Routine Health Information system

By Atsede Mazengia (BSc, MPH)

UoG- 2022
Course Information
Course name: RHIS
Course code:HeIn2123
Course ECTS: 7 ECTS
Target: 2nd Year Advance standing BSc. Health Informatics Students
Academic year:2014 E.C (2022)

Course Instructor: Atsede Mazengia

Email: [email protected]

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 Chapter 1:
Health Information Systems
Learning outcomes

At the end of this session , students will be able to:

 Define Health system
 Identify building blocks of health system
 Define Health Information system(HIS)
 Identify the components of Health Information System
 Identify the data sources of HIS
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 Definition of terms
Health: Is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity.

System: Is an arrangement of parts and their interconnections that come

together for a purpose.
Health system: A health system is the sum total of all organizations, people,
resources and all activities whose primary purpose is to promote health, to
restore or maintain health.

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 Health System con…
Health systems have three objectives
 Improving the health of the population they serve
 Providing financial protection against the costs of ill-health (Risk Protection)
…sharing risk and providing financial protection => Fairness in financial
contribution
 Responding to people’s expectations (Responsiveness)…reflects the importance
of respecting people’s dignity, autonomy & the confidentiality of information

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 Health System Building blocks
 The 6 building blocks of the health system are:

1. Service delivery
2. Leadership and governance
3. Health workforce
4. Health Information systems
5. Medical products, vaccines and technologies
6. Health Financing
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 Health Information system (HIS)
It refers to any system that captures, stores, manages or transmits
information related to the health of individuals, which will improve
health care management decisions at all levels of the health system.

Sound and reliable information is the foundation of decision-making

across all health system building blocks.

It is essential for health system policy development and

implementation, governance and regulation, health research, human
resources development, health education and training, service delivery
and financing. 7
Key Functions of HIS
1.Data generation
2.Compilation
3.Analysis and synthesis
4.Communication and use

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 Components of Health Information System(HIS)
1. HIS Resources 4. Data management
 HIS coordination and leadership
 HIS information policies
 Data storage
 HIS financial and human resources  Ensuring data quality
 HIS infrastructure  Data processing and
2. Indicators compilation
3. Data Source
 Censuses 5. Information Products
 Civil registration  Data transformed in to
 Population surveys information
 Individual records
 Service records 6. Dissemination and use
 Resource records
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 Sources of data
 Data requirement is a continuum from patient care to strategic
management level & this implies that not everything needs to be
known at every level of the system.

 The quantity and detail of data needed is generally greater at lower

levels of the system, where decisions on the care of individuals are
made, than at higher levels where broader policy-making takes place
with different data sources. 10
Health Information Data Sources
Administrative
Census records

Vital
registration Services
records

Pop based Individual

surveys records

Population-based Institution-based

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 Data sources can also be classified as
routine and non-routine
A. Routine data sources
Routine HIS data source is an information system that allows routine data
Are collected continuously at various times periods (daily, monthly etc.)
Come from the HIS and its subsystems that are collected as part of an ongoing system
B. Non-routine HIS data source

Are collected at certain periods of time, or over a specific period of time

Come from special studies or surveys carried out for specific purposes

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 Sources of data…
Data sources of the Ethiopian HIS:
 Community level: CHIS, surveys and different household studies
 Facility level (HCs, Hosp. Private Facilities): Routine HMIS report &
surveillance report (PHEM), facility based researches and surveys
 Woreda, Zonal and Regional levels: HMIS, Surveillance data,
administrative data, surveys
 National level: HMIS, Census, demographic and health surveys (DHS),
national household surveys, different national level researches, modeling
and estimates
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 Activity 1

• Read the HMN framework and categorize the different Health

information systems

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 Chapter 2:
Historical development of RHIS

At the end of this session, students will be able to:

 Definition of RHIS, HMIS
 Historical development of RHIS
 RHIS/HMIS in Ethiopia
 HMIS reform guiding principles
 HMIS reporting hierarchy
 HMIS implementation challenges
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 Definition of RHIS/HMIS
 RHIS: is any system of data collection, aggregation, analysis,
interpretation, communication and use that provides information at
regular intervals.
 It is produced through routine mechanisms and comprises data
collected at regular intervals at public, private and community level
heath facilities and institutions.
 It includes HMIS, CHIS, LMIS, HRIS and LIS.
 In Ethiopian context usually RHIS is equivalent with HMIS.

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 Health Management Information System (HMIS)
 Is a system for collection, compilation and analysis of routine health
service data.
 It is the processing of data from various health components into
information that enables health workers & managers, planners, policy
makers and other stakeholders to make informed decisions.

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 Purposes of HMIS

 To routinely generate quality health information

 To use that information at each level of the health system for
management decisions to improve the performance of health services
delivery.

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 Components of HMIS

HMIS has two main components:

1. Information management component
2. Use of information for management purpose.

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 Components of HMIS cont…
1. Information management 2. Using information for management
purposes
 Data collection
 Problem identification
 Data processing
 Prioritizing problems
 Data analysis and presentation
 Decision making
 Action taking
 Monitoring
 Evaluation

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 Historical development of RHIS/HMIS
 Information systems are increasingly important for measuring and
improving the quality and coverage of health services.
 The global shift from
curative to preventive care,
hospital care to community and public health care,
centralized to decentralized health care,
a specific project approach to a comprehensive sectoral approach,
has necessitated the restructuring of fragmented health information
systems into single comprehensive HMIS.
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 RHIS/HMIS in Ethiopia

 FMOH adopted the three ones of harmonization principles; i.e. one

plan, one report and one budget principles across the health system

 The Ethiopian HMIS is designed in a way that can capture data from
the different level of health institutions (health facilities and
administrative health units) in the country.

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 Milestones of HMIS development in Ethiopia
Before 2008 G. C

 There was a huge data burden on health care providers due to Collection of many data
elements that cannot be used for decision making
 The health sector didn’t have a standardized HMIS: There were no standardized set of core
indicators, and no standardized recording and reporting tools and procedures
 The HMIS was not fully institutionalized
 Unintegrated data flow where different program units and institutions parallelly transmit
reports.
 Poor information use at all levels
 Very Limited resources for HMIS 23
 2008 to 2013 G.C
 A set of 108 core indicators were selected to monitor and evaluate the
performance of the health sector.
 Standardized data recording and reporting tools were developed for
each level of the health system
 Huge investment on capacity building and HMIS infrastructure
 Health information technician (HIT) curriculum was developed

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 2014-2016 G.C.
 The HMIS was revised for the first time since 2008 to address the
requirements of the changes in the health sector
 A total of 122 core HMIS indicators were selected.
 The recording and reporting procedures and tools were revised
 Since then some improvements have been observed with regards to
data quality and information use for evidence-based decision making.

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 2017 till now
 The HMIS indicators were revised due to a number of driving forces that have
resulted in the need for indicator revision.
 A set of 131 core indicators were selected
 The recording and reporting procedures and tools were revised
 Information revolution roadmap development with a focus on pillars of cultural
transformation in information use and digitalization
 There has been observed improvements with regards to data quality and
information use for evidence-based decision making.
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 The driving forces for HMIS revision at
different periods include:
 Gaps in monitoring the health sectors strategic and annual programs.
 Due to the introduction of new health initiatives.
 Requirements to align with international indicators and other factors.
Example: Need to align with WHO, SDG,
 Feasibility of data collection (cost, time, data burden, ...)
 Focus on quality, equity and universal health coverage

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 HMIS reform guiding principles

1. Standardization
 Common definitions throughout the health sector
 Define standardized recording and reporting instruments & procedures
2. Integration
 One report and one reporting channel
3. Simplicity
 Reduce number of data items, limited to those required by indicators selected
 Develop user friendly forms and procedures
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HMIS reporting hierarchy/channel

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HMIS information flow

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 Types of HMIS reports by content

o Service reports

o OPD morbidity report

o IPD morbidity and mortality report

o PHEM reports

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 HMIS reporting formats
o By Type:
 Service delivery report forms
 Disease (Morbidity & Mortality) report form
 PHEM reports
o By Health institution:
 Health post, Health center ,Hospital, clinics and WorHO/ZHD/RHB
o By reporting Period:
 Immediate/ Weekly report
 Monthly /Quarterly/annual administrative report
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 HMIS reporting period
S.No Type of Health Reporting level Latest date Frequency of
. care facility report should
be submitted reporting

1 Health facilities Sub-city/woreda/town 26th of the Monthly,

month Quarterly &
health offices Annual

2 Woreda Health Zonal Health Departments 2nd of the next Monthly,

month Quarterly &
Offices (Sub-cities) Annual

3 ZHDs/Sub-cities Regional Health Bureaus 7thof the next Monthly,

month Quarterly &
Annual

4 Regional Health FMOH 15thof the next Monthly,

month Quarterly &
Bureaus Annual
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 HMIS implementation challenges
 Lack of reliable data and Misuse of available information in
planning and management of health services were two main
weaknesses of the health information systems.
 The reason for non-use and under-use of information includes:-
Leadership
Working environment
Accountability
Resource constraint
Lack of management training, skills and personality
Inadequate dissemination

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 Activity 2

• Read HSTP of Ethiopia

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 Chapter 3:
RHIS Recording and reporting

At the end of this chapter, you are expected to:-

1. Identify the different types of registers
2. Identify the different types of tally sheets
3. Identify the different types of reporting formats
4. Identify reporting Periodicity in Ethiopia
5. Know and practice data entry in DHIS-2

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 1. Registers
Register: is a form/tool that is used to record the abstract information
from each service/ department required by indicators

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 Registers cont.…
 Every register has columns & rows
 Each row contains information for one patient
 The column contains information about that patient , and one piece
of information per column is available
 Contains reportable and non-reportable data elements
 Are data sources for computation of HMIS indicators
 Most registers have tally sheet , those registers which don’t have
tally sheet have a box for computation of reportable data elements

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 Types of registers
Serial (Case) Registers:
Each subsequent visit is registered as a new entry. E.g. OPD,
VCT, Abortion registers...

Longitudinal Registers:
Each client is stayed in the register so long as s/he is in the
service. E.g. EPI, ANC, FP, ART , TB...

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 Common Elements of ALL Registers
Identification:
Registration Number: sequential number.
Medical Record Number (MRN): Card number
Name: clients’ full name
Age: age in years/ in months
Sex: M for Male and F for Female
 Address:
Region, Woreda, Kebele, Gott and House number
Date: All dates are written in the EC as Date/Month/Year (DD/MM/YY)

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 2. Tally Sheet
Tally Sheet: is a piece of paper that is used to mark the number
of clients that use specific services
 A sole purpose of tally is to ease reporting
 each stroke represents single unit to be counted in
service; client/patient, dose
Example:
 Immunization tally,
 VCT tally
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 Registers and tally sheets…
There are
36+ Registers including logbook
15+ tally sheets

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 MCH Register(14)
1. Family Planning Register
2. Long acting FP Removal Register
3. ANC Register
4. Delivery register
5. PNC Register
6. PMTCT Register
7. Abortion care Register
8. Infant Immunization & growth Monitoring
9. TT Register
10. Human Papilloma Virus (HPV) immunization Register
11. Pregnant and Lactating Women (PLW) Nutrition Screening register
12. Therapeutic Food Program (TFP) Register
13. Neonatal and Intensive Care Unit (NICU) Register
14. Comprehensive and Integrated Nutrition Screening (CINuS) register

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 MCH tally sheets (8):

1. Family Planning Service Tally

2. Family Planning Methods Dispensed Count Tally
3. ANC Tally

4. PMTCT tally
5. Pregnancy testing tally
6. Abortion Tally

7. Immunization tally
8. Comprehensive and Integrated Nutrition Service (CINuS) Tally

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 Family Planning Register
 A longitudinal register used to record FP information for one year
for a single client
 After the fiscal year is completed, the client is registered again in
the same registration book
 kept in the FP Room
 The information required to complete the FP register is obtained
from woman’s card

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 FP Register cont…
New acceptors
 A client who has not received a contraceptive from a recognized FP program
previously at the time of registration
Repeat acceptors
 A client who has received a contraceptive method from a recognized FP program
in previous year (EFY).
Note: A client is counted only once as new or repeat in one fiscal year

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 Tallies used for Family planning service:

1. Family planning service tally

 Count the total number of new & repeat client, disaggregated by age

and type of method

2. Family Planning Methods Dispensed count tally sheet

 Collect the total amount of contraceptives distributed, by type of method

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 Long Acting FP (LAFP) removal register
 LAFP register is used to document the number of long acting family

planning methods removed

 It is used for women who came for removal of Long Acting Family

Planning methods

 The LAFP methods are disaggregated by method and period of removal

since insertion (< 6 months and >= 6 months)

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 Antenatal Care register
 It is a longitudinal register

 One row is used to document follow up data for one pregnancy

 Enables to follow the expectant mother throughout her

pregnancy
 The information required to complete this register is from
integrated RH card
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 ANC tally sheet
 Used for collecting 1st ANC disaggregated by Trimester
and age, 4th ANC visits disaggregated by age

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 Delivery Register

 It is a case register
 lists all clients who gave birth at the facility
 The information required to complete this register is found on the
clients’ integrated RH card
 Placed in the delivery room

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 Postnatal (PNC) Register

 Lists all clients receiving postnatal services at the health facility

 Each row has 5 sub rows; each sub row is used for one visit

 Information for this register is collected from the integrated RH card

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 PMTCT Register
 A longitudinal register.

