Statement of principal findings
This study analyzed the reality of hospital managers in the health region of Huíla in Angola regarding using the HIS as a tool to support the decision-making process. The analysis of the questionnaires to thirty-six managers from seven hospitals that participated in the study revealed that hospital managers do not use the HIS to support decision-making, both for clinical and administrative aspects. In addition, the participants expressed an assessment of dissatisfaction with the HIS.
Strengths and limitations
The main strengths of this study are the fact there are very few studies on health informatics in the large region of Southern Africa, a region that has more than 210 million inhabitants. Also, this work gives a very clear picture of an Angola province (Huila), covering all but the military hospitals. In the current pandemic moment, having this picture of less-studied but very populated regions is critical to support worldwide efforts.
However, this study has some limitations. First, in this study, only Huila province was assessed. Although the main cities of Huila (Lubango and Matala) are among the most populated cities in Angola, we believe that it would be interesting to include a broader sample to picture better the Angolan use of HIS for decision-making in hospital management. Moreover, in the study's questionnaire, additional questions assessing specific characteristics of the HIS that are in use at each hospital would be helpful. Finally, we assessed HIS-related perceptions, but we cannot guarantee that all hospitals used the same specific HIS (which can drive diverging perceptions as their features might be different).
Interpretation within the context of the wider literature
To the best of our knowledge, this is the first study analyzing the use of HIS as a tool to support decision-making by hospital managers in Angola. This study involved the main actors responsible for hospital management (e.g., clinical, nursery, administrative manager), most with a long experience within the institution and a good knowledge of the available HIS. We understand that these are vital aspects when looking for a critical view about what ought to be changed or enhanced on HIS and strengthening our findings.
Some studies have shown that a high educational level of healthcare managers can improve patient care and data quality. However, our study noted that most respondents had a minimum level of education (bachelor’s degree), which could make our results less generalizable to settings where most hospital managers are highly schooled.
Previous studies have shown that having informatic courses/training could significantly affect competencies levels36. However, in our study, despite most of the respondents had complementary informatics training, they did not have health statistics training, which would be very important to improve their data understanding and practical application. This lack of exercise may be related to the absence of specific health informatics curricula in many health-related schools (e.g., medical and nursing)37. However, should actively pursue training in health management to enable hospital managers to effectively improve the decision by making better use of the vast amount of data produced within each healthcare institution 24 38 39.
We found that half of the participants had never or rarely used HIS information to support decision-making regarding hospital management in Angola. However, in other countries, such as Iran and Brazil, some studies found that hospital managers frequently used evidence-based hospital management and acknowledged that HIS is a relevant tool to the institutional organization and should be used during the decision process11 21 35 40. Found Similar results in a study conducted in the Brong Ahafo region in Ghana on Utilization of the national cluster of district health information system (DHIMS2)for health service decision-making at the district, subdistrict, and community levels, where found that although 93% of the health facilities studied submitted data to the DHIMS2 platform, the evidence suggested low use of these data in decision making41.
Otherwise, in Angola, we found that most of our participants regarded HIS as inadequate or fairly adequate tools, with excessive data volume but lacking relevant information (e.g., to compute healthcare indicators) and proper communication channels, leading to general dissatisfaction with HIS features. Although these aspects can be "true" limitations of HIS, we cannot exclude that a possible lack of training in HIS parts might also influence hospital managers´ perceptions. Another study held in Brazil found that ample amounts of information and data were available but that managers did not know about existing data and did not use that information to guide hospital management20.
Auditing procedures are fundamental to assess the information pathway and guarantee that recommended data collection, storage, and access procedures are fulfilled; it allows the early identification of system misuse and enable the intelligent implementation of preventive and corrective measures30 42. However, we found that almost half of the participants reported that they never performed information-related audit procedures in their institutions. Findings from several studies invoke the critical need for formal and informal training in health management for health managers, emphasizing members of hospital boards7 14 22. Most hospitals in higher-income countries use comprehensive HIS, while in other parts of the world, hospital orders for medications, laboratory tests, and other services are still paper-based33 43.
Our participants reported that they did not appeal to admission, archive, and medical statistics services to examine a patient returning to an appointment after 30 days. In other words, we can say that for patients registered to a meeting, if they return to the hospital after more than 30 days, a new admission will be performed, ignoring information collected in the appointment before.
Moreover, hospital managers' use of HIS information seems to be influenced by several factors such as age, personal motivation, work commitment, work experience, and so on17 44. Some of these factors might affect our findings in Angola. For example, although our study's participants had long experience within the institution, more than 80% worked in hospital management for less than five years. Did not assess personal motivation and work commitment in this study. The studies conducted show that longer follow-up is needed to evaluate the sustainability of programs in developing countries 6 26 45. Anther findings support that HIS functions in Turkish hospitals are generally not as available as quality managers would like13.
Implications for policy, practice, and research
However, the weaknesses of the HIS have limited managers to resorting to this essential support tool for the decision-making process. For example, the HIS for-budget plans should be a procedure legislated by the Angolan government. Creating rules and guidelines for hospital financing based on information will create new information systems that will improve quality. Would motivate managers to strengthen and use hospital information to make clinical and administrative decisions24 46. This study stresses the need to invest in the organization and health information technologies in Angola to gather data needed to support the decision process locally, in the province, and the country.
Various researchers have posited that more investment is necessary for health infrastructure. Hospital information systems may contribute in different ways to quality assurance activities such as assessing the quality of primary care, monitoring quality indicators, supporting clinical care evaluation studies, and auditing concurrently the ongoing care process using reminders or decision support techniques. However, to meet all requests of quality assurance in real-world settings, many efforts to develop new technologies will still be necessary.
Regarding the hospital managers, this study shows that they need to change how their work is performed to use the existing data collected in hospitals. The increase in such data will also improve its quality and usefulness in the long run.
Our results show the need to understand better the underlying causes and possible solutions for the underuse of HIS and its data in hospital management. It is not just a question of whether the technology is available, human aspects like motivation or institutional organization need to be central.
Also, the reality found has a significant impact on the possibility to perform clinical and epidemiological research. Primary administrative and clinical data are essential to follow populations' health, and this data often comes from the executive or financial departments29.