District health information systems

Transcription

1 District health information systems The development of district health information systems (DHIS) in the country is beginning to harmonise. This chapter notes that the Health Information System Programme (HISP) has established credibility and is being rolled out from several localities in the country. The results from eight health districts in five provinces are reviewed in the chapter. In the eight districts reviewed, standard data collection tools are being used now, mostly in the form of tick registers. These registers are different in several respects from one district to another but the most significant difference is in the number of data items required. It is observed that the use of computers for data capture has greatly enhanced the value of HISP. Introduction of computers at clinics has not been excessively difficult, provided that adequate training is given. The added advantage of having the data computerised at the clinic level is that electronic mail is also available and is used to transmit statistics to the district office. The point is made that it is essential to computerise clinics for a district health information system to function effectively. The definition of what is essential district information is still in evolution. Data analysis and feedback is on the whole still weak. However, it is also evident that little is known about what analysis and feedback is useful and appropriate. Both of these issues will require more work. Further issues for the future are the need to get people to use information more effectively, especially in the periphery, integrating district and hospital information systems, ensuring enough district level support for HISP, and providing central support for HISP software. The chapter concludes that for the proper functioning of clinics and the district health system generally it is necessary to standardise data collection tools. Furthermore sustainable ongoing support must be planned for and provided. Minimum data sets required at provincial level must be defined and set and there must be a provision in the plans for regular review of the process and of the information provided by the data collection and collation process. Jeff Muschel Liverpool School of Tropical Medicine and Department of Community Health Medunsa (Polokwane Campus) 147

2 Introduction In the last 12 months, district health information systems (DHIS) developments at the provincial and national Departments of Health have become increasingly harmonised. In addition to a variety of districtspecific activities, most provinces have agreed in principle, and in some cases have embarked on initiatives, to introduce the Health Information Systems Programme (HISP) process and data capture software at district, regional and provincial offices. The HISP process involves a co-ordinated programme of information training and support. These initiatives are supported by HISP, National Health Information System of South Africa (NHIS/ SA) and the Equity Project, and are based on the work of HISP in the Western Cape. For the short to medium term, initial HISP roll out activities in most provinces are likely to be on a limited, pilot or phased basis. In many parts of the country, there have been steady and sometimes significant changes to district health information systems. Some districts, however, are just beginning to reform and rationalise their information structures. Examples of good practice have been spreading rapidly. The objective of this chapter is to provide an overview of DHIS developments from a district perspective highlighting useful lessons. Eight districts in five provinces were reviewed for this chapter. a To select the districts, key informants were asked to recommend districts characterised by moderate to severe resource constraints where DHIS activities were progressing steadily and where interesting or useful experiences had been noted. District level developments that represent clear progress are reviewed. The focus is on areas in which there has been emerging consensus in the DHIS community regarding design, structure or functioning of DHIS components. Where appropriate, specific examples from individual districts are provided. Then issues requiring further attention are highlighted. This includes observations and recommendations concerning the proposed nation-wide HISP roll out. Concluding remarks and a summary of the more critical recommendations end the chapter. Areas of progress at the district level In each of the districts reviewed for this chapter, there have been significant strides made toward the development of an appropriate district health information system. Many of the positive developments are similar across districts, suggesting that there is emerging consensus on several key issues and that examples of good practice are beginning to be shared. Four main areas of progress are reviewed in the sections below. Implementation of standardised data collection tools In several provinces, a great deal of effort has been invested in the development of standardised data collection tools for the daily recording and monthly compilation of clinic statistics (and patient-linked information). These efforts have helped to enable relatively smooth and reliable data flows. a Four districts were visited under HST sponsorship during the last three weeks of July 99, and included Impendle/ Pholela/Underberg (IPU) and Okhahlamba-Emtshezi (O-E) districts in KwaZulu-Natal, Kwabhaca (Mt Frere) district in the Eastern Cape, and South Peninsula district in the Western Cape. Two districts in Mpumalanga were visited earlier in the year, under UNICEF sponsorship, as part of DHIS developments in the Northern Province. Finally, further insights are drawn from the author s work with two districts in the Northern Province (Halegratz and NMTTS). 148

