in a good state of repair (process indicator)

2. Percentage of public health facilities without any stock outs of 4 tracer drugs and 1 vaccine (process indicator)

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4. Total outpatient department attendance per capita (output indicator) 5. Proportion of children under one year fully immunised (output indicator)

6. Top 6 causes of morbidity among OPD attendees and top 6 causes of mortality (outcome indicator)

7. Proportion of all under-five case fatality that is due to malaria (outcome indicator)

The report states that the data quality is poor for two of these (numbers 1 and 3), fair for two (numbers 4 and 6), good for one (number 4) and not available yet for two (numbers 2 and 7) (Ministry of Health 2002). Therefore, there is some way to go before the HMIS is performing adequately to provide reliable information for the monitoring of the health sector.

The second major use of the HMIS data at national level is for national planning, aside from the close monitoring of the 26 indicators chosen to reflect health sector developments over the coming years. This includes strategic planning, such as which diseases the public health system should focus on, as well as day to day planning, such as identifying which health system objectives still need attention and which resources to provide a minimum standard of care (repairing buildings and equipment, improving drug supply). For these planning activities, the DSMPHDS clearly has a responsibility to improve the data quality in the HMIS as well as the timeliness of the information. Some findings of the review team in 2002 should be noted in planning how to improve the HMIS and what is reported. For example, the review team found that most senior MoH respondents reported that the current presentation of information in the HMIS report did not assist senior staff in decision-making, citing several barriers to interpretation of information, including crowded format, reliance on out of date/inaccurate data, and lack of analysis and absence of year-on-year trends. Also, outside the MoH at national level, knowledge and use of the published HMIS report was minimal. It was found that there were a number of key constraints affecting the accuracy, timeliness, and completeness of reports, in particular missing data and software limitations. In turn, these issues appear to be influencing the perceived relevance of routine data for evidenced- based decisions at the national level. Furthermore, it was found that there was an absence of systematic maintenance of computers, and a lack of thorough back up on hard drives as well as floppy diskettes and inadequate virus protection, which all contributed to the increased vulnerability of the information stored in the event of disasters. Therefore, all these issues should be examined and addressed at the level of the DSMPHDS.

108 5.5.3 Sub-national level information needs

At sub-national level, information is playing a much more central role due to the decentralisation process in the Tanzanian health system that is now near completion. The most important development in this respect is that districts and municipalities are now responsble for planning and evaluating their own health services, while some control is still maintained by the centre (Ministry of Health) who agree the release of funds based on the plans and reporting from previous periods. Therefore, HMIS is useful both at the strategic level for planning which health services should be delivered and how, but also for monitoring and evaluating services, and ensuring the day to day running of the facilities meets the overall objectives of the health system. Clearly, a lot of the information contained within the HMIS will be useful for both of these levels (strategy and monitoring/running of services). However, the HMIS will not necessarily meet all the needs of the DMOH and the health management teams. As was pointed out by the health sector review team (HMIS evaluation team 2002), new information systems related to health include the Health Sector Performance Monitoring and Evaluation (HSPME), Local Government Reforms Monitoring and Evaluation (LGRME), Poverty Monitoring, and development of the Tanzania Social and Economic Database (TSED). Also, established systems undergoing modification include: National Sentinel Surveillance (NSS); Integrated Disease Surveillance (IDS); Personnel Database and Human Resource Development Database (HRD). While some of these information systems feed into other information systems, such as the HMIS feeding into HSPME as discussed previously, there is also some complementarity and duplication that should be noted. Especially where there is duplication, the MMOH should be aware not only of the fact that data reported in different data bases may give different values for the same variable, but also the MMOH should collaborate with other information systems and seek ways of reducing duplication of staff time in collecting identical data.

The following recommendations are made for improving data collection and reporting, taking into account some of the critiques of the 2002 health sector review team (HMIS evaluation team 2002):

• Improve supervision of staff (supervision quality as well as quantity) and validation checks

• Build HMIS tasks into daily workload rather than expecting staff to do over time

• Provide other incentives to staff, such as linking good performance to promotion and attending training, and reducing the re-recording of information presently necessary (i.e. transferring the same data from one register to another)

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• Improve the link of HMIS to decision making and feedback from district level to the facilities to inform staff how the information is being used and what data can be improved, as well as feedback on performance relating to normal duties (such as patient throughput)

• Lighten the workload of data collectors or increase staff numbers, especially the work of the Private Health Facility secretariat in Dar es Salaam MMOHs who have a huge workload

• Increasing completeness of the data (i.e. that 100% of facilities report data) so that aggregate district statistics reflect the entire district as soon as possible to allow time- series analysis. This includes private facilities

• Improve analysis and use of statistical packages to make data easy to interpret, such as the use of simple graphs to show cross-sectional and time-series data. Sending staff on training courses will help to achieve this

• Train more than just the central HMIS staff, so that when staff leave there is some continuity in the HMIS.

Although some of these initiatives can be taken by the MMOH and health facilities in isolation, clearly the districts rely heavily on developments at the national level for improving the performance of the HMIS, in terms of policies, strategy, guidance, training and resources. On the other hand, with the resources available and the current responsibilities of the district regarding the HMIS, through a sustained effort the districts in Dar es Salaam can take the necessary steps to vastly improve the quality and timeliness of information under the HMIS in the short-term, through following these and other recommendations.

5.6

Financial resources