 Used to follow HIV positive pregnant and lactating

women and the new born

 The register is kept in PMTCT service room.

 The register is completed by the PMTCT care provider

PMTCT Tally
 This is used to capture reportable data elements
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 Comprehensive Abortion Care Register

 It is a serial register

 Used to document Post abortion and Safe abortion care services

 Completed by service providers

 Kept in a room where abortion care service is provided

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 Abortion tally

 Abortion tally is used to tally data elements related to abortion

care services
 Abortion tally simplify reporting of the disaggregated data
elements

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Infant Immunization & Growth Monitoring Register

 A longitudinal register

 Each row is used to document all the required immunization

services data of one child
 completed by the service provider at time of service

 kept in the immunization room

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 EPI Immunization tally
 collects all infant vaccination and TT vaccine to women

 Immunization tally is filled at the end of each service

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 Human Papilloma Virus (HPV) immunization Register

 A longitudinal register

 Each row is used to document HPV vaccine for 9 years old girl

 completed by the service provider at time of service

 kept in the immunization room

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 TT (Tetanus Toxoid) Immunization Register

 A longitudinal register

 each row is used to document all 5 doses of TT vaccine

provided for pregnant and non-pregnant
 completed by the service provider at time of service

 kept in the immunization room

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 Neonatal Intensive Care Unit (NICU) Register

 It is a Case register where each row is used only for one visit

 It is used to record information about neonates who have been

treated in the NICU
 It should be completed by service providers after the service is
provided

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 Pregnant and Lactating women(PLW) Nutrition
screening register

 It is a longitudinal register

 It is used to record information regarding screening of pregnant

and lactating women for acute malnutrition
 It is kept at a department where the service is provided

 completed by the service provider at time of service

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 Comprehensive & Integrated Nutrition Services
(CINuS) Register
 It is a longitudinal register, where each row can be used for one child for one year in
repeated visits.
 It is used to record the following services:
Growth monitoring for children under 2 years of age
Nutritional screening for children under 5 years of age
De-worming and Vitamin A supplementation

 It is kept at a department where the service is provided.

 The information is completed by service provider after delivering the service.
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 Comprehensive and Integrated Nutrition Service tally
sheet

 It is used to simplify reporting of CINuS related reportable data

elements
 The tally is used to tally GMP, nutritional screening and Vitamin A
& de-worming services, disaggregated by age and nutritional status
category.

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 Therapeutic Food Program Register
 It is kept at a department where the service is provided

 It is used to record therapeutic feeding that is provided for Children < 5 years

of age with Severe Acute Malnutrition (SAM)

 The information is completed by service provider after delivering the service.

 Data related to admission and treatment outcome of children who have been

admitted to TFP centers will be recorded in this register

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HIV/AIDS HMIS Tools

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 VCT Register

• It is a case register

• Each row is used for one client only

• The register is kept in VCT service room

• VCT service provider (counselor) completes the register

VCT Tally sheet

• It is used to capture reportable data element from VCT service

• The tally is completed by the care provider

• Kept at the VCT room 66
 PITC Tally

 Help to tally information about all patients/ clients who are tested for HIV

 It should be available to all Service outlets except VCT

 The required information is tallied from OPD, IPD, FP, ANC, Delivery, PNC ,
safe abortion care, and TB registers …..

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 Pre ART Register
 Pre-ART register is a longitudinal register.
 It is used to follow PLWHIV until they start ART.
 The register is kept in HIV chronic care service unit.
 The register is completed by the care provider

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 ART register

 ART register is a longitudinal register.

 It is used to follow PLWHIV who are on ART.
 The register is kept in ART service room and is completed by the ART
care provider/ART data clerks
 The data is abstracted from ART follow up card

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 ART Tally
 ART clinical care and ART regimen tallies
 They are used to capture reportable data element from ART service provided.

PEP register
 PEP register is a longitudinal register.

 It is used to follow people who received PEP for occupational and non-
occupational exposure for HIV.

 The register is kept in ART service room and is completed by the ART care
provider. 70
TB and Leprosy HMIS Tools

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 Unit TB register
 Used to record data for patients who are on TB treatment

 It is a longitudinal register where patients are followed for the whole

period of treatment once they are registered
 Completed by the health service provider and kept at TB treatment
room

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 TB Contact screening & LTBI treatment follow up
register

 It is a longitudinal register where screened contacts are followed .

 Used to record data for TB patient contacts screening and follow up
for LTBI treatment..
 Completed by the health service provider and kept at TB treatment
room

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 DR TB Register

 It is a longitudinal register where patients are followed for the whole

period of treatment once they are registered
 It is used for facilities which started drug resistant tuberculosis
treatment.
 It is used to record data for patients who are on DR TB treatment.

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 DR TB follow up Register

 It is a longitudinal register where DR TB patients are followed

for the whole period of treatment once they are registered.
 The Register includes information for clinical monitoring for the
health facility.

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 Leprosy Register

 A longitudinal register where a patient registered is followed

until the end of the treatment period.
 The register is kept in leprosy treatment room and is
completed by the leprosy care provider

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 Leprosy referral and transfer form
This form used for leprosy cases
 Which is referred to your health facility for registration and starting
Leprosy treatment:
 Which is transferred out to your health facility to continue and
complete Leprosy treatment
 To refer the cases for further investigation and managements with other
health facility. 77
 Leprosy register for care after completion of treatment

Used to follow leprosy patients after completion of treatment

– For any disability or medical care

78
Clinical Service, Emergency and
Health system (Others)

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 OPD Abstract Register
 It lists all patients who received outpatient services at the facility.

 It is used for outpatient patients 5 years & older.

 Under five year children will be recorded in the IMNCI register.

 Data will be abstracted from the patient form

 The patient form and register are both completed by the service provider at the time

of OPD service.

 The register is kept at all out patient department 80

 New Vs repeat visits at OPD
Definitions:
New Visit

 A patient who visit for a new episode of illness

Repeat Visit

 A patient who visits the health facility for the same episode of
illness and or for follow up etc

81
 IPD/Admission/Discharge/ register

 It is a case register and is used to abstract data from the inpatient

departments
 Each row is used for one admitted patient.
 The same row is completed by the service provider on admission
and upon discharge.

82
 Tally sheets used in IPD;
1. IPD Service tally sheet
 completed at the time of discharge of admitted patients
2. PITC tally:
3. NCoD summary sheet
– Help to capture morbidity and Mortality cases at time of admission and
discharge.

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 Trachomatous Trichiasis(TT) surgery register

 It is a case based follow up register used to capture basic information

of patients who have TT surgery.
 Each row used for one patient.
 Kept at department where the procedure is done at HC or at Eye clinic
if available

84
 Cervical Cancer screening Register

 It is longitudinal register helps to capture basic personal and service

related information of clients who are screened for cervical Cancer

 Helps to follow clients with suspicious cervical ca treatment.

 Each row used for one client.

 Register kept where the service provided

85
Visceral Leishmaniasis Treatment and Follow up Register

 It is case register helps to capture basic personal and service related with

Visceral Leishmaniasis

 Helps to follow clients with Visceral Leishmaniasis Treatment and

Follow up

 Each row used for one client.

 Register kept where the service provided

86
 ICU Register

 A case register covering each row for a single client

 It is used to record information about patients who are treated in the

Intensive Care Unit (ICU).
 The Register should be placed in the intensive care unit room

 It is filled by service providers after service is provided

87
 Emergency Register

 A case register that is prepared for use in the emergency

department

 each row covers for a single client

 lists all clients who arrive with emergency case at facility

 It should be placed in the emergency unit/department

 It filled by service providers after service is provided

88
 Referral register

 It is used to document patients who are referred to or referred in

– The referral out can be to higher health facilities (for better care) or to lower health
facilities for continuity of care.
– The Referral in can be from other health facilities or from the community
 This register is kept at Liaison department for Hospital and Outpatient Department for HC
 The information required to complete this register is found on the clients’ referral paper

89
 Ambulance Service Register

 It is used to record information about community ambulance

request and service provided.
 Register is to be placed in ambulance dispatch center

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 Tracer drug availability Tally sheet

 This Tally sheet is kept at Pharmacy unit/Department

 It is used to follow the availability of tracer drugs in each day of the
month
Dispensing Register

 This register is kept at Dispensing unit

 It is used to record information about clients who received prescription and

came to dispensary

 Information in the register is filled by dispenser after service is provided

91
 Dispensing Register

 This register is kept at Dispensing unit

 It is used to record information about clients who received prescription and

came to dispensary

 Information in the register is filled by dispenser after service is provided

Supplier fill Card

 This Card is kept at Pharmacy unit/Department
 It is used to record the request and received line items by supply category and by
Supplier
92
 Central patient register

 It is a serial type of register

 It is kept at card room and completed by card room providers.

Data quality and performance monitoring logbook

It is a log book kept at HMIS/M&E unit at HF and Administrative health unit
This log book help to track report timeliness, completeness, LQAS score,
RDQA Data verification, Performance Discussion and... 93
 Reporting formats

By Type:
 Service delivery report forms
 Disease (Morbidity & Mortality) report form
 PHEM reports

By Health institution:
 Health post, Health center ,Hospital , clinics and WorHO/ZHD/RHB

By reporting Period:
 Immediate/ Weekly report

 Monthly /Quarterly/annual administrative report

94
 Activity 3
• Practice the revised 2017 HMIS recording and reporting tools
in Ethiopia

95
 Chapter 4.
Health and health related indicators

At the end of this chapter, you are expected to:-

Define terms related to health indicators like indicator, data element
Describe how to formulate indicators
Classify types of indicators
Explain indicator selection criteria

96
 Definition of Terms
Indicator
• Indicator is a variable that evaluates status and permits
measurement of changes over time.
• An indicator does not always describe the situation in its entirety,
but sometimes only gives an indication of what the situation might
be and acts as a proxy.
• Indicators are the basis of effective M&E system.
• Indicators are warning signals

97
 Definition cont.…

Data element:- refers to the name of an ‘event’ that can be counted.

• It is an input in calculating indicators.

Targets: Are a subset of objectives that state exactly what has to be

achieved, by whom and when.

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 Definition cont.…
Health Indicator: Is a variable that is used to measure change of
health service status over time.
e.g., life expectancy, mortality, disease incidence or prevalence)

Health Related Indicators: are indicators that are used to

measure/assess the necessary requirements/inputs for the healthcare
delivery like the human resource for health, the budget allocation and
utilization etc.

99
 Benefits of health and health related indicators
 Indicators are powerful tools for monitoring population health. 
 Indicators are used to support planning (identify priorities, develop
and target resources, identify benchmarks) and track progress toward
broad community objectives.
 Inform policy and policy makers, and can be used to promote
accountability among governmental and non-governmental agencies.

100
 Who should develop indicators?
 Indictors should be developed in a consultative process that includes
all those who have a stake in the development of the program/project.
 Once agreed upon, indicators give all parties, program managers and
personnel, researchers and key stakeholders, a common framework
against which to measure the progress and success of the program
over time. 

101
When should indicators be developed?
• Indicators should be developed at the beginning
of programs and can help researchers and
program managers track program progress over
the life of the program as well as measuring the
results of the program at the end.

102
 Steps in formulating indicators
1. Setting criteria for indicator formulation
2. Listing down possible indicators
3. Selecting indicators as per the agreed criteria: Documenting
rationale for selection
4. Defining the selected indicators: Numerator and denominator
5. Defining data source & frequency of data collection for the selected
indicators
6. Defining possible interpretation & use of the indicators
7. Setting benchmarks and targets for the indicators
103
 The following criteria can be considered during indicator formulation:
 Relevance: There should be a clear relationship between the indicator and
program
 Accuracy: The indicator measures what it needs to measure
 Importance: The measurement captures something that "makes a difference"
in program effectiveness;
 Feasibility: Data can be obtained with reasonable and affordable effort;
 Credibility: The indicator should be aligned with national and international
standards like WHO, UNAIDS, USAID etc.
 Validity: The indicator has been field-tested or used in practice;
 Distinctiveness: The indicator lacks redundancy and does not measure
something already captured under other indicators.
104
 Common Indicator Metrics
1. Count: describes the number of persons who received a particular
service or who have a particular disease
1. Number of service providers trained
2. Number of condoms distributed
2. Ratio: It expresses a relationships in the form of X:Y.
It is a measure for which numerator is not included in denominator (e.g :
sex ratio per 100 , Maternal mortality ratio)  
3. Proportion: Is a ratio in which the numerator is part of the denominator
4. Rate: Frequency of occurrence of an event during a specific time,
usually expressed per “k” population (k=1000, 10000, etc.).
e.g. Total fertility rate
105
 Types of indicators

 There are different classifications for indicators.

