District Health Information Systems Topic 5 Data analysis turning data into information João Carlos de Timóteo Mavimbe & Humberto Muquingue Oslo, April 2007

USE Presenting Interpreting Indicators ANALYSIS Processing Collection Input Raw data

By the end of this session, you should be able to: LEARNING OUTCOMES By the end of this session, you should be able to: Explain how data is converted into information Explain basic epidemiological terms and concepts Explain concepts of numerator and denominator Explain the meaning and use of terms: count, rate, ratio and proportion Make simple calculations Clarify session topic & learning outcomes

Data analysis turning data into information Review the situation of overloaded health workers who collect a range of stats without knowing why (% nursing time spent on stats collection) Comment on how health workers are often expected to collect stats and send them up without expectation of analysis, feedback & use of information Reinforce how the aim of a DHIS, to improve coverage & quality of local health services, is facilitated by only collecting data that can be analysed & used at the local level

Data analysis what, why and how? WHAT ? (meaning) turns raw data into useful information is the process of producing indicators – most important step in data analysis uses quality data – with the 3 C’s Explore the meaning (what) & purpose/use (why) of data analysis Emphasize that information allows comparisons between facilities & supports decision-making Explain that analysis (how) is based on epidemiological concepts

Data analysis what, why and how? WHY ? (purpose) the aim of a DHIS - the improvement of coverage and quality of local health services - is facilitated by only collecting data that can be analyzed and used at the local level allows comparisons – facilities / teams favors self assessment (have I reached my target ?) supports decision-making Explore the meaning (what) & purpose/use (why) of data analysis Emphasize that information allows comparisons between facilities & supports decision-making Explain that analysis (how) is based on epidemiological concepts

Data analysis what, why and how? HOW ? (use) calculates indicators uses basic epidemiological concepts Explore the meaning (what) & purpose/use (why) of data analysis Emphasize that information allows comparisons between facilities & supports decision-making Explain that analysis (how) is based on epidemiological concepts Can you provide examples?

Indicators - many definitions Occram’s rule Indicators - many definitions variables that help to measure changes, directly or indirectly (WHO, 1981) indirect measures of an event or condition (Wilson and Sapanuchart, 1993) variables that indicate or show a given situation and thus can be used to measure change (Green, 1992) Explore common definitions of indicators (meaning & use)

Indicators measures of COVERAGE and QUALITY variables used to measure CHANGE: monitor progress towards defined targets describe situations measure trends over time provide a yardstick whereby facilities / teams can compare themselves to others Explore meaning & use of indicators – application Illustrate with appropriate examples – immunisation indicator (% children fully immunised < 1 yr)

Indicators – there are many calculation types 1. “Count” – no denominator numerator - number of events, observations, individuals (frequency) 2. “Proportion” – numerator is part of denominator expressed as per 100 (%), 1000, 10 000, 100 000 3. “Ratio” – numerator is not part of denominator comparing 2 different numerators 4. “Rate” – a detailed proportion number of events during a specific period Reinforce that indicators are measures of the frequency of events Unpack how indicators can be viewed as calculation types – count, proportion & ratio Explore the 3 types of calculations that can be carried out on indicators Explore how indicators can be used to measure events in terms of – count (raw numbers), proportions (aggregated) & ratios

5. “Aggregated, composite or indexed indicators” - DALY (disability-adjusted life years) HALE (health-adjusted life expectancy) QALE (quality-adjusted life years) Explore the meaning (what) & purpose/use (why) of data analysis Emphasize that information allows comparisons between facilities & supports decision-making Explain that analysis (how) is based on epidemiological concepts

There are about 1,500 indicators in the health sector (World Bank inventory)!

An ideal indicator RAVES !!!  An ideal indicator RAVES !!! 

An ideal indicator RAVES RELIABLE it gives the same result if used by different people APPROPRIATE it is the best way of measuring what we want to know VALID it measures what you want to measure EASY it is feasible to collect the data to produce this indicator (KISS) SENSITIVE, SPECIFIC it reflects changes in events being measured Unpack formulation of indicators – how to write them Explore how indicators are used in the management & planning of health services Clarify the use of terms: input, process, output & outcome, as they relate to aspects of service management

a count of the event being measured Atop the line – numerators (activities / interventions / events / observations / people) a count of the event being measured How many occurrences are there: morbidity (health problem, disease) mortality (death) resources (humanpower, money, materials) Generally raw data (numbers) Unpack the meaning & use of numerators (illustrate with appropriate examples)

Under the line - denominators (population at risk) size of target population at risk of the event What group do they belong to: general population (total, catchment, target) gender population (male / female) age group population (<1, >18, 15-44) cases / events – per (live births, TB case) Unpack the meaning & use of denominators (illustrate with appropriate examples) Explore population groups used most frequently – age group cohorts

I. Systems classification INPUT monitors affordability of resources measures availability / quality of resources PROCESS monitors activities that are carried out measures accessibility of services – coverage and quality OUTPUT monitors results of activities measures acceptability - use, change, performance, coverage and quality OUTCOME monitors changes in health status of populations  IMPACT measures appropriateness - effectiveness, efficiency, equity, sustainability Explore how indicators are used in the management & planning of health services Clarify the use of terms: input, process, output & outcome, as they relate to aspects of service management

II. Functional classification Indicators can be grouped according to their function in plannning and monitoring: Health status Activities Quality Resources Output / Efficiency Efficacy Impact / Outcome

A. Health status indicators They inform about the causes of disease and death in a given population. Examples: Morbility rates of measles Death rates of TB Incidence rates of diarrhea Low birth weight rates

