Assessment of Health Management Information System (HMIS) implementation in South West Shewa Zone, Oromia, Central Ethiopia.

Background: Health management information system (HMIS) is a system that allows for the collection, storage, compilation, transmission, analysis and usage of health data that assist decision makers and stakeholders manage and plan resources at every level of health service. The objective was to assess Health Management Information System (HMIS) implementation in south west shewa, oromia, central Ethiopia 2019. Methods and Materials: The assessment was conducted in south west Shewa from August 17 to 25, 2019. Facility based cross sectional study design was employed and 22 health centers were included in the study. Collected data was entered in Epi-data and analyzed using SPSS 23 and Microsoft excel 2010. Results: Among health centers assessed 58% and 92% had HMIS unit and electric power respectively. In all woredas HMIS focal person was assigned and trained on information use. At health center level HMIS recording and reporting, indicator reference, NCoD and information use manuals availability were 25%, 33%, 17% and 58% respectively. The assessment shows that implementation of information display, and functionality of PMT were 74% and 58% respectively. During the assessment interviewed midwives on the service delivery unit only 75% of health center define and record new and repeat acceptor of family planning according to the national revised HMIS indicators. Also 67% of health officer assigned to outpatient department define new and repeat diseases classification and filled in the register properly and 33% of them didn’t use NCoD to classify HMIS disease classification. Conclusions: Health management information System (HMIS) in south west shewa zone was not fully implemented and there is a challenge related to improving data accuracy, access to computerized HMIS data and competencies to analyze, interpret and use of HMIS data at health center levels. Also, presence of reporting mechanism, displaying information and feedback mechanism were poor at health center level. Therefore, it is important to function performance monitoring team meeting and supportive supervision regularly at all levels.


INTRODUCTION
Health Management Information System (HMIS) is a system that allows for the collection, storage, compilation, transmission, analysis and usage of health data that assist decision makers and stakeholders manage and plan resources at every level of health service (1). Health information is the processed data and knowledge that an individual or group use to support their decisions in the health sector (1,2). It is fundamental for the overall health system which informs decision-making in each of the other five blocks of the system and improving managerial decisions by providing quality information for evidence-based health practices. The World Health Organization (WHO)'s framework for health systems strengthening identifies six attributes of a health system (2). The attributes, or building blocks, include a health workforce; health services; health financing; governance and leadership; medical products, vaccines, and technologies; and health information. While each building block of the WHO framework is important to improving health systems and ultimately health outcomes, quality and timely data from health information systems (HIS) are the foundation of the overall system and inform decision making in each of the other five building blocks in the health system (3).
Routine health information is vital for operational, tactical, and strategic decision-making. Major problems in relation to health information which was identified by the World Health Organization (WHO) are inadequate use of existing information and evidences due to fragmentation and duplication of health information (4). In line with this the participants of the Global Summit on Measurement and Accountability for Health identified a five-point call to action with a set of targets for better data use in support of healthrelated sustainable development goals (SDG). One of this five-point call to action is ''by 2020, countries have health information flows that involve the use of data locally to improve services and programs" (5,10).
Public health decision-making is seriously reliant on a timely availability of sound data, and globally significant human and financial resources have been invested to improve health information systems (6). It is well accepted that information generated by health care systems is used for planning, management of health commodities, detecting outbreaks, and monitoring the overall performance of the health system that further maintains the quality of care (7,11).
Sub-Saharan African countries recognized and accepted Health Management Information System (HMIS) as a source of routine health information, however, health programs frequently fall short of its efficient use to inform decisions. Ethiopian implement Health Management Information System (HMIS) since 2008 to capture and provide 131 indicators (8) used to improve the provision of health services, ultimately to improve health status of the population.
The findings of the assessment will be expected to identify major problems observed in health institutions in implementing HMIS in south west shewa zone. It will provide relevant information for planning monitoring and evaluation and show areas that needs special attention and further follow up for program improvement.
Furthermore, zonal health office, woreda health offices, and health center can use the finding of this assessment as an input for informed decision making in resource allocation and identifying areas needs special concern.

Study area and period of assessment
The study was conducted in health facility of south west shewa zone, Oromia, central Ethiopia, from August 17 to 25, 2019. Southwest Shewa zone is one of the zonal administrations located in Oromia regional state.
The zonal capital, Woliso, is 114 km from the capital city of Ethiopia, Addis Ababa. According to a report

Study Design
• Cross sectional study design.

Source Study
• Source of the study were all health centers found in south west shewa zone,

Study units
• The study units of the assessment were selected health centers,

Inclusion criteria
• Health centers implementing health management information system were included in the assessment.

Sample size determination
According to the WHO guideline for sampling district health system for assessing its functionality we select 4(30%) of the zone woredas were taken (13). Therefore, 22 health centers were included in the assessment and all health facilities' documents from April to June 2019 were reviewed.