 Health indicators can be classified as
–Input
–Process
–output and
–outcome indicators

106
 1. Input indicators
Monitors affordability of resources
Measures availability of resources
 It measure resources devoted to a particular program or activity
(e.g., number of hospital beds, number of health workers,
vaccination doses purchased).
 It can include, among other items, buildings, equipment, supplies,
and personnel.
 Input indicators can also include measures of characteristics of a
target population (e.g., number of persons eligible for a diagnostic
trial).
107
 2. Process indicators
 Monitors activities that are carried out
 Measures accessibility of services coverage & quality
 It looks at the ways services are provided.
 They often measure the consistency or timeliness of activities carried
out in assessing and treating service recipients (e.g., diagnosis error
rates, order fill rates, stock wastage due to expiration or damage).

108
 3. Output indicators

Monitors results of activities

 Measures acceptability - use, change, performance, coverage & quality
• It measures the quantity services produced from the results of
process activities, or the efficiency of those activities (e.g., live
births per caesarean deliveries performed, post-surgical infection
rate).

109
 4. Outcome and Impact Indicators
Measures long term results of a program. Includes changes in knowledge,
attitudes, behavior, effects in the health status of the population, morbidity,
mortality etc.
Measures appropriateness - effectiveness, efficiency, equity and
sustainability
• Outcome and impact indicators measure the broader results achieved
through the provision of services.
E.g.. rate of stunting or wasting in children under the age of 5

110
 Key Performance Indicators (KPIs)
• KPIs are measures that a sector or organization uses to define success and
track progress in meeting its strategic goals.

Well-designed KPIs should help health sector decision makers to:

 Establish baseline information
 Set performance standards and targets
 Measure and report improvements over time
 Compare performance across geographic locations
 Benchmark performance against regional and international peers or norms
 Allow stakeholders to independently judge health sector performance.
111
 Selection of indicators

 Indicators should be feasible

 Indicators should be comprehensive, valid (sensitive), standardized,
meet quality criteria, and be flexible (never fixed and final) to
support evolving health strategies and policies.
 Indicators should consider the long-term as well as the short-term
objectives and how each will be measured.
 Indicators should be SMART

112
 Characteristics of Indicators
Indicators should be SMART
 Specific:- It should be able to measure a specific disease, service provided,
practice or task.
 Measurable:- consistently measurable in the same way by different
observers
 Achievable:- Does the indicator measure something within the program?
The target level should be a challenge, but not impossible to reach.
 Relevance:- Does the indicator measure the most important result of the
activity?
 Time-bound: There is a clear deadline for when the target must be
achieved. 113
 Chapter 5:
HMIS indicators in Ethiopia

At the end of the session you will be expected to:-

• Describe the national HMIS indicators

• Describe data source for HMIS indicator formula, calculation and
interpretation and identify reportable data elements for registers

114
 Overview of the national HMIS indicators

 The revision of Ethiopian HMIS in 2017 has resulted in the selection

of 131 HMIS indicators
 These are categorized into 4 major perspectives during the
development of the HSTP.

1. Community Perspective :- “C”

2. Internal Process :- “P”
3. Financial stewardship:- “F”
4. Capacity building:- “CB”
115
 131 Indicators by 4 perspectives
C1: Improve Access to Health Services (97 indicators)
C2: Community Ownership (3 indicators)
F1: Resource Mobilization and Utilization (4 indicators)
F2: Health Insurance (3 indicators)
P1: Quality of health Services (8 indicators)
P2: Pharmaceutical Supply and Services (4 indicators)
P3: Evidence Based Decision making (3 indicators)
CB1: Health Infrastructure (4 indicators)
CB2: Human Capital and leadership (4 indicators)
CB3: Regulatory System (1 indicator)
116
 HMIS indicator data source, formula and interpretation

 The national core HMIS indicators are described in an indicator

reference sheet, a table that includes their definition, formula,
interpretation and disaggregation, source of data and frequency of
reporting by level.
 This standardized sheet allows us to have a standard guide to
measure the performance of the health sector from routine health
information system.

117
 Data sources and data elements
 In order to compute each HMIS indicator, it is essential to identify
the data elements and data sources that are used to calculate the
indicator.
 The data sources for each data element can be register or tally sheets.
Data sources: This includes population based or facility based sources
for the health information system.
 A facility based sources of health information includes registers and
tally sheets.
Reportable data elements: These are the important elements to be
reported on regular basis from the source documents like registers.
118
A. Maternal and Child Health
Program Indicators

119
 Family Planning Program Indicators

1. Contraceptive acceptance rate (CAR)

Formula Number of new and repeat acceptors *100

Total number of women of reproductive age (15-49) who are

not pregnant

Interpret CAR is directly related to operations and measures the number of

ation new and repeat contraceptive acceptors in one fiscal year. In order to
increase contraceptive utilization (and hence Prevalence), the
numbers of both new and repeat acceptors should increase. Each
acceptor is counted only once, during the first visit when s/he
receives contraceptive services in the specified Ethiopian fiscal year.

120
 New and repeat acceptors
 New acceptor: a client who has not received a contraceptive from a
recognized FP program previously at the time of registration
 Repeat acceptor: a client who has received a contraceptive method
from a recognized FP program in previous year (EFY).
Note: A client is counted only once as new or repeat in one fiscal year

121
 Data source for CAR
• Family Planning Register
• FP register is a longitudinal register used to record FP information
for one year for a single client
• After the fiscal year is completed, the client is registered again in the
same registration book
• kept in the FP Room
• The information required to complete the FP register is obtained
from woman’s card

122
 Reportable data element in FP registers
frequency and level of reporting
No. Reportable data element Disaggregation Frequency Level of Type of
Reporting tally used

1 Number of new acceptors, Age, Method Monthly HP, HC, clinic, FP tally
Hospital

2 Number of repeat acceptors Age, Method Monthly HP, HC, clinic, FP tally
Hospital

3 Number of clients tested for Age, Sex Monthly HC, clinic, PITC
HIV Hospital

4 Clients testing positive for Age, Sex Monthly HC, clinic, PITC
HIV (at PITC) Hospital

5 Number of Family planning Method Annual HP, HC, clinic, FP methods

methods issued/dispensed Hospital dispensed
123
 Antenatal Care Program Indicators
1. ANC coverage – first visit
Formula Number of pregnant women that received antenatal care at least once
X100
Total number of expected pregnancies

Interpretation  Antenatal care coverage is an indicator of access and use of health care services during
pregnancy.
 ANC first visit coverage is categorized into two as:- early ANC (< 16 weeks) and those
>16 weeks so that ANC initiation period (Early Vs late) can be determined and
monitored.
 Early ANC often detected if the woman exactly knows her LNMP, and or in Ultrasound
detection.
 Pregnant women who begin ANC visit before 16 weeks play crucial role in early
detection of complications that may affect the outcome of the pregnancy.

Data source  ANC Register

124
 2. ANC coverage – four visits
Formula Number of pregnant women that received antenatal care at least four visits X100

Total number of expected pregnancies

Interpretation  The fourth antenatal care visit is an indicator of quality and continued
use of health care during pregnancy.
 The antenatal period presents opportunities for reaching pregnant
women with interventions that may be vital to their health and
wellbeing and to their infants.
 Receiving four focused antenatal care visits increases the likelihood of
receiving effective maternal health interventions during antenatal visits.

Data  ANC register

source

125
 3. Percentage of pregnant women attending antenatal care clinics
tested for syphilis:

Definition Proportion of pregnant women attending antenatal care tested for syphilis

Formula Number of pregnant women tested for syphilis

Number of pregnant women that received 1st ANC X100

Interpretation  Syphilis affects the health of pregnant mothers and their fetus.
 It may cause abortion, still birth, premature birth and congenital anomalies.
 Performing syphilis screening test for all pregnant mothers helps to detect the
disease early so that appropriate treatment can be provided to protect the mother and
the fetus from complications

Data source  ANC register

126
 Reportable data element in ANC register, frequency and level
of reporting
No. Reportable data element Disaggregation Frequenc Level of Type of
y Reporting tally used
1 Number of pregnant women that received ANC Age, Gestational Monthly HP, HC, clinic, ANC tally
first visit week Hospital  
2 Total number of pregnant women that received Age Monthly HP, HC, clinic,
four ANC visits Hospital
3 Total number of pregnant women tested for Test result Monthly HC, clinic,
syphilis Hospital
4 Total No. of reactive pregnant women treated for None Monthly HC, clinic,
syphilis Hospital
5 No. of pregnant women tested for hepatitis Test result Monthly HC, clinic,
Hospital
6 Total number of reactive pregnant mother treated None Monthly HC, clinic,
for hepatitis Hospital
7 Number of pregnant women tested for HIV and Age Monthly HC, clinic, PITC tally
know their result during pregnancy Hospital  

8 Total Number of partners of pregnant ,laboring None Monthly HC, clinic,

and lactating women tested and know their Hospital
127
results
 Delivery Program Indicators
1. Proportion of births attended by skilled personnel

Formula The number of births attended by skilled health personnel

X 100
Total number of expected deliveries

Interpretati  All women should have access to skilled care during pregnancy and childbirth to ensure prevention,
on early detection and management of complications.

 Assistance by properly trained health personnel with adequate equipment is key to reducing maternal
deaths.

128
 Other delivery indicators
 Caesarean section rate
 Proportion of institutional maternal death
 Still birth rate
 Early neonatal death rate (institutional)
 Percentage of Low birth weight
 Proportion of asphyxiated neonates who were resuscitated (with
bag & mask) and survived

Data source for delivery program indicators: delivery register

129
 Reportable data element in delivery register,
frequency and level of reporting
No. Reportable data element Disaggr Frequenc Level of Type of
egation y Reporting tally used
HC, clinic, Hospital
1 Number of births attended by skilled None Monthly
Health personnel
HC, clinic, Hospital
2 Number of deliveries by cesarean None Monthly
section
HC, clinic, Hospital
3 Number of institutional maternal None Monthly
None
deaths
HP, HC, clinic,
4 Number of live births None Monthly Hospital

HP, HC, clinic, Hospital

5 Number of still births None Monthly

130
 Cont.….
No. Reportable data element Disaggregati Frequenc Level of Type of
on y Reporting tally used
6 Total number of newborns weighed None Monthly HP, HC, clinic,
Hospital
7 Number of newborns whose weight is less None Monthly HP, HC, clinic,
than 2500gms Hospital
8 Number of early neonatal deaths None Monthly HC, clinic,
Hospital
9 Number of women who received HIV test Age Monthly HC, clinic,
Hospital None
10 Number of women who tested HIV positive Age Monthly HP, HC, clinic,
Hospital
11 Total IPPFP acceptors Age Monthly HC, clinic,
&Method Hospital
12 Number of neonates treated for birth asphyxia None Monthly HP, HC, clinic,
Hospital
& survived
131
 Postnatal (PNC) Care Program Indicators
 Early postnatal care coverage
 Institutional maternal death
 Percentage of pregnant women who were tested for HIV and who know their
results during pregnancy, labor and delivery and post-partum period
 Early institutional neonatal death rate
 Proportion of Sick Young infants treated for sepsis/VSD (Very Severe Disease)
 Proportion of low birth weight or premature newborns for whom KMC was
initiated after delivery
 Proportion of asphyxiated neonates who were resuscitated (with bag & mask) and
survived

Data source for PNC Program indicators: Postnatal (PNC) Register 132
Reportable data element in PNC registers frequency and level of reporting
No. Reportable data element Disaggregatio Frequency Level of Type of
n Reporting tally
used

1 Number of postnatal visits within 7 days of Period Monthly HC, clinic, None
Hospital
delivery

2 Number of institutional maternal death None Monthly HC, clinic,

Hospital

3 Number of pregnant women who were tested None Monthly HC, clinic,
Hospital
for HIV and who know their results during
post-partum period

4 Number of women tested positive for HIV None Monthly HP, HC, clinic,
Hospital

5 Number of neonatal deaths in the first 24 None Monthly HP, HC, clinic,
Hospital
hrs of life/institutional/
133
 Cont.…
No. Reportable data element Disaggregati Frequency Level of Type of
on Reporting tally used
6 Number of neonatal deaths between Period Monthly HC, clinic, None
1-7 days of life/institutional/ Hospital

7 Number of sick young infants 0-2 None Monthly HC, clinic

months treated for sepsis Hospital

8 Total IPPFP acceptors Age Monthly HC, clinic

Method Hospital
9 Number of Newborn weighing None Monthly HP, HC, clinic,
<2000gm and premature newborns for Hospital
which KMC initiated

10 Number of neonates treated for birth None Monthly HP,HC, clinic

asphyxia & survived Hospital
134
 PMTCT Program Indicators
1. Percentage of pregnant, laboring and lactating women who were tested for HIV and who
know their results
2. Percentage of HIV-positive pregnant women who received ART to reduce the risk of
mother-to child-transmission during pregnancy, labor & delivery (L&D) and PNC
3. Proportion of HIV exposed infants with virological test
4. Percentage of infants born to HIV-infected women who were started on co- trimoxazole
prophylaxis within two months of birth
5. Percentage of infants born to HIV-infected women receiving ARV prophylaxis for PMTCT
6. Percentage of partners of pregnant, laboring and lactating women tested for HIV
7. Percentage of HIV exposed infants receiving HIV confirmatory (antibody test) test by 18
months

Data Source for PMTCT Indicators: PMTCT Register

135
 Reportable data element in PMTCT register, frequency and level of
reporting
Reportable data element Disaggregation
No.

