THE STRATEGIC PLAN FOR THE DEVELOPMENT OF THE NATIONAL HEALTH INFORMATION SYSTEM FOR REPUBLIC OF ARMENIA

Transcription

1 THE STRATEGIC PLAN FOR THE DEVELOPMENT OF THE NATIONAL HEALTH INFORMATION SYSTEM FOR REPUBLIC OF ARMENIA YEREVAN 2008

2 TABLE OF CONTENTS LIST OF ABBREVIATIONS... iii PREFACE...v 1. INTRODUCTION NHIS Functioning Context: Healthcare System of Armenia Health Information System Changes/reforms on the National Health Information System Main Operators of the Health Information System Strategic vision of the National Health Information System NHIS Assessment SUMMARY OF CONCLUSIONS FROM THE HIS ASSESSMENT NHIS Resources Policy and Planning HIS institutions, human resources and financing HIS Infrastructure Indicators Data sources Census Vital statistics Population surveys Health and disease records Health service records Administrative records Data management Information products Health status indicators Health system indicators Risk factor indicators Dissemination and use Analysis and use of information Information use for policy and advocacy Information use for planning and priority setting Information use for resource allocation Information use for implementation and action General conclusions based on the assessment STRATEGIC PLAN FOR THE DEVELOPMENT OF THE NHIS Strategic Planning of the Population Census, Vital Statistics and Household Surveys Census Vital statistics/ civil registration Population surveys Objectives and activities Strategic Planning of Capacity Building and Quality Assurance for Health Services- Based Statistics Health service-based statistics Capacity building for services-based statistics Improving the quality of data collection, management and use Key guidelines for building capacity and quality for services-based statistics Objectives and activities...31 i

3 3.3. Strategic Planning of Information and Communication Technology (ICT), Data Management and Data Integration Key guidelines for improving data management Objectives and activities Strategic planning related to special monitoring of health finances, the health workforce, service availability and service quality Key guidelines for special monitoring of health finances, the health workforce, service availability and service quality Objectives and activities Strategic planning related to coordination of the development of the health information system Key guidelines for coordination of the development of the health information system Key guidelines for development of the legal and policy framework Key guidelines for selection of core health indicators Objectives and activities Strategic planning related to analysis, dissemination and use of health information Key guidelines for improving analysis, dissemination and use of health information Objectives and activities...52 BIBLIOGRAPHY...56 TABLES AND FIGURES...57 Table 1: SWOT ANALYSIS...57 Flowchart 1: Overview of the Health Information System...60 Table 2: Health data and information sources...61 APPENDIX...62 ii

4 LIST OF ABBREVIATIONS ADHS AIDS CIDA DSS GAVI GFATM GPS HIS HMN HR ICD ICT IHR IMF MIDAS MoH MoJ NHA NHIAC NHIS NSS RA RDH SAM SHA SHED SRS TB USAID UNDESA Armenia Demographic and Healthcare Surveys Acquired Immune Deficit Syndrome The Canadian Development Agency Demographic Surveillance System Global Alliance for Vaccines and Immunization Global Fund to fights AIDS, tuberculosis and malaria Global Positioning Satellite Health Information System Health Metrics Network Human Resources International Classification of Diseases Information and communications technology International Health Regulations International Monetary Fund Medical Institutions Database Analysis System Ministry of Health Ministry of Justice National Health Accounts National Health Information Analytical Centre National Health Information System National Statistical Service Republic of Armenia Regional Departments of Health Service availability mapping State Health Agency State Hygienic- anti Epidemic Department Sample Registration System Tuberculosis U.S. Agency for International Development United Nations Department of Economic and Statistical Affairs iii