3 12: District health information systems In all but one of the districts reviewed for this chapter, tick registers are used to collect the raw patient contact data needed to compile routine monthly statistics. (There remains, however, an astonishingly wide variety of data collection and data storage tools in use throughout the country.) For provinces or districts that are developing similar registers, Table 1 below outlines some of the advantages and disadvantages of the tick register models encountered in the districts visited. Table 1: Comparison of alternative tick register models Advantages Disadvantages Eastern Cape model KwaZulu-Natal model Mpumalanga model If used properly, statistics compilation at the end of the month takes minutes Permits individual facilities to monitor data items of their choosing (the register is large enough to include several blank columns) If used improperly, or if only a few tick columns are used routinely, can be a waste of resources Relatively small number of data items may be associated with higher accuracy (see discussion below) A4 size makes it less cumbersome than A3 models; may be more suitable for mobile services The register is not bound, but printed as separate A3 pages. This means that changes to the data sheet can be made easily and quickly Printing and distribution of the register sheets could be decentralised and fully customised at the district level Large number of data items may lead to inaccuracy (see discussion below) Can worsen duplication if clinicor patient-retained records are also in use There is no provision for keeping track of running totals, meaning that statistics compilation is demanding No space to permit monitoring of locally determined data items Space for diagnosis and treatment remarks appears insufficient There is no provision for keeping track of running totals Space for diagnosis and treatment remarks is limited leads to the use of multiple rows for each patient Summary tables at the bottom of the data sheet are complex and require considerable effort to complete Note: A simple statistics summary form is used with all models to compile monthly statistics. The registers currently used in the Eastern Cape, KwaZulu-Natal and Mpumalanga differ with respect to physical size, design and layout. More importantly, however, they differ in terms of the quantity (and content) of data required for each. A recent review of tick register models, conducted for the Health Systems Trust (HST) by the Department of Community Health at the University of Natal, 1 compared and contrasted an Eastern Cape model tick register used in Okhahlamba-Emtshezi (O-E) district with a provincial model issued by the Department of Health in KwaZulu-Natal. A key difference between the two registers is the number of data items required (46 tick columns vs. 14 respectively). 149

4 As part of the appraisal, a detailed assessment of individual patient entries in a selection of O-E registers found that only 65% of the expected number of ticks were actually recorded. In the KwaZulu- Natal register by contrast, 97% of the expected number of ticks were recorded. It should be noted that since the number of data items is different between the two registers, the expected number of ticks per patient is also different. Based on the diagnosis recorded for each patient entry reviewed in the study, a patient recorded in the O-E register should receive, on average, 2.5 ticks. By contrast, each patient recorded in the KwaZulu-Natal register should receive 1.4 ticks on average. It is unwise to generalise from these results, but if data quality is negatively correlated with data quantity, as the study suggests, then provincial management should evaluate carefully when choosing a standardised data collection tool. Where standardised tools have been introduced, there is evidence that efficiency has improved. The burden of information collection has been reduced as complex systems have been trimmed and streamlined. Unfortunately, in many cases the standardised tools are not being used as they were designed, and this may be leading to additional inefficiency. In Mpumalanga, because of a lack of space for recording patientspecific information, many of the data sheets examined at one clinic contained entries for only 3-5 patients, whereas the data sheet is designed to record 25 patients. Other examples can be found in the Eastern Cape and the Northern Province. It is evident that the basic data collection tool is an important element in the overall District Health Information System (DHIS) and efforts to develop appropriate tools can pay off. Problems with design can lead to potentially significant inefficiency and, possibly, problems with data quality. For this reason, sharing of data collection and analysis of experiences need to be actively facilitated at the provincial and national level. The use of computers for data capture In each district visited, computers are in place at the district office level to handle data capture, analysis and presentation, and data storage. HISP software is installed and in use on a routine basis in 5 out of the 8 districts visited. In Mpumalanga and in the Impendle/Pholela/Underberg (IPU) district, spreadsheets are used for data capture and storage instead of a database system. The experience of districts indicates that the introduction of computers at the district level has not been excessively difficult. In the majority of districts visited, the individuals involved in computerised data capture had had limited computer experience prior to DHIS efforts. Nevertheless, computers are presently used routinely. At the same time, however, ongoing support has been needed in several districts to help solve hardware and software problems and to enable the district information staff to become more productive. The foundation of this progress is, of course, training. In most of the sample districts, especially those with ISDS and/or HISP involvement, resources have been targeted for training both in basic computer literacy and in using the HISP software specifically, but there is evidence that additional training or more concentrated follow-up is necessary. In one of the clinics visited in KwaZulu-Natal, for example, a computer is used routinely to compile clinic statistics. The clinic also uses electronic mail to transmit the monthly statistics to the district office. Based on discussions with the staff using the computer, it was evident that this fairly sophisticated process was not always possible, because of periodic problems with either hardware or software. At the time of this author s visit, the clinic was unable to transmit via , and no one at the clinic could determine why the system was not operational. This would clearly have implications for the logistics of data reporting. 150