1 Number of HIV positive Pregnant women who received ART to reduce the risk of mother to none
child transmission during ANC for the first time
2 Number of HIV positive Pregnant women who received ART to reduce the risk of mother to none
child transmission during L&D for the first time
3 Number of HIV positive Pregnant women who received ART to reduce the risk of mother to none
child transmission during PNC for the first time
4 Number of known HIV-positive women who get pregnant and linked to ANC/PMTCT none

5 Number of HIV-positive women who get pregnant while on ART and linked to ANC none

6 Number of HIV exposed infants who received Virological HIV test 0- 2 months of birth Test Result

7 Number of HIV exposed infants who received an Virological HIV test 2-12 months of birth Test Result

136
 Cont.…
Reportable data element Disaggregation
No.

8 Number of infants born to HIV positive women started on co-trimoxazole prophylaxis within none
two months of birth

9 Number of HIV exposed infants who received ARV prophylaxis 6 wks, 12 wks
10 Number of HIV exposed infants receiving HIV confirmatory (antibody test) by 18 months Test Result

11 Total Number of partners of pregnant ,laboring and lactating women tested and know their HIV positive
results
12 Number of adults who are currently on ART Age , regimen type

13 Number of PLHIV on ART documented as Lost/lost to follow up during the reporting period. none

14 Number of adults and children with HIV infection newly started on ART Age, Pregnancy, Status

15 Number of adults and children who are still on treatment at 12 months after initiating ART Age, Pregnancy, Status
137
 Cont.…
Reportable data element Disaggregation
No
.

16 Number of persons on ART in the original cohort including those transferred in, minus those transferred Age, Pregnancy, Status
out (net current cohort).
17 Total number of adult and pediatric ART patients with an undetectable viral load <1000copies/ml at 6 Age,Pregnancy, status
month
18 Number of adults and children who initiated ART in the 6 months prior to the beginning of the reporting Age,Pregnancy, status
period with a viral load count at 6 month visit

19 Total number of adult and pediatric ART patients with an undetectable viral load <1000copies/ml in the Age, Pregnancy, status
reporting period
20 Number of adult and pediatric ART patients with a viral load test in the reporting period. Age, Pregnancy, status

21 Number of PLHIV who were assessed/screened for malnutrition Age, Pregnancy, status

22 Number of PLHIV that were nutritionally assessed and found to be clinically undernourished Age,
Pregnancy ,nutritional
status
23 Number of clients who were on ART and screened for TB during the reporting period Age,Pregnancy, status

24 Number of PLHIV women who are using modern family planning Age,Method
138
 Comprehensive Abortion Care indicators

Number of women receiving comprehensive abortion care service

• Data source: Comprehensive Abortion Care registers

139
 Reportable data element from comprehensive abortion care register
No. Reportable data element Disaggregati Frequency Level of Reporting Type of
on tally used
1 Number of safe abortions performed age Monthly HC, clinic Hospital
  and above

Comprehensive Abortion Tally sheet

2 Number of post abortions performed age Monthly HC, clinic Hospital
and above
3 Number of women receiving comprehensive Trimester Monthly HC, clinic Hospital
abortion care and above
4 Number of women who were tested for HIV Age Monthly HC, clinic Hospital
and above
5 Number of Positive HIV tests Age Monthly HC, clinic Hospital
and above
6 Number of maternal deaths (institutional) None Monthly HC, clinic Hospital
and above
7 Number of new and repeat family planning Age ,Method Monthly HC, clinic Hospital
acceptors and above

 
140
 Expanded Program on Immunization (EPI) Program Indicators:
• DPT1-HepB1-Hib1 (Pentavalent first dose) immunization coverage (< 1 year)
• DPT3-HepB3-Hib3 (Pentavalent third dose) immunization coverage (< 1 year)
• OPV 3 (Oral Polio Vaccine third dose) Immunization Coverage (< 1 year)
• PCV3 (Pneumococcal conjugated vaccine) immunization coverage (< 1 year)
• Rota2 (Rotavirus vaccine 2nd dose) immunization coverage (< 1 year
• IPV (Inactivated Polio Vaccine) Immunization Coverage (< 1 year)
• Measles (MCV1) immunization coverage (< 1year)
• Full immunization coverage (< 1 year)

141
 Cont…

Formula Number of children received all vaccine doses before 1st

birthday X 100
Total number of surviving infants
Fully immunized child (FIC): The indicator measures the capability of the system to
Interpretation provide all vaccines in the childhood schedule at the appropriate age and the
appropriate interval between doses in the first year of life

others Measles second dose (MCV2) immunization coverage (1-2 year)

Proportion of infants protected at birth against neonatal tetanus(PAB)
Vaccine wastage rate

Data source for EPI Infant Immunization & Growth Monitoring Register
indicators

142
 Reportable data element in Infant Immunization & GM register
No. Reportable data element Disaggregation Frequenc Level of Type of
y Reporting tally used
1
BCG
2
OPV 1 & 3
3
Pentavalent vaccine 1 & 3
4
PCV vaccine 1 & 3
5 None

Hospital And above

Rota vaccine 1-2

EPI Tally Sheet

HP,HC, Clinic,
6
IPV

Monthly
7
Measles vaccine 1-2

 
8
Fully immunized
9
Protected at birth(PAB)
10 Vaccine wastage rate Type of vaccines
11 Number of children less than 2 yr Age, nutritional status
weighted during GMP session
12 Vitamin A Age, Dose
143
 HPV Immunization Indicators

 HPV 1 (Human Papilloma Virus vaccine (1st

dose) )Immunization coverage (9 years old girls)
 HPV 2 (Human Papilloma Virus vaccine (2nd
dose) Immunization coverage (9 years old girls)

Data source: Human Papilloma Virus (HPV)

immunization Register

144
 Reportable data element in HPV Immunization
register, frequency and level of reporting
No. Reportable data element Disaggr Frequ Level of Type of
egation ency Reportin tally
g used
1
Number of girls 9 year of age who
have received first dose of human
papilloma virus vaccine   HP,
2   HC
  Clinic,

No Tally
Number of girls 9 year of age who None Mont
Hos
hly

 
  And
have received second dose of human
  above
papilloma virus vaccine in 6 months  
 
interval from the first dose
3 HPV doses given
/opened/damaged/expired
145
 Neonatal Care Program Indicators:
1. Proportion of low birth weight or premature newborns
for whom KMC was initiated after delivery
2. Proportion of asphyxiated neonates who were
resuscitated (with bag & mask) and survived
3. Treatment outcome of neonates admitted to NICU
4. Number of sick young infants 0-2 months treated for
sepsis
5. Early institutional neonatal death rate

Data source: Neonatal Intensive Care Unit (NICU) Register

146
Reportable data element in comprehensive abortion care
register
No. Reportable data element Disaggrega Freque Reporti Type
tion ncy ng of
tally
1 Number of Newborn weighing <2000gm None HC/
and premature newborns for which KMC Hosp
initiated
2 Number of Newborn weighing <2000gm None HC/
and or premature Hosp
 
3 Number of neonates resuscitated and None   HC/
survived   Hosp No
4 Total number of neonates resuscitated None   HC/
  tally
Hosp  
5 Total neonates admitted to NICU None   Hospital
Monthl
6 Number of sick young infants 0-2 months None y Hospital
treated for local bacterial infection(LBI)

7 Total neonates discharged during the Treatment Hospital

reporting period outcome
147
Pregnant and Lactating Women (PLW) nutrition screening
Program indicator
• Proportion of pregnant and lactating women
(PLW) screened for acute malnutrition
• Data source: PLW Nutrition screening register
Reportable data element in PLW register and reporting
technique
No. Reportable data element Disaggr Freq Level of Type
egation uenc Reporting of tally
y used

1 Total no. of PLW screened for acute malnutrition HP/HC/

clinic,
2 Total no. of PLW with MUAC < 23 cm
Mon Hospital No
None
3 Total no. of PLW with MUAC >= 23cm thly   tally
4 No. of pregnant women De-wormed
148
 Nutrition Indicators
1)Proportion of children < 2 years of age who participated in Growth
Monitoring and Promotion
2)Proportion of children < 5 years of age screened for acute malnutrition

3)Proportion of children aged 24-59 months de-wormed

4)Proportion of children aged 6-59 months who received vitamin A

supplementation
5)Treatment outcomes for management of severe acute malnutrition in
children under 5 year

Data source: Therapeutic Food Program Register

149
Reportable data element in Therapeutic Food Program
register
S. Reportable data element Disaggreg Frequen Level Tally
N ation cy of of used
reportin Repor
g ting
1 Total number of children None Monthly HP/ No
with SAM admitted to TFP HC/ tally
(OTP &SC) during the Hospit
reporting period al
2 Total number of children outcome Monthly HP/ No
who exit from severe acute HC/ tally
malnutrition treatment Hospit
al
150
 B. Disease Prevention and Control Program Indicators

HIV testing and counseling indicators

• Percentage of people living with HIV who know

their status

• Data Sources: VCT Register and PITC tally sheet

151
Reportable data element in VCT register, frequency and level of
reporting
S. Reportable data Disaggrega Frequency Level of Tally
N element tion of the report sheet
o report
1 Clients receiving HIV Age, Sex, Monthly HC, VCT
test results (at VCT) HIV result, Clinic tally
Population Hospital
group

2 Number of STI cases Sex, HIV Monthly HC,

tested for HIV in the result clinic
reporting period Hosp

152
Reportable data element from PITC tally, frequency and level of
reporting
No. Reportable data element Disaggregation Frequency of Level of
the report report

1 Clients receiving HIV test results (at Age group, Sex: Monthly HC, Clinic
PITC) HIV result, Population Hospital
group

2 Number of STI cases tested for HIV in Sex, HIV test result: Monthly HC, Clinic
the reporting period Hospital

153
 HIV care and treatment program indicators

1. Percentage of people living with HIV who know

their status
2. Percentage of adults and children living with HIV
receiving ART

Formula Number of adults & children receiving ART at the end of

X 100
the reporting period

Estimated number of people living with HIV

Interpret This indicator measures the ongoing scale-up and uptake of ART
ation and retention in ART programs as a critical step in HIV service
provision and assesses progress towards coverage of ART.
154
 Other HIV program indicators
1. Early viral load suppression rate (Percentage of ART patients
with an undetectable viral load at 6 month after initiation of
ART)
2. Viral load suppression (Percentage of patients on ART with a
suppressed viral load (<1000 copies/ml) in the past 12 months)
3. ART retention rate (Percentage of adults and children known to
be on treatment 12 months after initiation of ART)
4. Number of adults and children with HIV infection newly started
on ART
5. Proportion of clinically undernourished PLHIV on ART who
received therapeutic or supplementary food
6. Percentage of non-pregnant women living with HIV on ART
using a modern family planning method
155
 • Data sources for HIV treatment and care
indicators: Pre-ART and ART Registers
No. Reportable data element Disaggregation

1 Number of adults and children who are currently on ART Age, Sex,

Regimen
2 Number of adults and children with HIV infection newly Age, Sex,
started on ART Pregnancy
Status
3 Number of adults and children who are still on treatment Age, Sex
at 12 months after initiating ART pregnancy
status
4 Number of persons on ART in the original cohort including Age, Sex
those transferred in, minus those transferred out (net pregnancy
current cohort). status
5 Total number of adult and pediatric ART patients with an Age, Sex
undetectable viral load <1000copies/ml at 6 month Pregnancy
status

156
 Cont. …

No. Reportable data element Disaggregation

6 Number of adults and children who initiated ART in the 6 months prior to Age, Sex,
the beginning of the reporting period with a viral load count at 6 month visit Pregnancy status

7 Total number of adult and pediatric ART patients with an undetectable viral Age, Sex,
load <1000copies/ml in the reporting period pregnancy status

8 Number of adult and pediatric ART patients with a viral load test in the Age, Sex, Pregnancy
reporting period status
9 Number of PLHIV who were assessed/screened for malnutrition Age, Sex,
Pregnancy status
10 Number of PLHIV that were nutritionally assessed and found to be clinically Age, Sex,
undernourished Pregnancy status,
Nutritional status