5 VR WB WHO ZAGS Vital Statistics World Bank World Health Organization Department of Civil Status Registry iv

6 PREFACE In May 2005 World Health Assembly created Health Metrics Network (HMN) to address the problems of health information systems (HIS) in developing countries; with an ultimate goal to improve global health, as well as to support the countries and partners in strengthening health information systems and to enable evidence-based and better decision-making. Both producers of health information in the health, statistics and research communities, and users of information such as the media, donor and development agencies, funds and foundations collaborate with HMN. Founder members of HMN are Ministries of Health (MoH) and state statistical bodies of different countries, a lot of other institutions, Global Alliance in Health Sphere, bilateral donors and technical professionals. The goal of HMN is to promote the availability, quality, value and use of timely and reliable health information essential for health systems strengthening and decision-making, both nationally and internationally. Therefore, this international initiative does not focus on specific diseases in countries. It emphasizes the need to develop entire health information and statistical systems as well as the need to strengthen country leadership and capacity for the production and use of timely and reliable health information. Thus, an agreed-upon Framework and Standards for Country Health Information Systems (the HMN Framework ) was elaborated to stimulate the coordination and alignment of partners around a harmonized framework to develop and strengthen country health information systems, as well as to be the universally accepted standard for collection, reporting and use of health information by low-middle income countries (including Republic of Armenia) and international institutions by The framework has six main components and standards: HIS policies and resources; core health indicators; data sources; information management process; data availability and quality; and dissemination and use. The HMN Framework aims to: 1. direct investments and technical support to the development of standardized HIS in countries, as well as to serve as a gold standard for the baseline assessments of the system. 2. enable access to and better use of quality health information in countries and at global level. The HMN framework, in essence, is just a technical document that needs to be affirmed in official strategic programs of different countries. This means that countries must act as active v

7 collaborating partners, accepting basic elements of the suggested model and making appropriate adaptations when needed. Countries must also assign differentiated investments and create favourable political and economical atmosphere for the effective realization of the program. Key stakeholders to support the adoption of the HMN Framework are: World Health Organization (WHO) Member States, United Nations Statistical Commission, the High Level Forum on the Health Millennium Development Goals (MDG), and the forums and board meetings of partners and alliances such as the Global Alliance for Vaccines and Immunization (GAVI) and the Global Fund to fights AIDS, tuberculosis and malaria (GFATM). The information system of Armenia is under continuous reforms. The introduction of the HMN Framework in the republic will lay the ground for making the ongoing health reforms more effective and in line with international standards. vi

8 1. INTRODUCTION 1.1. NHIS Functioning Context: Healthcare System of Armenia During the last years, the health system of the Republic of Armenia underwent process of functional and administrative restructuring. After declaring its independence, in parallel with the collapse of public financing for health care, Armenia faced another challenge: managing a radical reform of the health system. The fundamental problems in the Health care system of Armenia were the following: heavy dependence on governmental financing, inefficient and highly centralised health care system with vertical management (focused on inpatient services)), poor management of the health system, absence of significant planning and control, absence of advanced medical technology. The reforms of the health care sector in Armenia began in mid 1990s and were focused on system management and structure, health care financing and medical education. Major changes have involved decentralisation, introduction of market mechanisms, and privatisation. The MoH has retained a planning and regulatory role, but has largely devolved service provision to regional and local government bodies. Health sector reforms and decentralization raised new information needs and consequently led to changing requirements for information. The reforms increased the need for standardized and quality information for routine management and policy making Health Information System The HIS can be defined as a dynamic and flexible infrastructure, operating at the national and/or sub-national level, for the monitoring of health activities and population health outcomes. It encompasses human resources, values, legislation, inter-institutional relationships, technology and standards which contribute to the different stages of the data processing, such as: collection, analysis, storage, transmission, display, dissemination, and accessibility of data and information from complementary sources. Therefore, the HIS has been described as an integrated effort to collect, process, report and use health information and knowledge to influence policy-making, program action and research. The ultimate goal of the HIS is to produce relevant and quality information for making transparent and evidence-based decisions and taking actions in the health sector. Therefore, evidence of the continued use of the produced data for improving health system s operations and health status is needed to evaluate the system performance. 1

9 Thus, the HIS is an indispensable source of information for the effective management of health services, identification of strategy for healthcare system development, health policymaking, monitoring of health care provision, and conducting medical research. It also serves as a source of information on population health and provided health services for the mass-media and/or general public. HIS facilitates the exchange of health information for domestic and international cooperation. Health data is an important part of the state statistics. The abovementioned implies that the HIS should be an integral part of the health care system in every country. The National Health Information System (NHIS) implementation was initiated a few years ago by the Division of Health Information, Evidence and Communication at the WHO Regional Office for Europe. Development of the NHIS is currently on the agenda of the health sector reforms in Armenia Changes/reforms on the National Health Information System In February, 1996 the MoH approved the National Program of reforming and developing the HIS up to 2002, which was lately approved by the Government. Within the program the National Health Information Analytical Centre (NHIAC) was established in It was responsible for proper registration of state reporting forms and included various indicators, statistical data to develop analytical software and standardize the processes. The State Health Agency (SHA) was established in 1997, which is now the only institution authorized to reimburse providers for the provision of the services included in state financed Basic Benefits Package. It was originally designed to improve the efficiency of health financing management through the development of new medical and financial reporting forms, automation of data collection, analysis, and agency payments to providers. Meantime the Government decided to have integrated HIS for the entire health sector and the work commenced on the design of the HIS. In October, 2000, the Government of Armenia and the World Bank (WB) discussed the progress in Armenian HIS. According to the advice provided by the WB, the HIS proposal submitted to the Bank should include definition of information needs, flows, volumes and frequency of collection, followed by the presentation of technical hardware requirements to meet these needs. The detailed action plan, developed with technical assistance of the USAID/PADCO, was approved by the Ministry and accepted as a basis for further development of the HIS using internationally accepted methodologies. 2