5 12: District health information systems The key message is that computers and computer support will be needed in the district to facilitate data capture, analysis and reporting. It is unlikely that a district office will be able to function effectively without a computer based information system, for example. The challenge for district management will be to determine the most appropriate balance between paper-based and computer-based tools for information management throughout the district. The district offices visited seemed to be coping well with relatively modest computer assets. Computerisation at sub-district offices or even clinics may yield benefits, but only if sufficient support is available. In all cases, investments in computer technology within the district should be based on clear objectives and on assessments of cost effectiveness. Defining a broader package of essential district information Presently, most provinces have adopted or will be adopting a provincial primary health care (PHC) Minimum Data Set (MDS). To a large extent, HISP and NHIS/SA have driven this process. It is clear, however, that an MDS for PHC is only one component of a broader set of information needed for more comprehensive district management. This broader set of essential district information would include, for example, management data on drug supply and transport systems, hospital data, human resources information, financial data plus qualitative and descriptive data. To date, there has been some progress in some districts on broadening the data set available to district management. In O-E district, hospital data and indicators have been incorporated into the basic data set captured and maintained on the HISP software by the district information officer. The O-E district data set also includes data items for school health. However, the hospital and school health data sets combined include over 80 data items, only some of which are likely to be useful to district management. Other examples exist of efforts to augment the essential district information package with information relevant to district management. In the Eastern Cape, for example, the minimum data set for PHC includes data items on essential drug availability. In Kwabhaca district, the transport co-ordinator generates useful monthly transport performance indicators. In the time available for district visits, it was difficult to determine whether or not this additional data has had any impact on district or peripheral level decisions regarding, e.g. drug supply or transport. Data analysis, reporting and feedback In each district visited, information staff have been working to improve data analysis and efforts are underway to generate useful feedback. In most of the districts reviewed, examples of both monthly and annual reports are available and have been disseminated to various target audiences within the districts. In IPU district, for example, the district information officer routinely produces a monthly report, which includes about a dozen raw data tables as well as several graphs and charts. In O-E district, the district information officer has started to generate analysed data, but its dissemination and use remain unclear. Kwabhaca district also routinely generates tables and charts that are compiled into reports and provided both to district management and to clinic supervisors. In addition to what has been observed during district visits, there are several good examples of district reports that have been produced in various places around the country (e.g. district reports from the HISP pilot districts, the 1997 report of the Stellenbosch Health District). On the whole, however, analysis, reporting and feedback remain quite weak at the district level. 151