11 Clinically undernourished PLHIV who received therapeutic or Age, Sex,

supplementary food Pregnancy status,
Nutritional status

12 Number of Women living with HIV aged 15-49 using any method of modern Age, Method
family planning
13 Number of clients enrolled in HIV care who were screened for TB during the Age, Sex,
reporting period Pregnancy status
14 Total number of HIV positive clients with Active TB Sex, Age 157
 Post-Exposure Prophylaxis (PEP)Program Indicator
1. Number of persons provided with Post-Exposure
prophylaxis
• Data source: PEP Register
S.No Reportable data element Disaggrega
tion

1 Total number of persons provided with PEP for Exposure

risk of HIV infection type

2 Total number of persons exposed for HIV

infection and eligible for PEP

158
 Tuberculosis Program Indicators
1. Tuberculosis case detection rate (all forms)
2. Tuberculosis re-treatment rate
3. Cure Rate for bacteriologically confirmed new PTB cases (CR)
4. Treatment Success Rate (TSR) among bacteriologically confirmed PTB cases
5. Treatment success among of clinically diagnosed TB cases
6. Death rate among all forms of TB cases
7. Lost to follow up rate among all forms of TB cases
8. TB case detection through community TB care
9. Treatment success of TB patients who received community-based treatment support (New)
10.Drug Susceptibility Test (DST) coverage for TB patients
11.Latent TB Infection (LTBI) treatment coverage for under five years children who are contacts
of pulmonary TB cases (New)
12.Number of Drug Resistant (DR) TB cases detected
13.DR-TB cases enrolled on DR TB Treatment (Second Line Drugs)
14.DR TB Treatment six month interim result
15.Final outcome DR-TB cases
159
Data sources for TB program indicators are:
• Unit TB register
• TB Contact screening & LTBI treatment follow up
register
• Drug Resistance TB Register
• DR TB follow up Register

160
 Reportable data element in Unit TB register
S.No Reportable data element Disaggregation
1 Number all forms Tuberculosis case detected Category, Type,
Age, sex
2 Number of re-treatment TB cases Sex, Category
3 TB treatment Outcome Type of TB
4 Number of TB case detected and registered on TB unit register who None
are initially
5 Treatment success of TB patients who received community-based None
treatment support
6 Number of TB cases (all forms) notified in public health facilities None
with initial referral by PPM sites for TB diagnosis or initiation of TB
treatment.
7 DST result (DS
Total number of contact with index of TB and DR TB)
8 DST result
Total number of contacts screened for TB (DS and DR TB)
9 Number of DR TB cases Age, Sex, DST
result
10 TB patients with documented HIV test result Sex, HIV

161
 Reportable data element from TB Contact
screening & LTBI treatment follow up register
S.No Reportable data element Disaggrega
tion
1 Total number of children under 5 contacts with None
index of Drug susceptible pulmonary TB cases
2 The number of under-five years contacts with None
index of pulmonary TB cases screened for TB
3 The number of under-five years contacts with None
index of pulmonary TB cases and screened
negative
4 Total number of under-five years contact None
screened negative and put on treatment of LTBI
treatment ( IPT)

162
 Reportable data element from DRTB register
S.No Reportable data element Disaggregation
1 TB cases put on second line Sex, HIV status,
treatment Previous History,
Diagnosis type

2 DR TB Treatment Six month Interim Regimen

result (Short term, long
term)

3 Number of cohort DR-TB cases Outcome

started short term second-line anti-
TB treatment regimen 9 -12 month
earlier

163
 Leprosy Program Indicators
1. Leprosy case notification
2. Grade II disability rate among new cases of
leprosy
3. Leprosy treatment completion rate

Data source: leprosy Register

164
 Reportable data element in leprosy register
S.No Reportable data element Disaggregation
1 leprosy case detected Category, Type
Age & sex
2 New cases of leprosy with disability Sex & Age
grade II

3 New leprosy cases treatment Total cohort cases

completed in the last 16-18 months and treatment
outcome by type

165
 Indicators from OPD Service
1. Top Ten causes of Morbidity
2. Morbidity attributed to malaria
3. Proportion of children treated by Zinc and ORS
for Diarrhea at health facility and community
4. Proportion of sick Young infants treated for
sepsis/VSD within a given period
5. Proportion of children treated for pneumonia at
health facility and community
166
 Reportable data element from OPD abstract register
S.No Reportable data element Disaggregation

1 National Classification of Disease type

Diseases Age and sex
2 Number of people who were Age ,Sex ,
tested for HIV HIV test result
Population category
3 Number of people who category
sustained Road Traffic accident

167
 Indicators from IPD Service
1. Inpatient mortality rate
2. Top ten Leading cause of Mortality
3. Admission rate
4. Bed Occupancy Rate
5. Average Length of Stay

Data source for inpatient service indicators:

IPD/Admission/Discharge/ register
168
Reportable data element from IPD register
S.No Reportable data element Disaggregation

1 Disease (National Classification of Disease type, Age, Sex,

Diseases) cases, death
2 Number of admission None
3 Number of Discharge None
4 Length of Stay None
5 Inpatient Death None
6 PITC Age, Sex, HIV test
result, Population
category

169
Trachomatous Trichiasis (TT) surgery Program indicator

1. Number of people with TT who received corrective TT surgery

TT surgery Register:

Reportable data element Disaggregation

S.No
1 Number of people with TT who Age, Sex
received corrective TT surgery

170
Cervical Cancer (Ca) Screening Program Indicators

1. Proportion of women between ages 30 – 49 screened

for cervical cancer

2. Percentage of women tested positive with acetic acid

and treated for cervical lesions

Sources for Cervical Ca screening indicators: Cervical

Ca Screening Register 171
Reportable data element in Cervical Cancer screening
register
S.No Reportable data element Disaggregation

1 Number women between ages 30 – 49 Result: Normal,

screened for cervical cancer Precancerous and
Cancerous

2 Number of women 30-49 years with Type of treatment

cervical lesion received treatment

172
 Visceral Leishmaniosis Program Indicator

1. Number of visceral Leishmaniosis patients treated

• Data Source: Visceral Leishmaniosis Treatment
and Follow up Register
S.No Reportable data element Disaggregation

1 Number of visceral Leishmaniasis Age ,sex, VL type , HIV

patients treated status, treatment out
come

173
 Intensive Care Program Indicators
1. Mortality rate in Intensive Care Unit (ICU)
Reportable data element in ICU register
Reportable data element Disaggregation
S.No

1 Total Death in ICU Type

2 Total discharge from ICU None

174
 Emergency Care Program Indicators
1. Emergency unit/department mortality rate
Data Source: Emergency Register
Reportable data element in Emergency register
S.No Reportable data element Disaggregation
1 Total death in the emergency unit Age, Sex
2 Total number of emergency unit None
attendances

175
 Referral Program Indicators
1. Referral rate
Data Source: Referral register
Reportable data element in referral register
S.No Reportable data element Disaggregation
1 Number of people Type
referred to other health
facility

176
 Ambulance Service Indicators
1. Ambulance service response rate
Data Source: Ambulance register
Reportable data element in Ambulance Service register
S.No Reportable data element Disaggregation
1 Total number of Ambulance Type of professional
requests get response The type of cases served

2 Total number of Ambulance None

requests made

177
 Pharmacy Program indicators
1. Essential drugs availability
2. Supplier fill rate
3. Stock wasted due to expiration or damage
4. Clients with 100% prescribed drugs filled
• Data Source: Dispensing register and Tracer drug
availability Tally sheet
S.No Reportable data element Disaggregation
1 Program products in ETB None
2 RDF products in ETB None
3 Beginning stock plus quantity received of None
products in terms of monetary value
178
 Activity 5
• Read the revised indictor definition manual of 2017, Ethiopia

179
 Chapter 6:-
INTRODUCTION TO DISTRICT
HEALTH INFORMATION SYTEM
 Lesson objectives
At the end of the session, you are expected to:
1. Describe the basic concepts of DHIS-2
2. Identify DHIS2 key functions and features
3. Describe dimensions of DHIS-2
4. Discuss DHIS-2 environment
5. Describe Organizational unit, groups and group sets in DHIS-2
6. Demonstrate DHIS-2 data entry and data quality check
7. Demonstrate DHIS-2 data importing and Exporting
8. Analyze and present DHIS-2 data
9. Develop and share DHIS-2 dashboard
10. Report generation and identify types of report in DHIS-2

181
 Overview of DHIS-2
 DHIS-2: is an open source health data management platform used
by multiple organizations and countries.
 DHIS2 is an abbreviation which stands for District Health
Information System.
 It is a system/tool for collection, validation, analysis, and
presentation of aggregate or individual data.
 It is an integrated system of tools that help operators and planners to
collect and use health data and information for progressive action.

182
 DHIS-2 key functions and features
DHIS2 provides a comprehensive health information systems solution for the reporting and
analysis needs of users at any level.

The key features and purpose of DHIS2 can be summarized as follows:

1. Capturing, analysis and dissemination of data
2. Handles routine data, events and surveys
3. Integrated warehouse for essential data
4. Provide different kinds of tools for data validation and improvement of data quality
5. Flexible and dynamic data analysis in the analytics modules (i.e. GIS, Pivot Tables, Data
Visualizer, Event reports etc.)
6. Communication (messaging and feedback).
7. A user-specific dashboard for quick access to the relevant monitoring and evaluation tools
including indicator charts and links to favorite reports, maps and other key resources in the
system 183
 DHIS-2 key functions cont.…
8. Functionality to design and modify calculated indicator formulas.
9. User management module for passwords, security, and access control.
10.Further modules can be developed and integrated as per user needs
11.Functionalities of export-import of data and metadata, supporting
synchronization of offline installations as well as interoperability with other
applications.
12.Using the DHIS2 Web-API, allow for integration with external software
and extension of the core platform through the use of custom apps
13.Easy to use user-interfaces for metadata management e.g. for
adding/editing datasets or health facilities.
184
 Dimensions of DHIS-2
• A data value or a data captured in DHIS 2 needs at least
three dimensions that answer three questions:
1. Where(Organizational units)
2. When(Periods)
3. What(Data Elements)

185
 Organization Units (WHERE)
 Organization Unit answers the where question of the data
dimension.
 Organization unit structure defines the hierarchy of health
facilities in a specific country or locality.
E.g., Ethiopia Amhara region Gondar town  Maraki PHCU
Maraki HC
 DHIS 2 assumes all hierarchies in the application are geographical
hierarchies since its GIS module is dependent on it.
 It has features to define name of the levels (national, regional,
Zonal, Woreda, PHCU, etc.).
186
 Periods (WHEN)
 Periods answer the “WHEN” question.
 DHIS 2 has pre-defined frequencies/period-types for data collection
including: Daily, weekly, monthly, bimonthly, quarterly, six-monthly,
six-monthly (and a variant), yearly (and variants).
 It also has relative periods used for analyses purposes (created at
the definition of the period parameters for analyses) – e.g., last 12
months, last 3 quarters, last 6 months.
 All periods are generated in the database when the first data
involving that specific period is created.
187
 Data Elements (WHAT)
 Data elements are the basis of DHIS 2 and capture what data is
recorded in the system.
 Data elements in DHIS 2 can be of:
– Either aggregate or individual domain;
– Data type Number, Text, Yes/No, Date value, etc.
– Can have Sum, Average, Average [Sum in Org Unit Hierarchy], Count,
Standard Deviation, Variance, Minimum or Maximum aggregation
operators.
 Examples of data elements include: Number of BCG does given,
Number of ANC4 visits
188
 DHIS-2 environment
 DHIS2 provides functionality to exchange messages within and
outside the system as feedback mechanism.
 Messages can be written to specific users within the system.
 They can also be sent to their e-mail address provided along with their
profile
 It also provides a platform to send SMS to individual users
 Users who have privileges to access the dashboard can send messages
to a user or a group of user’s feedbacks and interpretations
 The messages users receive within the system appear at the dashboard

189
 Getting started with DHIS2
 How to open the DHIS 2, How to log in and out of the application,
how to navigate the application and access its features
 Opening DHIS 2
•Open Dhis 2 application and write
•User name:- amhara
•Password:- Dhis_54321
• For practical purpose use
– URL: - www.play.dhis2.org/demo
– Username: - admin
– Password: - district 190
191
192
193
 Organizational unit in DHIS-2

• In DHIS2 the location of the data, the geographical context, is

represented as organizational units.
• Organizational units can be either a health facility or
department/sub-unit providing services or an administrative unit
representing a geographical area (e.g. FMOH, Regional health
bureau, Zonal health department, Woreda health office).

194
 DHIS-2 Data entry and data quality

Data entry with DHIS 2

 All data entry in DHIS2 is organized through the use of data sets.
 To enter the data in DHIS 2 click on the routine Data Entry option.
 Data sets are a collection of data elements that make a form and
open the data sets.
 Examples of datasets for data entry:
Health Center Monthly Service Delivery Form data entered at
Health Centers every month.