10 The Bank s program, which started in , continued until Their software was implemented at 3 pilot regions. The WB healthcare sector programs in Armenian have been approved; it envisaged modernization of SHA HIS as well as other components related to NHIS. In 2002 Department of Management of Information Flows and Legal Provision was created in the structure of the MoH. It was mainly responsible for: Coordination of health information related activities of all organizations and health care facilities; collection and analysis of medical statistics and important health indicators, registration, reporting and dissemination of information; Development of health information reform programs; policies and strategies; information technologies; information system models and infrastructure at national and sub-national levels (as well as improvement of existing models); Participation in evaluation and prognosis of population health; research and monitoring of population health, health services and resources; research of health care system problem; Other activities within the scope of the MoH functions and legislation of the Republic of Armenia. The Department dealt with introduction and application of ICD-10 th review in Armenia, as well as improvement of quality of data (its efforts reduced the difference between MoH and NSS data, improved registration process, doubling forms were excluded, and the methodology for filling in these forms was developed. In 2005 all these responsibilities were transferred to the National Health Information Statistical Center, which is a structural unit of the National Institute of Health of the MoH Main Operators of the Health Information System Main actors within the health sector are: the MoH HIS, designed in collaboration with the MoH, regional governments and medical facilities, and developed (started in June 2003) in the scope of the WB program by the group of programmers; and the Medical Institutions Database Analysis System (MIDAS), deployed at the central office of the SHA at the MoH and its regional departments, as well as in several hospitals of Yerevan and in eight regions of Armenia. The MoH HIS is the only system that has been ordered by the Ministry as a formal HIS for all health care providers of Armenia and it was mainly designed to gather such data from the medical institutions that the MoH uses to produce annual statistical reports on population health and Health Care System performance: patient records; physician records; diagnoses; patients 3

11 enrolment; human resources and payroll tracking. The system incorporates financial, clinical and managerial needs. It only partially supports patient care management. The system is based on client-server technology with a networked server. The software is not Internet compatible. Users can not construct their own reports based on the system data. The networked implementation of the system is possible. Data interchange is available but not implemented yet. There are not drug master and procedure tables. It takes 2 days to train a user on the system. The main objective of the MIDAS is to accumulate monthly reports coming from the medical institutions (both hospitals and polyclinics) on services provided under the State Order. The system collects data on patient records, diagnoses, procedures, medications, finance, and drug inventory. The system is based on client-server technology with a networked server. The software is not Internet compatible at the moment, but it is expected to be the one in future. The system users can construct their own reports, depending on their needs. MIDAS was designed by the SHA (as a principle user) without collaboration with the MoH, being a home-grown system. It is password protected. Users have their login name and password as well as different levels of access to the database. Interface of the system is user-friendly and pretty simple. MIDAS contains standard drug master and procedure tables. It takes 1-2 days to train a user on the system. This system implementation supports as many institutions as needed. There are no software licensing fees paid. Patients usually are being identified by the passport number, birth date, and date of admission or discharge. Another potential actor is the State Hygienic- anti Epidemic Department (SHED) of the MoH, which, however, does not have its own automated information system; it receives information and data (on about 20 infectious diseases from its 37 regional and local offices) through reporting forms and transfers to the MoH after analyzing and interpreting. In addition, SHED regulates the sanitary safety of health care facilities. It should be mentioned that this system does not have necessary technical and software resources. The communication between different regional branches can be evaluated as poor. Regional Departments of Health (RDH), subordinated to the MoH, collect data on healthcare institutions of the regions, special data about healthcare, as well as other indicators. Their main function is implementation of the healthcare policy in the regions, as well as organization of the work of the medical institutions. The data collection for the MoH HIS project of the WB should be realized through RDHs. Main actors outside the health sector are: National Statistical Service (NSS- provides mainly socio-demographic data necessary to 4