Sampling technique
For this assessment, at zonal level, woredas were randomly selected. After selection of woredas, health centers randomly selected using lottery method depending on the number of health centers found in each woreda. All health professionals and supporting staffs working on HMIS and those are available at the time of data collection was interviewed in the study and all selected health centers were physically observed.

Data collection Instrument
The data was collected using HMIS structured questionnaires to answer the objective of the assessment. The questionnaire contains five components 1) Appropriateness of the card room given weight of 9 scoring points 2) Functionality of HMIS system (service delivery point, records, registers, completeness and timeliness of reports) given weight of 12 scoring points 3) Information display given weight of 4 scoring points 4) Performance Monitoring Team (PMT) given weight of 11 scoring points 5) Supportive Supervision system given weight of 8 scoring points. Finally, data quality was observed from registers, tally sheet and reports.

Data Collectors
Ten BSc health professionals who know local language and trained on HMIS were recruited for data collection. One day orientation was given for data collectors on data collection tools and procedures by the principal investigators.

Data collection Field Work
Quantitative data were collected from health professionals and supporting staffs working on HMIS and service delivery unit was interviewed using structured questionnaire. Prior to start the interview, data collectors were communicated with health centers head to obtain information about the staffs and whom to interview. Data was checked for completeness and accuracy by data collectors though out the data collection period.

Data Analysis
The data was checked for completeness and coded by Epidata3.1 version. Microsoft Excel 2016 was used to develop the frameworks and SPSS version 23 was used for data analysis. A variety of descriptive statistics such as mean scoring, and percentage was calculated to describe the results.

Data Quality management
Questionnaire was prepared in English and translated to local language (Afan Oromo) and retranslated back into English to ensure its consistency. The questionnaires were pre-tested at Tare health center and to ensure that whether it is clear or not for other health centers and then some corrections was done accordingly. Data collectors were instructed to check the completeness of each questionnaire at the end of each interview. The completeness of the questionnaire at the end of the day was rechecked by supervisors.

Ethical consideration
Appropriate research ethical clearance was obtained from the ethical review committee of South West Shewa Zonal health office (reference number: WEFG/241/2019, July 2019) and woreda health office. This study was conducted in accordance with the Declaration of Helsinki: each study participant was well informed about the aim of the study, benefits and risks; informed written consent was secured from study participants; study participants' confidentiality was maintained; no personal identifiers were used in the data collection questionnaire and codes were used in place of them; data were kept in a protected and safe location where paper-based data were kept in a locked cabinet and computer-based data were protected using passwords; the recorded data were not accessed by a third person, except the researcher; and data sharing will be enacted based on the consent and permission of research participants and the ethical and legal rules of data sharing.

Overview of Woredas and Health Centers
Total numbers of study health centers were 100% response rate. Health staffs such as HMIS focal person, and heads of health centers were interviewed during the assessment. Health centers had HMIS unit and electric power access were 58% and 92% respectively. All Woredas HMIS focal person was assigned and trained on DHIS2 and information use (Table1).

Functionality and implementation of Card Room
Health Information System (HMIS) implementation in the medical record room (MRU) as per standard at Dilela, Chitu, Goro and Obi health centers using maximum scoring of 9 points and MRU implementation in Dulele and Selam Gatiro health centers were poor implementation (Figure 1).

Functionality of Health Management Information System
Functionality of HMIS system was assessed and checked at service delivery point, records, registers, completeness and timeliness of reports. Functionality of Health Information System (HMIS) implementation as per guideline were almost all implemented in Waliso, Goro, Chitu and Korke health centers using maximum scoring of 12 points and Selam Gatiro health center was poor implementation (Figure 2).

Performance Monitoring Team (PMT)
From the finding, performance monitoring team (PMT) were fully functional as per guideline in Chitu and Obi health centers and total not functional in Wayu and Leman health centers. Generally, functionality of performance monitoring team (PMT) was 58% (Figure 3). The assessment also revealed that Performance monitoring team conducting Lot quality assurance sampling (LQAS) at health facility level and Routine data quality assurance(RDQA) at woreda level were 58% and 21% respectively (Table 3)

Information Display
Availability of tables, charts and maps on maternal health indicators, child health indicators, facility utilization, and disease surveillance indicators were assessed for understanding the level of information display in health centers. The assessment shows that health centers display information as per guideline was 41% and 2(1%) of health centers not display information (Figure 4).

Supportive Supervision
Using standard checklist supportive supervision from different levels was one of the implementations of HMIS. During the assessment 9(41%) of health centers score eight and 2(1%) of health centers not conduct any supportive supervision for the next level as per guideline ( Figure 5).

Overall HMIS Implementation
The assessment finding shows that over all HMIS implementation Information display, and Functionality of performance monitoring team (PMT) were 74% and 58% respectively. Functionality of performance monitoring team was curial to implement HMIS as per guideline (Figure 6).