B. Activity indicators They inform about of volumes of work. Examples: Coverage rates of a programme Achievement indexes Use of services (OPD utilisation rates) Admission rates per inhabitant

C. Quality indicators They inform about the excellence of activities carried out. Examples: Antenatal attendance rates Direct obstetric death rates in the facility Vaccine dropout rates

D. Resource indicators They inform about the availability / quality of consummables, equipments, staff, health facilities and money. Examples: Cost of drugs prescribed per consultation Number of inhabitants per clinical officer Percentage of health facilities with vehicle for programme activities Availability of vital drugs

E. Efficiency indicators They refer to the volume of activities performed using a given resource. They inform whether the resources were well used, underused or overused  the ratio of inputs needed per unit of output produced Examples: Deliveries per nurse Bed occupancy rates Average length of stay

F. Output or efficacy indicators They show to what extent the expected result was attained with the available resources  “the degree to which outputs affect outcomes and impacts” Examples: Reported new cases of acute flaccid paralysis Incidence rates of EPI-targeted diseases Percentage of fully immunised children

G. Impact or outcome indicators The impact of a programme is the effect that programme induced on the overall health status and socio-economic conditions of the target population Examples: Nutritional status of children Percentage of new family planning acceptors Incidence and mortality rates due to HIV Infant mortality rates

III. Classification according to indicator level Local indicators Indicators from censuses and surveys

1. Local indicators Compiled from routine HMIS data Should follow principles of “minimum data set” and “information filter”

Minimum or Essential Dataset ► the minimum amount of data that needs to be collected ► for the effective management of services which allows them to make the greatest impact on the health needs of the community which they serve (thus improving coverage and quality) ► uses minimum number of data collection tools Unpack the main elements of WHAT, WHY & HOW of an EDS

The Information filter National Information Systems Community Information Systems District Information Systems Provincial Information Systems International IS Indicators, procedures and datasets: Community District Province National International Reinforce role of the info filter in developing a district-based EDS

2. Indicators from censuses and surveys Infant mortality rate Crude death rates Crude birth rate Death rates of children aged 0-4 years Maternal mortality rates Seroprevalence of HIV or BHep

Epidemiological questions

Explore what questions should be asked when confronted by any health scenario Comment that these questions are the basic epidemiological questions that are asked in order to fully describe & thus understand a health situation (potential health problems)

Epidemiology: who, where, when ? Explore the basic elements of any health problem that must be determined – who (person), where (place) & when (time)  

Epidemiology: what, why and how? WHAT ? (meaning) study of the distribution, frequency and determinants of health problems and disease in human populations WHY ? (purpose) obtain, interpret and use health information to promote health and reduce disease HOW ? (outcome) uses indicators to answer basic epidemiological questions Explore the meaning (what), purpose (why) and outcome (how) of epidemiology Unpack the meaning of the terms: distribution, frequency & determinants Explore WHY we analyze data? - when we study (understand) the distribution, frequency & determinants of health problems & disease - then we can obtain, interpret & use health information to - promote health & reduce disease (improve coverage & quality of care)

Information cycle meets Planning cycle

Information Cycle What do we collect? What do we do with it? Stages Tools Outputs Decision-making for effective management What do we collect? data sources & tools Good quality data What do we do with it? How do we use it? Quality at every stage EDS Interpretation of information analysis Data converted to information Revisit the information cycle – explore the role of information at each stage of the cycle & how it informs each stage - general discussion & brainstorming feedback How do we present it? Reports and graphs

Planning Cycle Where are we now? How will we know when we arrive? Stages Tools Outputs Where are we now? Situation analysis Review of plans Priority problems How will we know when we arrive? Monitoring and Evaluation Where are we going? Goals, Targets, Indicators Quality information at every stage EDS Reinforce that we are now at the last stage in the planning cycle – M&E – Reinforce that M&E are integral to the whole process Correlate M&E in planning cycle with use of information in info cycle – how do we use info? Comment that this is a poorly developed aspect in management – due to lack of training & lack of current & relevant information – DHIS is a mechanism to enable more effective management decision-making Reinforce that information should form the basis of all management decision making regarding planning of health services Comment that information is the means whereby the process & progress health services are making towards improving coverage & quality are monitored Key interventions Key strategies How will we get there? Action Plans

GOALS broad policies and long term objectives broad aims stated in general terms represent future direction Set at national level by political and health decision makers general objectives (aims, long term objectives) correlated with local context set at provincial and district levels by health managers Explain the meaning, use & formulation of goals Explore the importance of correlating national & provincial goals with the local context & need to modify if incongruent or disparity exists Explore differences between goals & objectives Illustrate with examples Goal: PHCA – Health for All by Y2K Objectives: 8 elements – eg. immunisation Targets: eg. 85% coverage

TARGETS they are a subset of objectives state exactly what has to be achieved, by whom and by when a realistic point at which to aim to reach a goal turning the goal into number terms Explain difference between objectives & targets – targets are a subset of objectives Explain the meaning, use & formulation of targets Explore the importance of correlating national & provincial targets with the local context & need to modify if incongruent or disparity exists

TARGETS Specific measurable based on changes in situation concerned should be SMART Specific measurable based on changes in situation concerned Measurable able to be easily quantified Appropriate fit in to local needs, capacities and culture Realistic can be reached with available resources Time bound to be achieved by a certain time Explain difference between objectives & targets – targets are a subset of objectives Explain the meaning, use & formulation of targets Explore the importance of correlating national & provincial targets with the local context & need to modify if incongruent or disparity exists