6 One contributing factor may be the ambitious nature of many monthly reports. Several reports that have been reviewed for this chapter are excessive - they probably include too much information. This situation may be due in part to general perceptions about what a sophisticated DHIS ought to be producing. A larger number of smaller topic or programme-based reports might be a more effective model. Comprehensive, sometimes dense district annual reports seem to be the gold standard; the logical conclusion is that a monthly report ought to be just a condensed version of an annual report. There is evidence from several districts, however, that the information provided in overly ambitious monthly reports - or in monthly reports that consist mainly of numerous graphs and charts without much contextual analysis - is not being absorbed either at the district level or in the periphery. In truth, we know very little about what constitutes useful and appropriate feedback, particularly where data are concerned. Initial results from a study in the Northern Province indicate that perceptions of feedback are all over the map. The implication is that a great deal of feedback sensitisation will be needed, especially at the periphery, and that such sensitisation will require, again, considerable ongoing support. This issue will be considered in more detail in the next section below. Key issues for the way forward As districts continue to develop and refine their information systems over the next year, guidance, support and careful thinking will be needed in several key areas. The sections below outline some of the more critical issues. Ideally, ways of dealing with the issues raised below should be incorporated into provincial and national plans for rolling out the HISP process and software across the country. Getting people to use information more effectively People must be encouraged and enabled to use information in a meaningful way. This issue is raised in this chapter precisely because information use remains very limited in many districts, despite the commendable and significant efforts of DHIS workers across the country over the last few years. This situation can be partly explained by the simple fact that in many districts, particularly those that are struggling to get off the ground, resource allocation decisions are still made largely at managerial levels higher than the district or sub-district. As district management teams become more involved and experienced in the budget cycle, information about activities and outcomes will naturally become more essential. In other words, district management teams are, in many places, only beginning to make decisions that require accurate and reliable information input on a routine basis. As alluded to above, information use at the periphery, e.g. at clinic level, is particularly weak. Again, this may be partly because many clinic staff do not have much experience seeing any operational consequences resulting from their data collection efforts. As decisions by district and sub-district managers begin to have more and more operational impact at the level of service delivery (e.g. on staffing patterns or drug supply), information use at the periphery is likely to become more relevant and thus will be perceived as more essential and useful. b The recommendations in this section grew out of discussions with Dr Jorn Braa during a joint visit to Kwabhaca district in the Eastern Cape. Dr Braa has provided similar recommendations to district health information staff in Region E. 152

7 12: District health information systems In the meantime, efforts will need to focus on simple ways to improve the relevance and application of information at the periphery. In particular, three areas will need more attention: b Ensuring that enough clinic staff have basic exposure to information concepts and skills Ensuring that monthly reports are relevant, useful and can be absorbed, especially at the periphery Ensuring that clinic supervisors are sufficiently capable of providing feedback and support on data collection, analysis and review. Monthly reports should be as simple as possible and should seek to avoid information overload. For example, a monthly report might consist of no more than two pages (front and back to save paper!) and could include raw data in time series - to provide a month-by-month review of clinic activity - and one or two indicators that speak to a particularly relevant problem. Finally, clinic supervisors represent the most obvious link between information generation at the periphery and analysis/feedback at the district office. Their role as information analysts must be strengthened and they should be encouraged to experiment with ways of making information more real and relevant for the periphery. Integrating hospital and district information systems Several provinces are introducing comprehensive hospital information systems as a means of improving efficiency and, hopefully, revenue collection at hospitals. These systems are controversial and are both ambitious and resource intensive. In the context of overall district health systems development, the biggest challenge in this regard is to ensure that the new hospital information systems interface well with the district information systems developments that are underway. The hospital systems tend to be viewed separately from the district systems; this may be logical in terms of the relative scope of the two systems and in terms of operational realities. Nevertheless, provincial managers would be well advised to consider how the hospital systems could contribute to overall district management. In the Northern Province, plans are being developed to experiment with ways of establishing an appropriate interface between the two systems. One proposal on the drawing board is to introduce patientretained records simultaneously with the implementation of the hospital information system (HIS) at a district hospital. The objective of the work would be to determine the most appropriate way to pass on patient information from the hospital system to the patient, from which it can then be accessed by other facilities (through the patient-retained record). Another proposal is to begin generating routine hospital performance indicators through the HIS and making them available in an appropriate format to district management. Sorting out organisational issues It is widely accepted that the six steps to establishing appropriate district health information systems, developed by HISP and outlined in the DHIS guidelines, 2 is a useful formula for most districts to follow. It is clear, however, that the extent to which districts are able to implement the six steps - in whatever sequence - is dependent on the general level of district health systems implementation in a particular district or province. In the South Peninsula district in the Western Cape, for example, it has been difficult to build districtwide enthusiasm for an integrated, comprehensive district health information system primarily because the district itself is not united. Health facilities in the district are still managed by more than one authority - 153