195
 To enter the data in FMOH DHIS2 Application
 Go to the App and click on the Routine Data Entry App.
 Go to the Org unit you want to enter the data.
 Select a data set from the dropdown list of data sets available to
your selected org unit.
 Select a period to register data for. The available periods are
controlled by the period type of the data set (reporting frequency).
You can jump a year back or forward by using the arrows above
the period. Do the data entry once the form is downloaded

196
197
 Event and Tracker Capture
• Event Capture: is used to enter individual’s data (person,
facility, event, etc.) The event capture app allows users to
enter events that occurred at a particular time and place.

• Tracker Capture: Advanced version of the event capture

app as it deals with events (multiple and single) with
registration.

198
 Data quality
Measuring data quality: Is the data complete? Is it collected on time? Is it
correct?
Reasons for poor data quality
 There are many potential reasons for poor quality data, including:
 Excessive amounts collected; too much data to be collected leads to less
time to do it, and “shortcuts” to finish reporting
 Many manual steps; moving figures, summing up, etc. between different
paper forms
 Unclear definitions; wrong interpretation of the fields to be filled out
 Lack of use of information
 Fragmentation of information systems; can lead to duplication of reporting
199
 DHIS2 to improve data quality:
Some type of data quality checking mechanisms
1. Data input validation
2. Min and max ranges
3. Validation rules
4. Outlier analysis
5. Completeness and timeliness reports

200
 DHIS-2 Data importing and Exporting
 Metadata export/import: Export/Import of metadata like Data Elements,
Indicators, Options, Option Sets, Categories, Category Combos, etc.
 Metadata Export: Exports metadata like data elements and organization units
to the standard DHIS 2 exchange format.
 Metadata Import: Imports metadata like data elements and organization units
using the standard DHIS 2 exchange format called DXF 2 (XML, JSON and CSV).
 Data export/import: Similar to Metadata Export/Import, we can do Data
Export/Import with DHIS2.
 Data Export: Exports data values. This is the regular export function which
exports data to the DHIS 2 exchange format called DXF 2.
 Data Import: Imports data values on the DXF 2 XML, JSON, CSV and PDF
formats. DXF 2 is the standard exchange format for DHIS 2.
201
DHIS-2 Import /export

202
 DHIS-2 data analysis and presentation
Data analysis: Turning data into information
• WHAT? Turns good quality data into information
• WHY?
Analyzed data:
• Tells us what effects our service delivery has on the health status of the
population;
• Gives direction in decision making; and
• Shows patterns and trends.
• Comparisons
• Assessment of progress toward targets
HOW? By using basic epidemiological concepts. DHIS2 has self-data analysis
modules. 203
 Data Analysis in DHIS2 can be carried out using:

1. Pivot Table
2. Data Visualizer, and
3. GIS

204
 Pivot table
Pivot tables can be used to We use Pivot Tables for Analysis

 Generate reports in tabular format  When we want to show more than two
dimensions.
 Easily compare data based on different time  When the data to be presented are complex
and locations with multiple data elements/indicators/org
units/periods

 See the performance or coverage and, more  When we are interested in details

205
 Data visualizer
When is Data visualizer Preferable?
 When the purpose is presenting the general performance trends in an
attractive way.
 When we want to present performance to audiences who are not detail-
oriented (example, top management).
 When the nature of the data we present is not complex.
 When the presentation time is limited and as such we should focus only
on core stuff.

206
DHIS2 currently supports the following types of charts:

1. Column chart
2. Stacked column chart
3. Bar chart
4. Stacked bar chart
5. Line chart
6. Area chart
7. Pie chart
8. Radar chart
9. Speedometer chart
207
 Geographic Information System (GIS)
 The GIS module gives the ability to visualize aggregate data on maps
 It is useful for:
Mapping health facilities and other resources
Accessibility, planning new health facilities, outreach (mobile) activities
Complementing to charts & tables to better understand our data
Presenting data–creating attractive outputs for decision-makers and to
highlight interventions
Ideal for agencies, departments, organizations that don’t already use
proper GIS.
208
 DHIS-2 Dashboard

• DHIS2’s Dashboard is a place to post key analysis results.

• Dashboard in DHIS2 is intended to provide quick access to

different analytical objects (maps, charts, reports, tables, etc.)
to an individual user.

209
 Reports in DHIS-2
The following are the types of reports in DHIS2:
• Standard reports
• Data set reports
• Data completeness reports
• Static reports
• Organization unit distribution reports and Report tables

210
 Activity 6
• Practice the sera Leone demo version DHIS-2 application
• Lab practice on DHIS- 2 application

211
 Chapter 7
Overview of Evidence based public health practices
LEARNING OUTCOMES
At the end of this chapter, students should:
1. Define terms related to evidence based practice
2. Describe concepts of evidence based practice
3. Discuss concepts of Health sector planning
4. Demonstrate HMIS data presentation and visualization
5. Describe concepts of information dissemination
6. Discuss concepts of performance review meetings
7. Discuss concepts of integrated supportive supervision and feedback

212
 Definition of terms
Evidence: can be defined as the body of facts or information indicating
whether a belief or proposition is true or valid and provides proof.

Decision making: The process of making a selective intellectual

judgment when presented with several complex alternatives consisting
of several variables, and usually defining a course of action or an idea.

Evidence-based Practice: is also referred to as “best evidence.” An

approach of decision making and practice based on scientific evidences.
213
 Definition of terms cont. ..
Evidence-based Medicine: The process of systematically finding, appraising, and using
contemporaneous research findings as the basis for clinical decisions. Evidence-based medicine
asks questions, finds and appraises the relevant data, and harnesses that information for
everyday clinical practice.
Evidence-based public health (EBPH): is the conscientious, explicit, and judicious use of
current best evidence in making decisions about the care of communities and populations in the
domain of health maintenance and improvement.
 Evidence-based Policy and Practice: explores the processes of systematically finding,
appraising and using scientific research as the basis for developing sound practices

214
 Concepts of evidence based public health practice

Public health is aimed at whole communities.

Evidence-based approaches within this context therefore; requires

understanding of the complexities of organizational structures,
interactions, and other dynamics that shape and influence decision making
at the local, state, regional, and national levels within which public health
operates and within which policies and programs are established.
215
 Who are principal users?

Some of the principal users of evidence-based practice in Health are:

 Policy makers
 Researchers
 Clinical practitioners
 Public health practitioners
 Health information professionals and
 The general public
216
 Concepts of Health sector Planning
 Planning is a key management process that must be supported
by reliable, timely and well-defined information, if it is to be
effective.
 It is essential that annual planning processes align with the
priorities identified in national policies, and strategies.
 Health care facilities and organizations at all levels will be
required to demonstrate the appropriate use of information in
health services planning and management.

217
Functions of Information in Planning

218
 Health Sector Planning in Ethiopia
The Federal Ministry of Health (FMoH) of Ethiopia introduced the Health Sector
Transformation Plan (HSTP).

The annual Woreda-based plan is a yearly operational plan of HSTP.

The health planning process is conducted through a top-down and bottom-up

approach with horizontal alignment.

Through this process, the health sector aspires to develop one unified health sector
plan with consultation of major stakeholders, including relevant government
institutions, donors, NGOs and the community at each level. 219
 Woreda Based annual planning
 Based on the broader objective, priorities and the targets of the five-
yearly HSTP, an indicative annual plan is developed at the Federal
level and send to the woreda.
 The Woreda-based Health Sector Planning is an evidence-based
result-oriented planning exercise.
 The Woreda-based Health Sector Plan and the performance
objectives set within that plan will become the basis for the
monthly, semi-annual and annual performance review meetings.

220
Annual Woreda based planning cycle

221
 HMIS data presentation and visualization

Data presentation is the systematic process of making information available and

accessible to potential users, stakeholders and/or beneficiaries.

Most common data presentation techniques are: tables, graphs and maps.
It is important to select the best type of data presentation technique that best display the
information of interest.

High-quality data displayed in a format that facilitates decision making helps program managers
and policy makers effectively allocate limited resources.
 Multiple software platforms, either open-source or proprietary, are available to facilitate data
visualization.
 The most common tools used for data visualization using simple electronic tools are: eScorecard,
Dashboard. 222
 Scorecard and Dashboard
Scorecard:

 Scorecards tell how the overall health systems are doing.

 The scorecard colors; red, yellow and green enable managers to easily visualize
and identify areas in which progress has been good or is sub-optimal.
Dashboard:
 The Ethiopian customized DHIS2 visualizer module enables to generate
dynamic data analysis and visualization through charts and tables.
 It gives different options of displaying charts, downloading charts as images or
PDF, saving charts as favorites, sharing interpretations and switching between
tables, charts and map visualizations.
223
 Information Dissemination

 It is the process of making information products readily

accessible to end users for information use.

 The common information dissemination media includes: 

Annual performance reports

224
Information Dissemination
It is the process of making information products readily accessible to end users for information use.
The common information dissemination media includes: 

 Annual performance reports  Special interest newsletters

 Broadcast Media  Radio or TV interviews
 Academic journals
 Websites
 Technical reports
 Social media
 Bulletins
 M&E digest
 Regular newspapers
 Health and Health related indicators  Community structures

225
 Performance review meeting

Performance monitoring is the continuous tracking of priority

information on executed activities and its indicators of successes in
order to identify achievement gaps and lessons learnt subsequently
leading to the planning and implementation of corrective measures.
• HMIS provides an input for performance monitoring
• It is an integral part of M&E
• Facilitates decision making
226
 Importance of PMT

 To carry out self-assessment and facilitate informed decision.

 It enhances performance and quality of data.

 Plays a significant role in achieving the overall organization

performance and objectives through team approach.
 Facilitates shared responsibilities among individual team members
of the institution
227
 Integrated supportive supervision and feedback

Supportive supervision is a process of helping staff to improve their

own work performance continuously.
It is carried out in a respectful and non-authoritarian way with a
focus on using supervisory visits as an opportunity to improve
knowledge and skills of health staff.
 Supportive supervision encourages open, two-way communication,
and building team approaches that facilitate problem-solving.
228
 Objectives of supportive supervision
 To confirm and support compliance with the health system management and
service delivery standards.
 To assist staff in providing improved preventive, promotive and essential curative
services.
 To review health services coverage and quality and to assist in the formulation of
plans and strategies for improvement.
 To build capacity for self-assessment, problem-solving, solution-finding and
solution implementation through guidance, support and on-the-job training. 229
 Activity 7
• Read HSTP plan of Ethiopia
• Show data visualization using DHIS-2 application

230
 CHAPTER 8:
OVERVIEW OF COMMUNITY HEALTH INFORMATION
SYSTEM

Learning outcomes

At the end of this session, students will be able to:

 Define terms related to CHIS
 Differentiate CHIS and HMIS
 Identify purpose and scope of CHIS
 Describe essential functions of CHIS
Introduction
 Generating information for evidenced decision making at each level of
health system is relied on RHIS.
 FMoH have been implementing the HSTP to ensure:
 High quality

 Equity

 Sustainable

 Adaptive and efficient health services

Introduction cont’d…
 HSTP has three key features

 Quality and equity

 Universal health coverage

 Transformation
 The four HSTP transformation agenda are:

- Information revolution

- Quality and equity in health care

- Woreda transformation

- Developing caring, respectful & compassionate health professionals

 Definition of terms
 Community: a community, either urban or rural, is a unit or group
usually identified and recognized by both the people comprising that
unit or group and by some geopolitical/administrative hierarchy.
 Community Health: A field within public health that concerns itself
with the study and betterment of the health of communities.
 Definition of terms cont’d….

CHIS involves:
 Data collection
 Management
 Analysis
 Dissemination and
 Use of data for health and related services provided to communities
outside of facilities
It is a dynamic system that includes health information on how data are
collected, how they flow, how to assess and improve data quality, and how
the information is used
 CHIS Vs HMIS?

(what is there relationship?)

 CHIS Vs HMIS

 CHIS is a component of HMIS

 CHIS primarily focused on health data management at community level

 HMIS comprises of RHIS at health facility (Hospitals, health centers and clinics),
including imbedded-CHIS

 Both CHIS and HMIS are inter-connected and

 CHIS data must feed seamlessly into HMIS and

 HMIS need to provide feedback and support to strengthen CHIS

 Purposes of CHIS
What are the purposes of CHIS?

