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

2. USE Presenting Interpreting Indicators ANALYSIS Processing Collection
Input
Raw data

3. 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

4. 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

5. 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

6. 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

7. 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?

8. 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)

9. 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)

10. 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, ,
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

11. 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

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

13. An ideal indicator RAVES !!!
An ideal indicator RAVES !!! 

14. 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

15. 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)

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

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

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

28. 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

29. 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

30. 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

31. Epidemiological questions

32. 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)

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

34. 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)

35. Information cycle meets
Planning cycle

36. 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

37. 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

38. 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

39. 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

40. 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