8 there is really no incentive to work together on DHIS development, although efforts have been directed at this objective. Similarly, in the Northern Province, the DHIS pilot work has to some extent been constrained by the pace of district establishment. It is difficult to expand DHIS activities into new districts, for example, when district information officers are not generally appointed and in place. The biggest challenge in this regard is to ensure that DHIS developments - in particular HISP roll out activities - are matched by general level of progress in DHS implementation. If DHIS developments outpace DHS developments, there is a risk that stagnation will set in as enthusiasm wanes and skills atrophy. Other issues relevant to provincial and national HISP roll out plans Ensuring enough district level support for the HISP process One of the most appealing things about the HISP process (and, indeed, the software, too!) is the grassroots feel about it. This is largely due to the general approach taken by the HISP group: information systems should be active, inclusive and friendly systems that can efficiently inform decision making at all levels. The HISP approach attempts to ensure that people get involved and engaged with information humanware figures prominently in the HISP philosophy, as it should. HISP s general approach to DHIS development is manifested on the ground by a great deal of training, face-to-face support and capacity building. Perhaps the greatest challenge associated with a nation-wide scaling up of HISP is to ensure that enough resources are available on the ground to maintain the in-depth and ongoing support that will be needed once initial roll out activities are completed. In the Western Cape, for example, the HISP group has recognised that more intensive support is required in the HISP pilot districts to ensure that sufficient skills are in place and that things are functioning well from a technical perspective. Operationally, this has meant the appointment of HISP facilitators in each HISP pilot district. This will not be a feasible solution for the provincial departments of health generally. Although the need for ongoing support is clearly recognised by the HISP group, as well as key individuals in provincial and national information units, it is not yet clear exactly what shape such support will take. Each province has been requested to develop a roll out plan. From an initial reading of available roll out plans, however, it is not entirely clear that the national or provincial departments of health have paid sufficient attention to ongoing support needs. For the most part, provinces with capable and adequately resourced information units (e.g. the Western Cape and the Free State) should have little difficulty developing HISP support mechanisms at the provincial level. Other provinces, however, will have much more difficulty. Support structures, with clearly defined roles and responsibilities must be established at each level, but particularly within provincial and national information units. It would be useful, if not imperative, that provincial (and national) roll out plans are thoroughly reviewed and assessed in terms of ongoing support capability before intensive roll out efforts are initiated. 154

9 12: District health information systems Ensuring enough centralised support for the HISP software Ironically, perhaps, the HISP software may require proportionately more ongoing support than other systems currently used in the health sector (e.g. stand-alone systems such as PERSAL), precisely because it is based on commercial software packages that are routinely upgraded with new versions. Technical developments in software generally will continue to have an influence on the HISP application. In particular, the following issues are among those that will influence the use of the HISP software at district, provincial and national levels: The eventual replacement of Windows 95/98 (still based on DOS) to Windows 2000 (no longer based on DOS) The eventual replacement of Office 97 with Office 2000 The ongoing need to monitor and fix bugs, improve and maintain the system and manage provinceby-province upgrades. In addition, future plans for the HISP application include the development of additional modules, ultimately leading to a more comprehensive district information system. All of this will require clearly outlined plans and advanced support and guidance for the provincial departments of health. To date, advanced support for the software has been provided by a small group of people working through HISP (assisted to some extent by a not-much-larger group of HISP enthusiasts in provincial, regional and district information units). It is unclear at this stage exactly who will provide such support in the future, after initial roll out activities are completed. The national Department of Health would be a logical home for an advanced support group, but it does not appear that sufficient capacity is in place to take on this role. This issue should be resolved before the roll out process has proceeded much further than it already has. 155