 To improve quality of data at community level

 Good-quality healthcare depends on a strong CHIS to measure

and evaluate critical elements of care and
 provide accurate data for evidence-informed decision making
aimed at improving services and outcomes.
 Purposes of CHIS cont’d…

 To facilitate quick retrieval of data

 Effective transformation of data into information
 Effective integration of information to other disciplined to
concretized knowledge and creates better understanding.
 Creation of computerized patient records, medical information
system
 Central repositions of all data such as data warehouse
 Purposes of CHIS cont’d…
 To create basic information at the community level for facilitating
evidence-based practices
o To provide data for short and long-term planning of health activities

o To calculate coverage indicators

o To monitor and evaluate performances

o To assess changes in health status of the population

o To facilitate research activities

o To identify community needs

 Scope of CHIS

 Data collection

 Processing

 Analysis and

 Dissemination and local level data use for evidence based practices
 Essential Functions of CHIS

 To promote community engagement in health

 To identify community needs
 To support case management and continuity of care
 To document individual-level needs to support care planning
 To enable bidirectional referrals
 To track lost to follow-up patients
 To monitor and evaluate performances
 To ensure accountability
243
 CHAPTER 9- CHIS in Ethiopia
LEARNING OUTCOMES

At the end of this session, students will be able to:

 Describe overview of Health Extension Program (HEP)
 Describe overview of CHIS system in Ethiopia
 Discuss Kebele/Woreda Profiling
 Explain Household profiling
 Discuss CHIS Recording and Reporting tools
 Explain overview of eCHIS
 Overview of Health Extension Program (HEP)

 HEP is a package of preventive, promotive and basic curative services

targeting households to improve the health status of families with their
full participation

 It’s educational approach is based on the diffusion model. Community

behavior is changed step by step:

 Training early adopters, then

 moving to the next group that is ready to change

 Overview of Health Extension Program (HEP) cont’d….

 The overall goal of HEP is to:

 Reduce morbidity and mortality of children and mothers
 Prevent communicable and non-communicable diseases
 Prevent illnesses from malnutrition, poor hygiene
 Prevent accidents and administer first aid
 Improve knowledge and skills of the community to prevent
contaminations
 Overview of CHIS in Ethiopia

 Ethiopian CHIS is designed for the health extension workers (HEWs) in rural

and urban areas to manage and monitor their work

 CHIS:

 Family centered at rural and

 Community-centered at urban

 The aim is to create basic health information at the grass root level
 Overview of CHIS in Ethiopia _ Tools

 CHIS data is captured through:

 Master Family Index (MFI)
 Field book,
 Registers (for pastoralist area) service and
 Disease tally sheets/reporting formats, and
 Additional administrative and personnel records.
 Kebele/Woreda Profiling
 Formats were designed to compile Kebele’s demographic profile

 The purpose is for Planning, Monitoring and Evaluation of performances

 Information is updated annually

 Resource mapping format is to compile potential resources

 Working areas are captured for health promotion activities

 Once the household registration is completed, the family health profile will
be filled to compile the family information.
 Household Profiling
 Family folder is used for rural, while community folder is for urban Health
Extension Programs.

 Family Folder is a pouch that helps to record the household and family
characteristics.
 It’s issued to every household in the Kebele.
 It contains information about the household (preventive, promotive &
environmental health) service needs
 Household Profiling

 Community Folder is used to file/document family registers filled for 5-12

households (mostly 10 households), that are considered as a community
 It uses to bind the family registers of a households.
 The information on the community folder helps the UHEP to identify the
Family/HHs
 CHIS Recording and Reporting tools
How Family Folder works?

 Front and back sides are used for recording information on:
 House hold information.
 Household members' description
 Household’s Possession of LLITN,
 HDA/WDA and CBHI membership status
 HEP packages practices
 Competency based Training Status for (WDA leaders)
 CHIS Recording and Reporting tools

 Family folder is issued through a campaign by mobilizing the Gote

Gote: is a sub segment of the Kebele which has different meanings in different
areas like ‘Zoni’ in Oromia and ‘Kushet’ in Tigray regions.

 HEWs with Kebele administration will assign Gote-code

 In each Gote, volunteers issue serial unique Household numbers

 When new household is emerged, the last serial number is given

 CHIS Recording and Reporting tools
 Register household characteristics on cover page of Family Folder

 During household registration, every household is issued a unique identifier

number consisting of a 2-digit Gote code followed by 3-digit household
number (xx.xxx).

 Later, HEWs aggregate data from Family Folders to compile basic

demographic and environmental sanitation profile of the Gote/Kebele
 Activity-2
1. See the hypothetical map of the community with about 51 households in four Gots. Discuss
in groups on the following points:
a) Give house number (code) for each of the following households?
b) How you will give code for the newly constructed household?
c) What if one household shift from one place to another?

2. Take all common recording and reporting tools of a health post, use hypothetical data and
exercise on:
a. Kebele/Woreda profiling
b. Family/household health information recording tools
c. Tallies
d. Reporting formats
Family folder with respective Got arrangement

256
Family folder has the following tools

nte g r ated
.i
a te r nal
m
family health and c re
hild
folder card h e a l th ca
pouch card

257
 CHIS Recording and Reporting tools
 Within the Family Folder,
 Health cards
1. Family health cards,

2. Hygiene and sanitation card,

3. Integrated communicable card,

4. Integrated maternal and child care card and

5. Comprehensive integrated nutrition card

 These tools are stored for recording disease information, preventive and
promotive services to individual members of the household.
 Health Cards
1) The Family Health Card: is issued for every HHs (for both male and
female) and individuals becomes sick.
 It helps to record individuals case based information and used to
document:
 Individual’s earlier health history,
 Disease information
 Health Cards
2) Hygiene and sanitation card: is used to record hygiene and sanitation of
the household’s:
 Latrine,
 drinking water management,
 waste disposal management and
 housing condition.
 Health Cards
3) The Integrated Maternal and Child Care Card: is issued to every woman
when she becomes pregnant. it is a longitudinal record used to document:
 Pre-pregnancy status,

 Pregnancy follow up,

 Delivery

 Post-delivery care of the mother

 Immunization and growth monitoring of the child

 Health Cards
4) Integrated communicable disease card: is used to record all the
information related with the service provided for:
 TB
 Leprosy
 HIV/AIDS
 NTD screening
 Health Cards
5) Comprehensive Integrated Nutrition card: is issued to children under 5
years. This card used to document:
 Growth monitoring and promotion (GMP)
 Time and age appropriate nutritional counseling
 Nutritional screening and
 Out patient therapeutic program (OTP) follow up
How Community folder pouch works?

 The front page contains basic information of HHs which includes:

 Community code,
 List of HHs,
 HH number,
 Category of the HH, and
 Status of the HH (active /inactive).

 These information helps the UHEP to identify health needs; and to ensure
every family member receive needed health services.
How Community folder pouch works?

 Community Code: Is a given code for the specific compound which consist
of 5 to 12 HHs in the community folder

 e.g. Naming could be Gote1/G1, G2, G3: Ketena 01, 02, 03, …

 The Community Code will be given according to the context of the town or
city

NB: Addis Ababa uses Woreda as the smallest administration level

How Community folder pouch works?

 Individual ID: In UHEP, unique identification number with digit sequentially

assigned serial number given for every member of the household

 The last two digits assigned for the HH member by sequential numbering
How Community folder pouch works?

 In UHEP the program implementation is primarily by categorizing the HHs

based on service delivery needs and income level.

 The method of the prioritization is called Household Category. 

 The household category is documented as IA, IIA, IIIA, IB, IIB, IIIB, IC, IIC
and IIIC.
How Community folder pouch works?

 The community folder has a print page on the front sides for recording
information on :
 Community Identifier or code,
 Household number,
 Health risk or condition,
 Households by their health category level and
 Household status (active /inactive)
How Community folder pouch works?

 Recording tools within the community folder includes:

1) Family Register: - family health information card
2) Maternal and child Health Recording forms: - documents:
 Identification,
 Assessment and referral of pregnant women,
 Postnatal care services,
 Family planning services and
 Childhood illness management service
How Community folder pouch works?

3) Chronic communicable disease screening and management recording forms:

- is designed used to document:

 HIV /AIDS counseling and testing,

 ART follow up,

 TB case identification and treatment follow-up and referral service being

provided at community level.
How Community folder pouch works?

4) Non Communicable Disease screening form: It is designed to collect on

 Diet and physical activity,

 Tobacco use and alcohol consumption

 Data on physical measurements such as:

 Blood pressure and

 Anthropometric measurements
 CHIS Recording and Reporting tools

  Rural Urban

a. Kebele demographic profile a. Kebele/Woreda demographic

Kebele profiling formats

b. Kebele resource mapping profile

c. Kebele household b. Kebele/Woreda resource mapping
environmental sanitation profile c. Kebele/Woreda household
 

environmental sanitation profile

 CHIS Recording and Reporting tools
  Rural Urban
a. Family folder a) Family Health Profile form
b. Health card b) Family Planning Service Recording Form
 Family health card c) ANC Identification and Recording Form
unity health information recording

 Integrated Maternal and Child d) Postnatal Service Recording Form

Care card e) Child Health and Nutrition Recording Form
 Hygiene and sanitation card f) NCD screening and management forms
 Integrated communicable disease g) ART follow up forms
card h) HIV/AIDS Counseling and Testing form
 Comprehensive integrated i) Referral Register
instruments

nutrition card j) Referral and Feedback Slip

 

c. Master Family Index (MFI) k) TB Screening and Treatment follow up form

l) Community Health Education Register
d. Field Book m)Field Book
 CHIS Recording and Reporting tools
  Rural Urban
a. Service delivery tally a. UHEP monthly disease and service delivery
b. Disease information tally tally

c. Tracer drug availability tally b. UHEP quarterly disease and service

delivery tally
d. Family planning method
Tallies

c. Urban HEP annual disease and service

 

dispensed count
delivery tally
d. Tracer drug availability tally
e. Family planning method dispensed count
 CHIS Recording and Reporting tools
  Rural Urban

a. Monthly service delivery reports a. Monthly service delivery and Disease

b. Quarterly service delivery reports report formats
Reporting formats

c. Quarterly disease reports b. Quarterly Service Delivery report

d. Annual reports formats
c. Annual report format
 
 CHIS Recording and Reporting tools
Pastoralist CHIS:

 The Health Extension Packages are all the same with rural HEP

 The difference is only on record keeping.

 Health Extension Workers in Pastoralist community don’t use

family/community folders

 Instead they use integrated registers. This is because of the mobile life style
of the community.
 Overview of eCHIS
 The glob has been radically transformed by digital technology and
transformed daily lives

 Health is an information-rich enterprise.

 A seamless flow of information within a digital health care improves

efficiency, quality and equity in health care.

 Electronic based Community Health Information System (eCHIS) is the first

step to transform primary health care under CHIS.
 Overview of eCHIS
 The benefits of eCHIS include:

 Improves health care provision of the HEW

 Facilitates informed-decision making

 Significantly Reduce errors for producing periodic reports

 The space saving benefit of a digital records environment

eCHIS in Ethiopia

In Ethiopia, e-CHIS is under

piloting
 There are 3 mobile applications in eCHIS system:
[PRIMARY] Health Extension Worker Application: support HEWs in Family
Folder (Pouch) management & prioritized RMNCH service delivery and
follow up. Each HEW has their own device with mobile application.

Health Center Referral Application: supports Health Center workers to

confirm referrals and provide referral feedback to HEWs. Shared device(s)
for Health Center personnel and not meant to act as real-time service
delivery job aid.

Focal Person Application: supports Focal Persons in providing technical and

programmatic support to the HEWs. Each HEW Focal Person has their own
device with mobile application.
280
The eCHIS mobile application system
Health Center Worker Focal Person

Health Center
Health Post
HEW
Community

Client
Introduction to System
eCHIS Application sends data over phone networks to view on the internet in real-time.

Data is sent to a server by the

mobile tower
Another mobile device
Can share form data sent
with another mobile
application user!

Application’s Forms
HEWs and Health Center workers
complete forms on their mobile device Database & Dashboards
Allows data decision analysts and
decision makers to access, review
and download data
Logging in to Health Center Referral application

Username: hc_afar3
Password: 321
Logging in to HEW Focal Person application
Tap here to select the application

Username: focal_afar3
Password: 321
Homescreen Change the Language

Sync with Server regularly to

ensure that:
Enter the application to - Forms are sent to the server
begin reviewing - Client data is updated from
information or to fill out Health Center
forms

Exit the application Displays the last time a sync was

securely to protect client completed and any pending
information forms
HEW App
Main Folders
Family Folder (pouch), Part 1
• Component included in Household registration
• Registration of Household Information              
• Registration of Household Member
Intro activity to Family Folder (pouch)
Question: How do we define the ‘Family Folder’?
Question: What components or types of information are part of
the Family Folder?

Question: In what ways does the HEW use the Family Folder in
their job?