12 calculate relevant health indicators and indices), Ministry of Labour and Social Affairs (collects various data on handicaps and other individuals which need help; develops the strategies for workplace injuries and occupational diseases prevention, elaborates and develops the information system in the fields of labour and social security), Department of Civil Status Registry (ZAGS) of the Ministry of Justice (MoJ) (provides data on natality and mortality), International organizations and donors: HIS under the project USAID (aimed at primary health care, mostly at family doctors activities), and HIS under the healthcare project of Canadian Development Agency (CIDA- targeted HIS implementation at primary healthcare level: e.g. establishment of database on immunization and prophylactic programs; as well as at the level of hospitals: intended to register patients visits, medical interventions). Thus, health information is produced and used by different institutions: the MoH, NSS, international organizations, donors... In other words, HIS have evolved in a fragmented way. Moreover, two large, relatively well-developed information systems, such as SHA and SHED, work relatively separately from the basic information flows within the health system; and a great deal of the data needed for the health sector is generated by actors outside the health sector. Therefore, one comprehensive and collaborative plan is needed to reform HIS, considering the need to sustain continued investments, since the resources required for strengthening HIS will mainly come from constrained national budget. On the other hand, the plan can help the international organizations, donors, communities, and all other concerned institutions to harmonize their efforts in a shared mission to strengthen NHIS in order to generate health information needed by all, since quality health information is a global public good Strategic vision of the National Health Information System The objective is to have a modern, sound, viable and effective NHIS reflecting the international standards (outlined in the HMN Framework) and on-going developments within the health sector of Armenia. High quality of health data will help to make better use of limited resources while planning, management and evaluating health sector activities, services and interventions and the better HIS will improve accountability and ensure evidence-based decision-making. Hence, the specific objectives are: 1. To adopt and adapt internationally accepted standards outlined in the HMN Framework to organize gathering, sharing, analyzing and using health-related data for decision-making. 5

13 2. To institutionalize the data quality assessment criteria according to Data Quality Assessment Framework (timeliness, periodicity, consistency, representativeness, disaggregation, estimation methods). 3. To present the health information (including epidemiological data) in formats that are relevant and comprehensible to policymakers, the public or those working in sectors other than health. 4. To be able to address emerging diseases and urgent health threats (since comprehensive surveillance is required for this). 5. To synthesize and analyze data, disseminate the resulting information to enable proper day-to-day management or longer-term planning and to improve health system functioning. 6. To seek a greater degree of integration of separate systems for surveillance and separate health information systems as well as ensure inclusion of non-state health care providers in the HIS NHIS Assessment The current Strategic Plan was mainly elaborated based on the results of the NHIS Assessment Project in Armenia, conducted with the support of the Health Metrics Network (HMN), and the document entitled "Using the HMN Assessment and Planning Workbook developed by the HMN to assure the data comparability between WHO Member States. Basic partners of the Assessment were the leading officials and experts of the health and related fields who represented regional and local governments, NGOs, health institutions, other international and local organizations, as stipulated in the HMN Framework. The list of the Assessment participants is representative enough for expert evaluation of HIS current condition in the republic, within the scope of the HMN Framework. In order to determine objectives and strategies for the NHIS development, there is a need to know exactly where it stands now. Thus, the main goal of the HIS Assessment in Armenia was estimation of the current level of HIS functioning in the republic according to stable but localized standards provided by HMN. In addition, the HIS assessment was needed to: serve as an objective baseline and facilitate follow-up evaluation; inform stakeholders on the aspects of HIS they may not be familiar with; reach consensus on priority issues for HIS development; support implementation of the NHIS. The assessment threw light on the HIS needs of the country and gave an opportunity to receive reliable data on: HIS resources of the republic (human, financial and technical), indicators, data sources, data management, information products, health information 6