10 Provincial updates Eastern Cape Information systems development has proceeded rapidly in the Eastern Cape, particularly in the last year. Early in the year, the HISP software was introduced at all regional and district offices in the province. In addition to using the PHC monthly data module, most regions have also begun to use the TB module to capture quarterly data. Standardised tick registers are used in many districts, and patient retained records are also fairly widespread. The Eastern Cape is taking a cautious approach to hospital information systems. Work has been done on developing a minimum data set (MDS) for district hospitals. It is likely that the HISP software will be used in some hospitals for data capture. The province is attempting to achieve a high degree of integration between district and hospital information systems. Free State In the Free State, a provincial PHC minimum data set is likely to be in place before the end of the calendar year. Efforts are under way to develop standardised data collection tools, based on a clinic register and monthly reporting form as used in other provinces. It is expected that systems in place at facility level will remain paper based for the short to medium term. A HISP rollout plan has been developed which will include the entire province, focusing initially on two pilot districts. The pace of rollout will be according to the capabilities and conditions in each region and district. A key challenge will be to find sufficient resources to upgrade existing PC hardware and to purchase new equipment. Gauteng Broad based information systems work in Gauteng is constrained by the complexity of organisational developments within the province. An action plan for HISP introduction is being developed, but the details of the plan are not available at the time of this writing. More work is needed on developing standardised tools for data collection and on establishing appropriate structures within districts for managing and using district information systems. In addition, commercial vendors are pushing a range of competing solutions, making it difficult to focus on a single standardised approach. KwaZulu-Natal In 1999, the Department of Health in KZN introduced a province-wide standardised clinic tick register, which includes 14 data fields in addition to fields for name, address and diagnosis and treatment, and is generating accurate patient statistics. 156

11 12: District health information systems A business plan for rolling out district health information systems has been drafted for the province. Support will be focused initially on a small number of learning sites. A provincial PHC minimum data set has been proposed, which includes a large number of data items and indicators - but the MDS is not yet implemented. As in other provinces, activities to strengthen and expand the DHIS may be hindered by the slow pace of district staff appointments. Mpumalanga District information officers have been in place in Mpumalanga for some time now, and information reporting structures are strong. Mpumalanga has developed a standardised PHC data sheet for monthly reporting which is used in all districts. The data sheet is very complex and includes a large number of data items, and may need re-working. In addition to province-wide developments in the districts, there are some local initiatives to improve the relevance and quality of information generated at clinics, including a project in Lydenburg to test a joint patient and clinic retained record system. Mpumalanga has declined to introduce the HISP software as a standard system for its districts. It seems, however, that the six steps of the HISP process and the HISP software may be initiated in two districts (as pilot sites) and in the regions (for collating existing data from the rest of the districts). This is considered an interim measure; longer term plans for Mpumalanga revolve around the introduction of a comprehensive computerised hospital information system and a corresponding system for district and facility implementation. North West District structures are well established in the North West; all districts have management teams in place, although district information officers are not appointed. The extent of information use at district level is unclear. Almost all hospitals are linked through a WAN and in roughly 20 hospitals, a Patient Administration and Billing System has been installed. The North West has developed a plan for HISP rollout and the Department of Health has approved the plan. HISP activities will begin in five pilot districts. The province has adopted a PHC minimum data set and is in the process of developing standard tools for collecting and reporting data. In a very positive development, the province has agreed to purchase sufficient PC equipment to support the rollout. Northern Cape A business plan for HISP rollout has been developed, focusing on Diamondfields and Namaqualand districts (there are only six large districts or regions in the Northern Cape). Standardised data collection tools are in use in some areas, but are not universal throughout the province. The Northern Cape has 157

