Moderated By: Ryoko Yokoyama (John Snow, Inc.) and Edward W. Kunyanga (Macro International)
August 13-18, 2007
More than 100 RHINO members from 13 countries registered for the RHINO forum on Community Based Health Information Systems (CBHIS). Thank you all for your participation and sharing experiences. Below is a summary of our discussions.
The forum started off with the moderator posing five key questions around which participants were asked to share their experiences.
- How can community level programs continue to meet community information needs while at the same time responding to needs at higher levels for standardized information and indicators?
- What factors related to the organization of the community should be in place to successfully scale up a CBHIS?
- How can community programs motivate front-line service providers to collect and use information? How do communities and community programs benefit from use of information?
- How can programs measure if action was taken as a result of information provided through a CBHIS?
- What interventions, tools or inputs are most needed to move CBHIS forward? For example, training? Data collection tools? Harmonized indicators?
Olusesan Makinde initiated the forum sharing his experience from Nigeria: a poorly functioning National Health Information System due to poor data use, lack of skills, lack of strong political will and high running cost. He described the biggest challenge as "getting data to work with". Mark Spohr echoed this call and referred to a recently published HISP article summarizing principles for successful National Health Information System reform.1
Chidozie from Nigeria continued the discussion by pointing out that many community based programs do not have appropriate data collection tools and process in place which results in under-reporting of activities. A number of participants also described the difficulties of developing data collection tools which accommodates reporting requirement of the donors and programs while meeting the literacy level of volunteers. Issues of low literacy rate, lack of commitment and lack of skills were presented as fundamental problems related to volunteers. According to Rudolph Maziya, the "first thing to address is the issue of volunteers and capacity development to understand and appreciate the importance of reporting. Adequate human resource capacity is the key to an effective [community-based] information system". He continued to say that the problem is not limited to the capacity of volunteers but also related to the development partners reluctant to support human resource related activities. As a result, few officers are thinly spread to attend to multiple issues and are consequently unable to provide close supervision or capacity building and training for volunteers. He concluded that the fundamental issue with CBHIS is that of "management rather than purely of an information system nature".
Chandra Shekhar Gowa addressed the issue of data quality by sharing her experience of working with sex workers who have a low literacy rate and limited capacity. According to her, 1) developing simple and visual data collection tools, 2) involving end users as part of the development process, 3) identifying own information needs and 4) understanding how these information needs can be captured are the important components for quality of data and successful implementation of CBHIS. Pooja Pandey from Nepal working with female community health volunteers program (FCHVs) also shared key ingredients to work with volunteers: 1) training and review meetings for community volunteers to express their view and to receive feedbacks on their work; 2) involvement of key community members in trainings for the recognition of volunteer's work; 3) strong support system (community groups, schools etc) to ease volunteers' burden; 4) supportive supervision to improve their performance; and 4) funding to motivate volunteers.
Others emphasized the importance of a strong coordination body to harmonize interests of many stakeholders in a community. According to Mercy Zimba, "Only when a coordinating relationship is fully established then can we start to look at establishing a comprehensive community based management information system". Then, Christopher Simoonga introduced Health Metrics Network (HMN) approach where multiple sources of information can be integrated through common platform at the national level. Mark Spohr described HMN approach as "very powerful approach since it allows countries to use and strengthen existing information systems and still take advantage of the ability to use information from multiple sources to gain new insights into their health information".
Dai Hozumi asked participants if anyone has an example of tools/mechanisms to ensure quality of data or timely use of data by communities. He also asked the issue of cost-effectiveness for CBHIS. Then, two examples of data quality tools developed by MEASURE Evaluation were presented by David Boone: Data Quality Assurance Tool and M&E System Strengthening Tool. These tools look at the qualitative and quantitative aspects to identify gaps and poor performing areas and to develop an action plan to improve data quality.
MEASURE Evaluation (Edward and Ryoko) introduced and circulated the CLPIR (Community Level Program Information Reporting) toolkit and explained how this toolkit addresses many of the issues raised by participants such as: the coordination challenge of a multisectoral approach by community programs, inadequate coordination among stakeholders, lack of suitable tools and well defined best practices, inadequate capacity, limited involvement of community level volunteers in defining information needs and quality of data. According to Edward, the goal of the CLPIR toolkit is to make available tools and processes that communities and country level programs can use to help them generally move from pure reporting systems to a "management information system" that is capable of providing useful information to stakeholders at all levels starting with the community level, and of improving data quality.
Theo Lippeveld presented a Community Tool for Immunization Self-monitoring (developed by the USAID funded Immunization Basics Project) as another example of how information can be used by communities. This tool is designed to track newborns for vaccination, especially at monthly outreach sites in the village.
Responding to the cost-effectiveness question raised by Dai Hozumi, some of the participants agreed that CBHIS is not always cost effective if the system is set up as a pilot project. However, there are not many choices if the program is supported by international donors with stringent reporting requirements. Furthermore, CBHIS can be very useful if the system is oriented towards "minimum/core indicators" to capture major health events.
While a number of useful tools and strategies were shared among participants, this forum was just the beginning of initial efforts to improve community level information systems. As we stated in the closing remarks of the forum, we would like to continue this discussion with a smaller group to come up with more concrete community level information system guidelines.
List of documents shared
Bridging the Know-Do Gap
Dr. Tikki Pang
Community-Level Program Information Reporting for HIV/AIDS Programs (CLPIR)Introduction to the CLPIR Toolkit
MEASURE Evaluation. March 2007
Evidence in action, acting on evidence: A casebook of health services and policy research knowledge translation stories
CIHR Institute of Health Services and Policy Research
Information and Knowledge Sharing at the Pan American Health Organization
Report of Task Force No4. Pan American Health Organization, Regional Office of the World Health Organization, Area of Information and Knowledge Management. 2005.
Monitoring and Evaluation Systems Strengthening Tool
Moving population and public health knowledge into action
CIHR Institute of Health Services and Policy Research
National Public Health Information Plan 2005
National Public Health Information Working Group. Australian Institute of Health and Welfare 2005
Towards High-Performing Health Systems Summary Report
The OECD Health Project. 2004.
World Report on Knowledge for Better Health Strengthening Health Systems
World Health Organization. 2004.
Various useful web-linkages
WHO KMS Useful Resources
Pan American Health Organization (PAHO). (2005). Information and Knowledge Sharing at the Pan American Health Organization: Report of Task Force No. 4.
Canada Institute of Health Research (CIHR). (2007). Canadian Knowledge Translation Strategy
Organization for Economic Co-operation and Development (OECD). (2006). Towards High-Performing Health Systems Summary Report
Ministry of Health New Zealand. (2006). Standards Development Process with Health Information Standards Organization (HISO), New Zealand Health Information Strategy Action Committee.
Ministry of Health, Australia - Institute of Health and Welfare. (2005). National Public Health Information Plan
Braa, J. et al. Developing Health Information Systems in Developing Countries: The Flexible Standards Strategy. MIS Quarterly Vol. 31. Special Issue August 2007.