Guidelines and manuals for implementation of HMIS
At least four manuals which facilitate the implementation of HIS are in place within the Woreda Health Office and Health center level. During this assessment at woreda level all manuals are available. At health center level HMIS recording and reporting, indicator reference, NCoD and Data quality and information use manuals are 25%, 33%, 17% and 58% respectively ( Table 2).

Data quality and information use
In the revised HMIS (9), definition of repeat contraceptive acceptors was modified to those clients who are ever users of any contraception and each year are coming for the first time for contraception either for resupply or restarting or starting a different method of contraception. Thus, ever-user clients who come for second and subsequent visits are not counted. Thus, there were chances that the health staff might confuse the definition of Repeat Contraceptive Acceptors. During the assessment interviewed midwives on the service delivery unit only 75% of health center define and record new and repeat acceptor according to the national standard. Also, the data elements of different registers were did not filled properly according to the national guidelines and manuals for instance Antenatal care, PNC, Delivery registration the column box of reportable data element at the end of the registration page also not filled.
On the other hand, in case of OPD attendance, the patients' data is recorded in OPD Abstract Register and in OPD Tally sheet. In the register, one row is used for one visit and the main diagnosis is recorded even if the patient comes for more than one illness. On the other hand, in the Tally sheet, every diagnosis is tallied; moreover, the tally sheet allows tallying by age and sex groups. This arrangement encourages the health staff to rely on the tally sheet for reporting and there are chances that the records in the register and tally sheet might not match. From this assessment 67% of staffs define new and repeat and filled in the register properly and 33% of them didn't use NCoD to classify HMIS disease classification.

Discussions
Among health centers assessed 58% and 92% had HMIS unit and electric power respectively. In all woredas HMIS focal person was assigned and trained on DHIS2 and information use. At health center level HMIS recording and reporting, indicator reference, NCoD and information use manuals availability were 25%, 33%, 17% and 58% respectively. The study also reveals that implementation of information display, and functionality of PMT were 74% and 58% respectively. During the assessment interviewed midwives on the service delivery unit only 75% of health center define and record new and repeat acceptor of family planning according to the national revised HMIS indicators. Also 67% of health officer assigned to outpatient department define new and repeat and filled in the register properly and some of them didn't use NCoD to classify HMIS disease classification. This is almost like the study conducted in southern nation nationalities and peoples of Ethiopia (11). This is may be due to the similarity of health facility. Poor understanding of definition of indicators such as OPD visits and low capacity to calculate data were also contributing to the low level of data accuracy. Even though reports are scanned and entered into the database automatically a similarly low level of data accuracy also was observed while comparing the paper report against district health information system.
The use of information, another dimension of HMIS performance, was found limited in the assessed woreda.
The revised HMIS in 2017 is geared towards supporting and strengthening local action-oriented performance monitoring (10). Health management information system using guidelines helps to identify gaps, to develop action plan and review progress continually improving service coverage over time. In the assessed health facilities absence of such guideline may be one of the contributing factors for the observed minimum use of HMIS information in the annual plans. This finding is consistent with the limited competence in data analysis, interpretation and problem solving at the health centers. It shows data are being collected primarily for reporting and use of data for evidence-based decision making is low at peripheral level.

Recommendations
The assessment identified strengths and weaknesses of the health management information system implementation in terms of the standards set on guidelines. Based on the findings, the following general recommendations are provided based on the findings of the assessment for further intervention for health centers, and woredas.

For Health Centers
✓ Monitor and confirm that the health facility executes the entire health management information system procedures in respective service units to generate quality data ✓ Compile reportable data and prepare reports timely; check report continent completeness using visual scanning; perform Lot quality assurance sampling (LQAS) with involvement of all performance monitoring team members; and then review in performance monitoring team meeting before reporting to next level ✓ Develop performance monitoring team work plan and implement properly to monitor data quality, review performance and provide technical support to the service units or departments ✓ Conduct regular performance monitoring tea meeting, check data quality, identify performance gaps, analyze root causes, develops action plans, implement and monitoring the progress using health management information system data ✓ Ensure proper documentation that all-important documents such as report copies, work sheets, used registers and tally sheets are properly archived

For Woredas and Zonal Health Department
▪ Make sure that health workers get proper orientation and skill on health management information system through gap identification, and facilitate the provision of orientation or training ▪ Check report timeliness, continent & representative completeness using report tracker and visual scanning through sharing the data to respective program and department units, and then review in performance monitoring team meeting before reporting to next level. PMT set priority to solve performance gaps 33% 50% PMT identify root causes and developed action plan using problem investigation and action plan form 33% 50% PMT conducted resource mapping using stakeholder analysis 25% 15% PMT ensure and implement proposed interventions and started result monitoring 25% 25% PMT conducting Lot Quality Assurance Sampling or Data Quality Assurance quarterly 58% 25%