12 awarded a tender for a hospital information system, but on a limited scale, with two initial modules (patient registration and billing) to be introduced in six hospitals. Most information systems development has taken place in the districts; information systems are relatively strong in Benede Oranje and Kalahari districts, which have benefited from ISDS support, and in Bo Karoo and Hantam districts, which have introduced tools based on the experiences in the ISDS districts. Strengthening of the provincial information unit will be a priority for the immediate future. Northern Province Since early 1999, two districts in the Northern Province Halegratz and NMTTS have been piloting a PHC monthly data package, which includes a tick register system (including a unified monthly summary form) based on the Eastern Cape model and the HISP software. To date, the project has been on a small scale, but will expand to 5 additional districts early in 2000 as part of the HISP rollout in the Northern Province. The Northern Province HISP rollout will focus initially on building capacity at regional and provincial levels. District level training programmes are also planned, but activities in districts are complicated by the uncertainty associated with district demarcation. Proposals have been developed to explore the integration of the evolving district information system with the ongoing hospital information systems project. The HIS project itself is experiencing considerable problems, including delays in LAN installations and difficulties with change management. Western Cape As the home of the HISP project, the Western Cape has benefited from significant information systems development activities over the last few years. The HISP software is in use in all regions and some districts and a standard Routine Monthly Reporting Form for PHC statistics is in use throughout the province. Individual facilities or municipal managers have often added fields to the minimum set to enhance the local management relevance of the data collected. The Western Cape continues to suffer from delays in establishing district structures; this problem is particularly acute in the urban metro areas. These delays are making it difficult to plan and implement information systems that are designed to serve an integrated district structure. Additional concerns in the Western Cape involve the planned implementation of a new hospital information system. The new system is very expensive and there are concerns that the hospital system is obtaining the lion s share of IT funding in the province, leaving few resources for district based developments. 158

13 Conclusions and recommendations 12: District health information systems Progress on DHIS development at the district level is readily apparent in many districts across the country. Still, a great deal of work remains to be done. In this concluding section, recommendations for the way forward are summarised. As districts begin to roll out the HISP process and software, sufficient attention should be given to the implementation of standardised data collection tools. The advantages and disadvantages of alternative models should be reviewed carefully, as there is considerable evidence that some data collection tool designs may exacerbate inefficiency at the district level. While there are recognised advantages to standardised data collection, observed inefficiencies and inaccuracies in currently used tools highlight the importance of a continued focus on data quality. DHIS implementation plans and activities should explicitly consider the ongoing support requirements for a) skills improvement and maintenance, b) hardware and software maintenance and problem solving, and c) nurturing and encouraging an information culture. Provincial departments of health should adopt minimum PHC data sets where they have not already done so, and then move on fairly quickly to identifying additional elements of essential information. District management teams should also be encouraged to identify their own districtspecific data items and indicators that should be collected in addition to the provincial MDS. In addition to a focus on the content of data collected, attention to the format and presentation of data is critical if data is to be useful for district level decision making. The importance of these issues will become more apparent as districts gain experience working through a budget cycle. District management teams should step back and review their practices for analysis and feedback of data and information. Efforts should focus on developing simple monthly reports that can be easily understood and appreciated by district staff. Provincial and district staff should experiment with ways of integrating DHIS development work with the hospital information systems that are being introduced in several provinces. Keep it simple and innovative. HISP roll out plans should be extensively reviewed to ensure that provincial capacity to support the process is either in place or can be developed reasonably quickly. A sustainable, long term mechanism for providing advanced support and guidance for the HISP software should be established (or at least proposed) as soon as possible, preferably before provincial roll out activities have moved ahead very far. 159

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