14 dissemination and use. Overall, the assessment helped to identify gaps and problems in HIS and served as a basis for reviewing and strengthening the NHIS. 2. SUMMARY OF CONCLUSIONS FROM THE HIS ASSESSMENT 2.1. NHIS Resources HIS resources include the legislative, regulatory and planning frameworks needed to have a fully functioning HIS, and the resources needed for a system to be functional, namely: human resources, finances, logistics support, information and communications technology (ICT), as well as coordinating mechanisms (within and between the six components). According to overall assessment, the HIS resources are not adequate at all to accepted international standards with their size and quality Policy and Planning: The country has up-to-date enforced legislation providing the framework for health information and covering the following specific components: vital registration; notifiable diseases (on prevention of the disease resulting from Human Immunodeficiency Virus (HIV)); confidentiality; fundamental principles of official statistics (see also Appendix, pg. 48). The national HIS coordination committee was created in 2002 within the MoH by the Department of Management of Information Flows and Legal Provision but never worked. Theoretically, there are coordination mechanisms established by the National Statistics Service (NSS) and the MoH. In addition, the National Assembly adopted a law on statistical program and data exchange between MoH and NSS. Nevertheless, these mechanisms are not operational. There is also a regular system in place for monitoring the performance of the HIS and its various subsystems, but it has never been used. No policy exists on promoting the culture of information use throughout the health system but discussion is ongoing. There is no policy to conduct regular meetings at facility, district and other levels to review HIS information and take an action based on such information. There was no written HIS strategic plan. Overall, HIS policy and planning are not functional HIS institutions, human resources and financing: There is national capacity in core health information sciences to meet health information needs (epidemiology, demography, statistics, health planning), including those outside the MoH, but this capacity is only partially adequate to the accepted standards. The central HIS administrative unit (National Health Information Statistical Center of the National Institute of Health), which is not directly in the MoH, has very limited functional capacity and undertakes few HIS strengthening activities. 7

15 Less than 50% of health offices at sub-national level (marzes/ regions) have a designated full-time health information officer position. Limited capacity-building activities have taken place over the past year for HIS staff (statistics, software and database maintenance, and/or epidemiology) and for health facility staff (data collection, self-assessment, analysis, and presentation). Availability of ICT and database support to health and HIS staff at national and sub-national levels is limited and does not meet the needs of the staff. There are written guidelines for the processes of HIS data collection, management and analysis which are not implemented/ used. Rate of health information staff turnover at national level (at the MoH and NSS) is problematic. The structure of HIS unit or department has changed during 10 years about 5 times. There are specific budget-line items within the national budget, where national HIS budget-line items are limited but allow for adequate functioning of all data sources. In summary, these resources are not adequate at all HIS Infrastructure: A list capturing at least 90% of public-sector health facilities exists and is updated every year. There is also an up to date list covering 50%-79% of privatesector health facilities. There are occasional "stock-outs" of recording forms, paper, pencils and supplies but it does not affect ability to record required health information. Some managers at marz/ regional level and majority of managers at national level have access to computers. However, basic communications technology is not in place at the national and all sub-national levels and it affects ability to compile national and sub-national data as needed. There is not always ICT equipment maintenance support available and data reporting requirements cannot be met. In summary, HIS infrastructure is present but inadequate Indicators A core set of indicators should cover the three domains of health information: determinants of health; health system inputs, outputs and outcomes; and health status. Overall, indicators have been assessed as adequate (main health indicators have been implemented) in HIS of Armenia. National minimum core indicators are identified at national and sub-national levels but they do not cover all categories. The list of national core indicators is not adopted by Government. Less than 50% of the appropriate MDG indicators are included in the minimum core indicator set. Core indicators are defined in collaboration with relevant ministries and the NSS but more external participation would be desirable. Mostly, but not all criteria for selection 8

16 of core indicators were clear and explicit. Reporting on the minimum set of core indicators occurs on a regular basis Data sources Health information system relies on a set of core data sources. The data sources can be presented in two main categories: population-based which refer to the whole population (include: censuses, civil registration and population surveys) and institution-based data (include: individual records, service records and resource records). According to evaluation by Assessment Tool for Country HIS, the data sources used by HIS of Armenia are adequate to accepted standards. Vital statistics is estimated as highly adequate to accepted standards. Population-based surveys and health service records are adequate. Census, health and disease records, including surveillance and administrative records are present but inadequate. Data sources were evaluated by the following criteria: content, capacity and practices, dissemination, integration and use Census Capacity and practices: The Republic Armenia has adequate capacity and practices for two of the following three: (1) implement data collection; (2) process the data; and (3) analyze the data. The last population census was conducted in The required expenses made drams, about the 80% of which was financed by donor-countries and international organizations (WB, UNFPA, USAID, DFID) the rest was financed by the state budget of Republic of Armenia. Besides, a great support, which was equivalent to 1 million U.S. dollar, was given by the USAID, in the form of technical and consulting services and computer techniques. Data were collected by local interviewers and processed by NSS. A sample of households was re-interviewed to evaluate the quality of census data and printed report is available Content: The last census included questions on recent household deaths as well as questions for indirectly estimating child mortality and adult mortality Dissemination: All regions/marzes have immediate access to the last census report including descriptive statistics (age, sex, residence by smallest administrative level). This descriptive statistics was published in 2 years after data were collected. Accurate population projections by age and sex are not available for small areas (districts or below) for the current year. Microdata of the last census are available on request with defined restrictions: only requests of competent institutions are fulfilled. 9

