2. Health service provision and Health Information Systems

3. Two parts: Primary health care and the debate on how to provide it – Some history of WHO and so-called «global health» – Comprehensive vs selective PHC – Implications on information systems The Health District – Why is the software called DHIS? – District as the area of managing primary health care (Warning: the two concepts Primary Health Care and Primary care are not the same.. More later…)

4. Part one: Primary health care and the debate on how to provide it Main learning points – WHO early focused on eradicating certain diseases – The Alma Ata declaration from 1978 changed the focus towards general health, taking into account social and economic issues also – Decentralized Primary Health Care was seen as the core of government health provision, a change away from curative hospital-based care – How to implement it remains a debate: an integrated comprehensive (and complex) way, or a selective (simpler) way? – A selective approach has become dominant, and it has led to a fragmentation of efforts – Fragmentation remains a challenge

5. WHO’s history of success with focused programmes Smallpox eradicated in 1977 Eliminating polio in the Americas in 1985 Eliminating measles in Southern Africa Reducing guinea worm disease by 99% in 20 African countries between 1986 and 2005 Relative successful compared to other UN agencies (such as World Bank). Each disease eradication program operated autonomously, with its own administration and budget and very little integration into the larger health system 4

6. Health systems continued to be inefficient Short-term successes were not addressing poor populations overall disease burden Health systems were urban based, high- technology, curative oriented. Gave little contact with the population for preventive care Health is socioeconomic: – Health services, economy, security, education, nutrition… More comprehensive approaches emerged in a number of developing countries 5

7. The Alma Ata declaration (1978) and Primary Health Care (PHC) “Primary Health Care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of selfreliance and self-determination” 6

8. Primary Health Care Promotive, preventive, and curative Involves related sectors (education, food, agriculture etc), and wider aims (equity, affordability etc) Promotes community and individual involvement and committment Came as a reaction to older, high-tech, curative approaches. Based on bottom-up experiences from ”developing world” How to implement it? Comprehensive vs selective? Overarching question ever since. 7

9. Comprehensive PHC “Some argue that comprehensive primary health care was an experiment that failed; others contend that it was never truly tested.” – Magnussen, Ehiri, Jolly 2004 Cuba a good example where it has been tested, and worked. Also Mozambique and Nicaragua in the 1980s Abandoned as a WHO strategy already a year after it’s formulation in 1978 Why? 8

10. Selective PHC Launched just one year after Alma Ata, as an ”interim” strategy to achieve results Abandoned the social and economic side of the health strategy, and systems thinking in general, also for ICTs Narrow selection of specific conditions, mostly for women of child bearing age, and children – Immunization, growth monitoring, breastfeeding, oral rehydration therapy – Family planning, female education, food supplementation added later 9

11. Comprehensive vs. selective now? Both exists WHO is still very fragmented in specific programs, which are replicated at country level http://www.who.int/about/structure/organigram/en/ Cross-cutting units have been created (and died); Health Metrics Network In other areas, new agencies have been created to target specific areas: Global Fund, UNAIDS, GAVI Alliance 10

12. HMN Framework: An example of comprehensive appraoch to HIS 11

13. Comprehensive vs. selective: information systems Comprehensive: integration, comprehensive information needs, varied outputs Selective: Silos, fragmentation, inefficient development and utilization of infrastructure. Closed-boundary ICT systems. Potential for cross-comparison of indicators is lower. Both: provision of health services decentralized. IS needs to allow local levels to collect, process, and use information 12

14. The MDGs in the PHC tradition Adopted by UN in 2000, to reach by 2015 goals related to: 1.Poverty and hunger 2.Universal primary education 3.Gender equality 4.Child mortality 5.Maternal health 6.HIV/AIDS, Malaria, and other diseases 7.Environmental sustainability 8.Developing global partnership for development 13

15. The MDGs in the PHC tradition Despite the comprehensiveness of the MDGs, selective approaches within health continues Addresses some critique of selective PHC – Take into account the broader context of development – Does ackowledge the role of social and gender equity Still challenges related to: – Donor-driven technocratic approach to priorities, rather than grassroot approach of Alma Ata – Vertical objectives, fighting one disease at a time – Little coordination among vertical programs New actors find legitimacy in the MDGs for focusing on specific areas, contributing to and sustaining fragmentation The post-mdg era is approaching, what will it bring? 14

16. Concluding example: integration of data sources supports comprehensive PHC management 15

17. The Health District or Searching for efficient management of primary health care

18. Part two: The Health District Main learning points – We talk about health management information systems; assisting in managing health services is the goal – The «District» as a concept of appropriate first level of management – There is no ideal district; it is a balance of resources, aims, organization etc. They exist in most countries under names like district, county, kommune, etc

19. District: Bridge between primary, secondary, (tertiary care) Primary care: most health care, first point of consultation for all patients Secondary care: provided by medical specialists who in general do not have first contact with patients. Referrals; for example to radiology (x-ray) Tertiary care: specialized health care for inpatients in hospitals (not in districts)

20. What are the characteristics of a health district ? Population between 30,000 and 500,000 (most cases) Clearly delineated geographical area Identifiable form of local government Managed by few officers Balance between population size and availablity of technical specialised staff

21. What advantages presents the health district ? It is the most appropriate level for coordinating top-down and bottom-up planning It is close enough to the community (“the patient” to understand and act on its problems and constraints It has easier communication with the community to ensure its participation in planning and organization It presents large potential for effective collaboration with other sectors towards the health of the community It has the ability to handle decentralisation of resources and of decision-making It is the most suitable place to provide support to health workers in the health posts and health centres

22. Why size matters ?

23. ....greater number of health districts, then...  more management structures and systems  cohesion and co-ordination more difficult at a national or provincial level  it will cost more and fail to capture economies of scale  district hospitals will be managed as separate entities from the rest of primary level health care  could create a further dislocation between primary level services and district hospital services (many health districts without a district hospital) If the health districts are too small:

24.  district-level management can become unwieldy and bureaucratic  the District loses its “service delivery" functions  The District becomes too remote from the community. If the health districts are too large...

25. Health Centre/Dispensary Curative care of acute and chronically sick patients who do not require a doctor (ideally up to 85% of all cases) Antenatal care Obstetrics Family planning Infant care including vaccinations and development checks Community development (primary disease prevention in particularm as regards drinking water, disposal of solid waste and waste water,medical back-up for traditional birth attendants,village health workers, social workers, youth initiatives)

26. District Hospital Treatment of outpatients and management of emergencies Surgery (moderately complex surgery in the fields of obstetrics, general surgery, traumatology, urology) Treatment of serious internal and pediatric cases Technically complex diagnostics (radiology, ultrasound, laboratory) Training and upgrading (especially for other district staff) Collaboration on both clinical and public health studies and operational research Collaboration on the supervision of health centres/dispensaries echnical services and maintenance (for the entire district)

27. District Health Management Team Planning and management of the DHS including financial planning Personnel assignment and further training Management of physical resources including procurement of drugs, medical supplies and equipment Organisation of supervision Responsibility for the uninterrupted supply of drugs Coordination of studies and operational research Inter-sectoral cooperation

28. Lov om kommunale helse- og omsorgstjenester

29. What is the role of the HMIS in the health district?