Dr. Frank Nyonator, Dr. Anthony Ofosu , Mr. Dan Osei , Mr. Dominic K Atweam

1. DISTRICT HEALTH INFORMATION MANAGEMENT SYSTEM DHIMS II THE EXPERIENCE OF THE GHANA HEALTH SERVICE Dr. Frank Nyonator, Dr. Anthony Ofosu , Mr. Dan Osei , Mr. Dominic K Atweam Ghana Health Service-Policy Planning Monitoring and Evaluation Division

2. It was established in 1996 through Parliamentary Act 525 and works in liaison with the Ministry of Health • Operates a decentralized system at five levels: National, Regional, District, Sub- District and Community. • GHS is authorized by MOH to collect, collate and report on all routine health services including health service data from Mission, Private and Quasi-government health facilities everywhere in the country BACKGROUND The Ghana Health Service (GHS) GHS is the largest autonomous national executive body responsible for implementing all national health policies in Ghana.

3. BACKGROUND • All service delivery points generate essential routine service data on health service utilization, morbidity and disease patterns. • Such data are very useful to health managers at all levels for planning, budgeting and decision-making. • Routine service data also feed into the Health   Sectors’ monitoring and evaluation system for analysis and dissemination of results. • Thus helping to reflect and judge performance, and highlighting weak areas for strengthening intervention programmes.

4. HIMS Challenges • Obtaining routine service data (USEFUL DATA) from all health facilities across Ghana has been the single most immediate challenge of the health sector • USEFUL DATA for health managers at all levels for planning, budgeting and decision-making has not been timely or complete. • Difficulty in tracking both reporting and non-reporting facilities • Greater challenge for monitoring and evaluation activities of the sector. • This culminates in the slow response of GHS in addressing potential health emergencies and epidemics and planning based on estimates.

5. Example –Neonatal Dealths • Burden of neonatal deaths, evident in routine data as unacceptably high, remained undetected for years because of late submissions and incompleteness of reports. • It took the Demographic and Health Survey (2008) to make this national crisis evident. • Subsequent analysis of routine data showed the same trend of high neonatal mortality.

6. ICT Solution • GHS Collaborated with the University of Oslo developed a software called the District Health Information Management System (DHIMS2) • DHIMS2 is a comprehensive HMIS solution for the reporting and analysis needs of district health administrations and health facilities at every level. It’s been designed to • Provide a comprehensive HMIS solution based on data warehousing principles and a modular structure which can easily be customized to the needs of different health systems - national, regions, districts, and facilities • DHIMS2 is centralized, which enables easy, online updates and deployment of the application.

7. ICT Solution • DHIMS2 has data entry alternatives that can be customized to replicate paper forms – to simplify the process of data entry . • Dashboard for monitoring and evaluation of health programs that can also be user customized to allow different indicators to be generated and analyzed for linking specific health outcomes, with the added functionality of, carrying out data quality analysis

8. ICT Solution • The DHIMS2 offers a very user-friendly interface that is easy to navigate. • Training is still required to equip data entry personnel as well as end-users to utilize DHIMS2 optimally for the desired outcome. • This is based on three fundamental premises – knowing what one is looking for (whether data element or indicator), where one requires this data or information from (location- regional, district, sub-district or facility level) and when (period or point) time reference. 


9. ICT Solution-Accessibility • DHIMS2 is accessible in all 170 (216) districts and is being used by health facilities and district health directorates to collect, collate, transmit and analyze routine health service data. • All staff in District Health Directorates and health facilities with the required capacity for DHIMS2 management has been registered as secure users on the DHIMS2 server. • There are currently 5,563 registered users from government, quasi-government, private and faith-based facilities that are submitting their service report each month.

10. ICT Solution • Data in DHIMS2 is organized in a hierarchy and reports are generated the same way. National, Regional, Districts , Sub districts and Facility level. • Health data is entered at the facility level only. And can be entered for a facility at the sub district or district level • Reports of administrative activities are entered using the administrative office facility corresponding to the sub-district, district or regional health directorate.

11. ICT Solution-Accessibility • Only population data is entered at the country, region, district or sub-district level. These levels are used to aggregate health data. • Facility -level organization units can be moved among sub-districts.. there is no need to re-create them when sub-district boundaries change

12. Requirement & Security • The only requirements for the user is to have a web browser installed on a computer and have an Internet connection. • To access DHIMS2 you do not need any software to be installed on your computer. It works independent of the operating system on your personal computer

13. INNOVATION • Data is encrypted , ssl certficate authentication • Requires strict user guide line • Districts data travels between their computer and GHS server, it is encrypted by a technology called Secure SocketsLayer (SSL) using 128-bit encryption.

14. Personalized Dashboard that Managers can track their service data of interest

15. Quick reports for managers

16. A user friendly interface for users to create their own graphs

17. INNOVATION • GHS ensured in-house capacity building and development of DHIMS2 application . • All modifications done on the DHIS2 platform to adapt it for GHS use as DHIMS2 were accomplished by our own staff, trained by a TA ‘s from the University Of Oslo. • We have accomplished a nationwide implementation of a web-based data collation and reporting system involve private, quasi government and government facilities without an initial pilot project.

18. INNOVATION • GHS to date has trained 5 health workers in each of the 170(216) districts (850 health workers), 180 system administrators across the 10 Regional Health Directorates and all 170(216) District health directorates to support the use of DHIMS2 in collecting and collating health service data. • Senior Managers at the headquarters level, Regional and district level have also been trained and all now use DHIMS2 to monitor the service utilization and inputs as well as to generate their own reports due to the real time data on DHIMS2

19. LESSONS LEARNED • When routine health service data is visible, easily available and accessible on a common platform for all managers, there are constructive critiques on what the typical trends of specific indicators should look like versus what anomalies are being recorded to prompt further inquiry. • This leads to continuous discussions on how to improve upon reporting rates, data completeness, accuracy and internal consistencies of the routine health service data. • This also helps to draw the true pattern of service utilization against the knowledge of the interventions that are being put into the health care service delivery system across the various districts

20. CONCLUSION • Introducing DHIMS2 into the Health Sector has been so far successful in mitigating the challenges with service data collection and reducing the information transmission bottlenecks and timeliness. • Prior to the creation and introduction of DHIMS2, the information systems and sub- systems within these defined levels were mostly spreadsheet-based. • This made the data management process prone to many errors with the knock on effect of many local level managers distrusting their own data, hence rarely using it in decision-making or predicting trends. • In turn data collation and aggregation at central level was made even more difficult. This resulted in heavy reliance on international estimates. • WE CAN NOW CONFIDENTLY SAY THAT THESE ISSUES HAVE BEEN RESOLVED TO A LARGE EXTENT .

21. Integrated architecture of interoperable systems Integrated architecture of interoperable systems and infrastructures (paper, computers, internet, mobiles telephones Replicated at each administrative level: National Regional District Reports, GIS, Pivot, Graphs etc DHIS2 Data from/to mobile phones Data Warehouse Data capture from Paper reports DHIS2/NBIT Import e data Household Tracking Monthly summary Reports Export e summary data Medical Records Logistics MIS Human Resource Records Open MRS Telephone Open LMIS iHRIS Register pregnant women and immunization