17 Integration and use: Census projections are used for the estimation of coverage and planning of health services but the level is still not adequate to accepted standards. Thus, the population census was not free of limitations, especially the following two components: dissemination (present but inadequate) and integration and use (recognized as completely inadequate) Vital statistics In Armenia the data source for vital statistics (VR) is civil registration. Information on VR is managed by MoH, NSS and Department of Civil Status Registry (ZAGS) of the MoJ Content: Coverage of civil registration of deaths is at least 90%. Cause-of-death information is always recorded on the death registration form. Thus, content is highly adequate Capacity and practices: The Republic has adequate capacity to implement data collection, process and analyze the data from civil registration. The completeness of civil registration is assessed each time census is conducted. International Statistical Classification of Diseases and Related Health Problems (Tabulation list ICD-10) are currently in use for causeof-death registration. Proportion of all deaths coded to ill-defined causes (garbage codes) ranges from 5% to 10%, which is adequate to standards but has a room for improvement. Published statistics from civil registration is disaggregated by gender, age, and region (or urban/rural). Partially representative Sample Registration System (SRS- where VR are collected in randomly selected sample sites across a country to improve knowledge about basic health statistics in a population) and non-representative Demographic Surveillance System (DSS- focus on specific local populations for a prolonged period of time and may offer another valuable data source, but are not part of a national sample) sites are developed but these systems (SRS and DSS) are inadequate. Verbal autopsy tool used by DSS and SRS is not validated Dissemination: Information on vital statistics is disseminated adequately through annual reports. The information is published after 3 months from the time the data were collected. The information on mortality rates and causes of death are available at NSS website: Integration and use: Information from civil registration on mortality rates and causes of death is used for national and sub-national analysis and is evaluated as highly adequate Population surveys Capacity and practice: The country has adequate capacity to conduct household surveys. In the last 10 years nationally representative household surveys, which included 10

18 questions related to health, health practices or health services have been conducted in the Republic. Thus, since 2001, the NSS of Armenia conducts annually Integrated Survey of Living Standards (the first integrated household survey was implemented in 1996) with support of the World Bank s professional knowledge, methodology, and financial resources, which build the required capacity. The surveys cover households. In 2000 and in 2005Armenia Demographic and Healthcare Surveys (ADHS) were conducted to provide information on population and health issues in the country. Both ADHS were conducted by the NSS and MoH with technical support of ORC Macro and funded by U.S. Agency for International Development (USAID). The 2005 ADHS (covered 6,566 women and 1,447 men aged 15-49) was aimed to collect national- and regional-level data on fertility, contraceptive use, maternal and child health, AIDS and other sexually transmitted diseases updating many estimates of basic health and demographic indicators covered in the 2000 ADHS. The data allow disaggregation by age, sex and by region (marz) when sample size permits. The data allow disaggregation by socioeconomic status: income and education and when sample size permits by age, sex and region (marz). Surveys followed international standards for consent, confidentiality and access to personal data Content: The 2005 ADHS has measured the percentage of the relevant population receiving key maternal and child health services (family planning, antenatal care, professionally attended deliveries, immunization) and provided sufficiently precise and accurate estimates of infant and under-5 mortality. The survey have measured the prevalence of hypertension (1 of the priority non-communicable diseases) and smoking (one of the leading risk factors). The 2005 ADHS included blood pressure measurement, height and weight measurement among women and children under 5 years of age and measurement of the level of haemoglobin in blood (to determine anemia levels among women and children under 5 years of age) by medically trained personnel Dissemination: Metadata (design, sample implementation, questionnaires) used during 2005 ADHS are publicly available. Microdata are available on request with restrictions Integration and use: There is a multiyear plan to coordinate the timing, key variables measured and funding of nationally-representative population-based surveys that measure health indicators but it is incomplete and coordination group is unable to effectively coordinate surveys. There is adequate collaboration between health and statistical 11

19 constituencies in the country to work on survey design, implementation and data analysis and use. Thus, though population surveys are adequate, they have some limitations with respect to integration and use Health and disease records Content: Appropriate case definitions have been established and cases can be reported on the current reporting format for almost all key epidemic-prone diseases and diseases targeted for eradication/elimination. For several leading causes of morbidity and mortality and disability a measurement/assessment strategy exists and there are plans for extending coverage. There is no mapping of public health risks Capacity and practices: The country has adequate capacity for two of the following three: (1) diagnose and record cases of notifiable diseases; (2) report and transmit timely and complete data on these diseases; (3) analyze and act upon the data for outbreak response and planning of public health interventions. Percentage of health workers making primary diagnoses who can correctly cite the case definitions of the majority of notifiable diseases ranges from 75% to 89%. Less than 75% of health facilities submit quarterly or monthly surveillance reports on time to the district level; and less than 75% of districts submit quarterly or monthly surveillance reports on time to the next-higher level, which is not adequate to the accepted standards. Proportion of investigated outbreaks with laboratory results comprises about 90%. Individual patient records (patient charts or patient-retained "health passports") are usually completed adequately and can be retrieved for the majority of patients in time to promptly inform clinical decision-making. International Statistical Classification of Diseases and Related Health Problems is currently used for reporting hospital discharge diagnoses Dissemination: During past year the surveillance data are disseminated through regularly-published (monthly or quarterly) bulletins which are available at majority district health offices, thus meet standard requirements Integration and use: Health workers and managers face a heavy burden completing and reviewing separate reports for disease surveillance and other focused public health programs (e.g. maternal care, family planning, growth monitoring). At least 90% of epidemics noted at regional/provincial or national levels are first detected at district level. In summary, there are deficiencies related to content, capacity, and integration and use. 12

20 Health service records Content: There is a health-service-based information system that brings together data from all public and private facilities. There is no systematic approach to evaluating the quality of services provided by health facilities. Information on quality of services is available only from a convenience sample of health facilities Capacity and practices: The health information system has a cadre of trained health information specialists who have at least 2 years of training in less than 50% of districts. About 25% - 49% of health workers were trained in health information in the past 5 years. The mechanisms for supervision and feedback on information practices; as well as a mechanism to verify completeness and consistency of data from facilities are present but inadequate. Population projections based upon census statistics are used to calculate coverage rates (e.g. for immunization) by at least 90% of districts Dissemination: The last time that an annual summary of health service statistics was published with statistics disaggregated by major geographical or administrative region was 2-3 years ago. Regions adequately compile their own annual summary reports, disaggregated by health facility, though the activity is not well-organized in all districts Integration and use: Vertical reporting systems such as those for TB and vaccination communicate adequately with the general health service reporting system. Managers and analysts at national and sub-national levels adequately use findings from surveys and civil registration to assess the validity of clinic-based data. The data derived from health service records are used to estimate coverage with key services such as antenatal care, delivery with a skilled attendant and immunization. The data obtained from statistical reporting forms serves as a source for information published in the Statistic Yearbook published annually. In summary, health service records are evaluated as adequate according to all criteria but capacity and practices have been considered as present but not adequate Administrative records Content: There is a database of public health facilities with a coding system that permits integrated data management. The republic does not have Global Positioning Satellite (GPS) that includes health care facilities. The location of health care facilities is defined by the mail address. The national human resources (HR) database tracks numbers of health professionals by professional category in both the public and private sectors. Annual numbers of graduates of certain health training institutions (e.g. nursing; private institutions) are not tracked. Financial records are available on only general government expenditure on health and 13

21 external expenditure on health (private expenditure is not available). There is a system for tracking budgets and expenditure from all sources of finance disaggregated by sub-national level (general government including social security and local government, donors, health insurance), except out-of-pocket payments. Facilities are not required to report to higher level on the inventory; status of equipment and physical infrastructure; and on their stock of health commodities (drugs, vaccines, contraceptives, other supplies) Capacity and practices: There are human resources and equipment for maintaining and updating the database and maps of facilities, but they are not adequate to accepted standards. The human resources for maintaining and updating the national HR database were assessed as adequate. The national database of facilities as well the national HR database statistics on the number of public-sector health professionals were last updated less than 2 years ago. Adequate numbers of qualified, long-term staff are regularly devoted to work on National Health Accounts (NHA) but there is a need of external technical support. NHA provides routine estimates every year with 2-year lag. NHA routinely provides information on the following classifications: sources, agents, providers, functions. NHA provides information on health expenditure by at least 1 major disease programs and another area of policy concern. The number of adequately skilled human resources for managing the logistics of equipment, supplies and commodities is not adequate. Reporting on equipment and physical infrastructure is done by requests. Reporting on health commodities is incomplete Dissemination: In most regions maps showing the location of health infrastructure, health staff and key health services are available but not adequate. NHA findings are available within the agency and have been disseminated to public Integration and use: Managers and analysts at national and sub-national levels commonly evaluate physical access to services by linking information about the location of health facilities and health services to the distribution of the population, but situation in the republic is not adequate to standards. Policy-makers and other stakeholders are aware of the NHA findings and some of these findings have been used in budgeting and planning. Reporting systems for different commodities are somewhat integrated. Managers at national and subnational levels occasionally attempt to reconcile data on consumption of commodities with data on cases of disease reported. Thus, administrative records are inadequate according to all the mentioned criteria. 14

22 2.4. Data management Data management covers all aspects of data handling from collection, storage, qualityassurance and flow, to processing, compilation and analysis. Data processing and compilation can be briefly described as extracting and integrating of data. The process captures extracting data from data sources, ensuring data consistency and quality, and achieving conformity through data transformation (aggregation, calculation, cleaning, normalizing or merging tables, translating code values, or transposing values). The processed data can then be integrated in formats allowing generating tangible outputs and helping HIS actors in decision-making. Overall, data management has been assessed as present but inadequate in HIS of Armenia. There is a written set of procedures for data management including data collection, storage, cleaning, quality control, analysis, and presentation for target audiences, but these are only partially implemented. The HIS unit at national level is running an integrated database containing data from facility-based data sources including all key health programs, but has no reporting utility. There is also a database at sub-national level, with no reporting utility. There is no metadata dictionary providing data-variable definitions as well as their use in indicators, specification of data-collection method, periodicity, geographical designations, analysis techniques used and possible biases. Similar identifier codes are used in different databases for health facilities and administrative geographical units (e.g. marz, region, municipality, etc.) to facilitate merging of multiple databases from different sources but some work should be done to merge them Information products Data must be transformed into information which will become the basis for evidence and knowledge to shape health action. Information products are: health status indicators, health system indicators and risk factors indicators. All information products were separately evaluated as adequate and mortality indicators were estimated as highly adequate. Information products have been estimated according to the following 7 criteria: data collection method, timeliness, periodicity, consistency, representativeness, disaggregation, estimation method. According to the findings of the HIS assessment, the information products are adequate to accepted standards Health status indicators (morbidity and mortality) are overall adequate. The subcomponent mortality (measuring under-5 mortality and adult mortality from all causes, and maternal mortality) is overall assessed as highly adequate. It is considered highly adequate by data-collection method (vital registration of at least 90% of deaths), timeliness, periodicity, 15

23 representativeness, and adequate by consistency, and disaggregation. Estimation methods are assessed as present but inadequate: they are particularly inadequate for under 5 and adult mortality (all causes), but are highly adequate for maternal mortality: estimates use transparent, well-established methods. Overall, morbidity indicators (HIV prevalence and underweight in children (<59 months or <36 months)) are evaluated as adequate: highly adequate by timeliness, adequate by datacollection method, periodicity, consistency, representativeness, and disaggregation; not assessed by estimation method. However, data-collection methods used to measure HIV prevalence are not adequate: they included only HIV case reporting and did not utilize high-risk population surveillance with either random or purposive sampling. The most recently reported HIV prevalence estimate is based on data capturing one high-risk population in one location. The most recent estimate on underweight in children is not disaggregated by all 3 characteristics, namely, demographic characteristics (e.g. sex, age), socioeconomic status (e.g. income, occupation, education of their parents) and locality (e.g. urban/rural, major geographical or administrative region) Health system indicators captured outpatient attendance, measles coverage by 12 months of age, deliveries attended by skilled health professionals, tuberculosis (TB) treatment success rate under DOTS, proportion of children (<59 months or <36 months) sleeping under insecticide-treated bed nets; general government expenditure on health per capita (MoH, other ministries and social security, regional and local governments, extra budgetary entities), private expenditure on health per capita (households' out-of-pocket, private health insurance, NGOs, corporations), density of health workforce (total and by professional category) by 1,000 population. Overall, these indicators are assessed as adequate: they are adequate by timeliness, data-collection method, periodicity and consistency; and present but not adequate by estimation method. Clinic reports are reviewed at each level for completeness and consistency; inconsistencies are investigated ad hoc. Revisions are not consistent over time, and datasets are not consistent between clinic reports and sample clinic records. During the household survey, immunization cards were shown for less than 2/3 of children and datasets were not consistent between recent surveys and reports. The most recent estimate on measles coverage by 12 months of age is disaggregated by demographic characteristics (e.g. sex, age) and locality (e.g. urban/rural, major geographical or administrative region). 16