Question: Do any other people or departments need access to

Family Folder information? If yes, what departments/people? What
information?
Family Folder components in the eCHIS pilot app

Households Household Properties One to Five Management RMNCH Services

Members HEP implementation Reports

One to Thirty Management
& Graduation
HEW App
Main Folders
Registration of Household Information
1.To register a new household tap on
the ‘Households’ button on the main
screen
2.This will take you to the list of
households of this logged-in user.
3.By swiping up you will get to the
bottom of the list and see the
‘REGISTER NEW HOUSEHOLD’ button
4.Tap on this button to enter the
Household Registration form
Registration of Household Information
Registration of Household Information
Registering Household Member
Registering Household Member
Registering Household Member
 Register the following households!
Bereket Daniel Mersha Alem Abebe Chala Abraham Kassa Woldu
• Gote 1 • Gote 2 • Gote 3
• Registration date: 22- • Registration date: • Registration date: 04-
12-2009 today! 03-2007
• Household number: • Household number: • Household number:
01/001 02/001 03/001
• Phone: 0970018723 • Phone: 0997987661 • Phone: no phone
• Not at house • At house • Not at house
• 2km from HP • 10km from HP • 1km from HP
• CBHI Member • Not CBHI Member • CBHI Member
• Membership date: • TIN: 1234567890 • Membership date:
22-12-2009 18-06-2008
• TIN: none • TIN: 1122334455
 Registration of Household Member

3. This will take you to the list of

2. Then tap on members of this Household
1. To register a new household ‘Household Tap on this button to enter the
member tap on a Household name Members’ Household Member
in the Households list Registration form
Household: Bereket Daniel Mersha
Bereket Daniel Mersha Hiwot Bereket Daniel
• Head of household
• Member id: 01
• Daughter to Bereket
• 42 years old • Member id: 03
• 20 years old
Genet Mebratu Tesfa
• Wife to Bereket Dagim Bereket Daniel
• Member id: 02 • Son to Bereket
• 38 years old • Member id: 04
• Pregnant, has already • 1 month old
completed ANC 1
Household: Alem Abebe Chala
Alem Abebe Chala Ayida Alem Abebe
• Head of household • Daughter to Alem
• Member id: 01 • Member id: 03
• 50 years old • 2 years old

Mahlet Tariku Gemechis Mekdes Alem Abebe

• Wife to Alem • Daughter to Alem
• Member id: 02 • Member id: 04
• 35 years old • 5 months old
• Pregnant, has not completed
ANC 1
 Modules of eCHIS
eCHIS comprises of all modules included in the health extension Package.
Activity
• Practice the Ethiopian eCHIS application

305
 CHAPTER 10 :
DISEASE SURVEILLANCE AND RESPONSE

LEARNING OUTCOMES
At the end of this chapter participants will be able to:
 Discuss overview of disease surveillance and response
 List components of disease surveillance and response
 Set priority diseases targeted for surveillance and response
 List core functions of surveillance system
 Discuss overview of Disease surveillance and response, Ethiopian context (PHEM)
 List diseases under surveillance in Ethiopia
 Identify reporting, types and tools
 Overview of disease surveillance and response
What is Surveillance?

It is an on-going systematic, collection, analysis,

interpretation and dissemination of health-related data
essential to the planning, implementation, and
evaluation of public health practice.
 Overview of disease surveillance and response
Surveillance:
 Includes dissemination of the resulting information
 Is also essential for planning, implementation and evaluation
 Helps health workers to set priorities, plan interventions, mobilize and
allocate resources, detect epidemics early, stimulate research, trigger
public health action, initiate prompt response to epidemics and evaluate

and monitor health interventions.

 Helps to assess long term disease trends
 Generally, it informs the management of public health programs and direction of

public health policy

 N.B: Collection and analysis should not be allowed to consume resources if action

does not follow

 Process of Public Health Surveillance

1. Data collection

2. Data analysis

3. Data interpretation

4. Information dissemination

5. Link to action
 Data Sources for surveillance

 Records of notifiable diseases

 Laboratories

 Vital records

 Registries

 Surveys

 Other data sources

 Vital Statistics
 Records of births and deaths: a basic but critical cornerstone of public

health surveillance

 Mortality data over past century show decrease in rate of deaths due to

infectious diseases; rate of death from non-infectious causes remain steady

 Infant mortality rate (number of deaths among infants per 1,000 births) is

used as indicator of overall population health

 Birth data used to monitor incidence of preterm birth, risk factor for

variety of adverse health outcomes

 Three types of surveillance
1. Passive surveillance/passive case detection

2. Active Surveillance

3. Sentinel Surveillance
 Passive surveillance
 Is a mechanism for routine survey based on passive case detection and
on the routine recording and reporting system.
 The information provider comes to the health institutions for help, be it
medical or other.
 It involves collection of data as part of routine provision of health
services.
 Passive surveillance
Advantages
 Covers a wide range of problems
 Does not require special arrangement
 It is relatively cheap
 Covers a wider area
Disadvantage
 The information generated is unreliable, incomplete and inaccurate
 Most of the time, data from passive surveillance is not available on time
 Most of the time, you may not get the kind of information you desire
 It lacks representativeness as it is mainly from health institutions
 There is no feedback system
 Active Surveillance

 A method of data collection usually on a specific disease, for relatively

limited period of time.

 It involves collection of data from communities

 This can be arranged on presence or absence of new cases of a particular

disease at regular intervals.
 Active Surveillance

 The techniques employed to collect information for active surveillance are:

 Sending out a letter describing the situation and asking for reports,
 Making a telephone call
 Visit the facilities to collect information on cases.
 Alerting the public directly, using local media, to visit a health facility if
they have symptoms
 Asking patients if they know anyone else with the same condition.
 Conducting a survey of the entire population.
 Active Surveillance
Advantages
 The collected data is complete and accurate
 Information collected is timely.
Disadvantages
 It requires good organization,
 it is expensive
 Requires skilled human power
 It is for short period of time (not a continuous process)
 It is directed towards specific disease conditions
 Active Surveillance

Conditions in which active surveillance is appropriate

 For periodic evaluation of an ongoing program
 For programs with limited time of operation such as eradication program.
 In unusual situations such as
 New disease discovery
 New mode of transmission
 When a high-risk season/year is recognized.
 When a disease is found to affect a new subgroup of the population.
 When a previously eradicated disease reappears.
 Sentinel Surveillance

 It uses a pre-arranged sample of reporting sources to report all cases of one or

more conditions.

 It provides a practical alternative to population-based surveillance, in developing

countries.
 Sentinel Surveillance
Advantages
 Relatively inexpensive
 Provides a practical alternative to population-based surveillance
 Can make productive use of data collected for other purposes

Disadvantages
 The selected population may not be representative of the whole population
 Use of secondary data may lead to data of lesser quality and timeliness
 Function of Surveillance

 The program monitoring function of surveillance of communicable diseases

encompasses a variety of goals such as

 Prevention and control (eg. Malaria)

 Elimination (eg. measles)

 Eradication (e.g. of guinea worm, poliomyelitis, onchocerciasis)

 Function of Surveillance
Surveillance Provides Information for action
 
Public Health Action
Surveillance    Priority Setting
 Collection    Planning, Implementing and
 Analysis evaluating diseases
 
 Interpretation  Investigation
 Dissemination    Control
   Prevention

Although surveillance is meant to guide a larger action it also provides the basis for identifying
individuals who need treatment and preventive services
Fig. Actions to follow during surveillance and action 
 Strengthening Surveillance Systems
A structured approach to strengthen disease surveillance systems could include:
 Identifying major public health threats.

 Prioritization of public health threats

 Assessment of existing systems (SWOT)

 Development of a strategic plan of action based on assessment findings

 Implementation of activities planned to strengthen the systems.

 Monitoring progress in implementation of planned activities

 Evaluating outcomes and overall impact of the surveillance system

 Components of disease surveillance and response

The components of surveillance and response systems targeted for M & E

comprise:

 The priority diseases targeted for surveillance

 The structure of the system

 Core functions of the system

 Support functions of the system

 Quality of the system

 Core functions

Case detection
Surveillance system structure 
Case registration
 Legislation Surveillance strategy 
Case confirmation
 Surveillance implementation 
Reporting
 Networking and partnerships 
Data analysis and
  interpretation
   Epidemic preparedness
   Response and control
 Feedback
Priority disease for
 
Surveillance quality surveillance
 

 Completeness, Support functions

 Timeliness,  Standards and guidelines
 Usefulness  Training
 Simplicity
 Supervision
 Acceptability
 Flexibility
 Communication facilities
 Sensitivity  Resources
 Positive predictive value  M&E
 Representativeness  Coordination
  Fig. Prioritizing diseases for
 Priority diseases targeted for surveillance and response
 Surveillance priorities may be communicable and non-communicable diseases,

conditions or events that include national or local priorities such as

 Acute outbreaks,

 Maternal deaths

 Events associated with human health

 Depending on the objectives of the system, priority diseases for surveillance should

be identified and reviewed regularly to ensure that they remain relevant and important.
 Priority diseases targeted for surveillance and response

 The following are some of the Selection Criteria for Disease Surveillance:

 Magnitude of the disease

 Feasibility of control measures

 Need for monitoring and evaluating the performance of a control program

 Resource availability Support functions of the system

 Core functions of surveillance system

 The core functions include:

 Case detection,

 Case registration,

 Case confirmation,

 Reporting,

 Data analysis and interpretation, and

 Public health response including reports and feedback

 Core functions of surveillance system
A. Case detection

 Case detection is the process of identifying cases and outbreaks.

 Case detection can be through the formal health system, private

health systems or community structures.

 Case definitions and a functioning rumor verification system are vital

for case and outbreak detection.

 Core functions of surveillance system

B. Case registration

 Case registration is the process of recording the cases identified.

 This requires a standardized register to record minimal data elements on

targeted diseases and conditions.

 Monitoring should establish the proportion of health facilities having the

standardized registers.

 Evaluation could then examine the validity and quality of information

recorded as well as factors that affect the registration of cases.
 Core functions of surveillance system
C. Case confirmation

 Case/outbreak confirmation refers to the epidemiological and

laboratory capacity for confirmation.

 Capacity for case confirmation is enhanced through improved

referral systems, networking and partnerships.

 This means having the capacity for appropriate specimen

collection, packaging and transportation.
 Core functions of surveillance system
D. Reporting

 Reporting refers to the process by which surveillance data moves

through the surveillance system from the point of generation.

 It also refers to the process of reporting suspected and confirmed

outbreaks.

 Different reporting systems may be in existence depending on the

type of data and information being reported, purpose and urgency of
relaying the information and where the data/information is being
reported.
 Core functions of surveillance system
E. Data analysis and interpretation

 Surveillance data should be analyzed routinely and the information

interpreted for use in public health actions.

 Appropriate "alert" and "epidemic" threshold values for diseases with

epidemic tendencies should be used by the surveillance staff.

 Capacity for routine data analysis and interpretation should be

established and maintained for epidemiological as well as laboratory
data.
 Core functions of surveillance system
F. Epidemic preparedness

 Epidemic preparedness refers to the existing level of preparedness for

potential epidemics and includes:

 Availability of preparedness plans,

 Stockpiling (buildup stocks),

 Designation of isolation facilities,

 Setting aside of resources for outbreak response, etc.

 Core functions of surveillance system
G. Response and control

 Public health surveillance systems are only useful if they provide

data for appropriate public health response and control.

 For an early warning system, the capacity to respond to detected

outbreaks and emerging public health threats needs to be assessed.

 This can be done following a major outbreak response and

containment to document the quality and impact of public health
response and control.
 Core functions of surveillance system
H. Feedback

 Feedback is an important function of all surveillance systems.

 Appropriate feedback can be maintained through supervisory

visits, newsletter and bulletins.

 It is possible to monitor the provision of feedback by the different

levels of surveillance and to evaluate the quality of feedback
provided, and the implementation of follow-up actions.
 Disease surveillance and response, Ethiopian context (PHEM)

 PHEM: is designed to ensure rapid detection of any public health threats,

preparedness related to logistic and fund administration, and prompt
response and recovery from various public health emergencies.

 It is the process of anticipating, preventing, preparing for, detecting,

responding to, controlling and recovering from consequences of public
health threats in order that health and economic impacts are minimized.
 Disease surveillance and response, Ethiopian context (PHEM)
 The major public health risks identified in the Ethiopian health system are:
 Epidemics of communicable disease
 Drought conditions with malnutrition
 Food contamination
 Flood
 Pandemic Influenza
 Diseases that affect people during conflicts and in displaced populations
 Accidents
 Earthquake, volcanic eruptions
 Bioterrorism
 Currently chronic disease is also an issue
 Guiding principles of PHEM
A. Multi-hazard approach
 Every hazard is determined by the potential importance of the risk
identified
 Any health hazard, irrespective of their origin or source, including
those caused by:
 Biological,

 Chemical agents or

 Radio-nuclear materials are considered by this approach.

 Guiding principles of PHEM
B. From risk assessment to recovery

 PHEM will cover the entire cycle of an emergency or disaster;

 From prevention and detection to response and recovery

 The extent of the activities in the process will vary according to the
type of Public Health Emergency (PHE).
 Guiding principles of PHEM
C. Risk assessment and mitigation

 One of the major changes in emergency management is change from the

old concept of disease management to a new approach of risk
management.

 Therefore, systematic analysis of the vulnerability to health hazards and

assessment of the risk is an innovative area of focus.

 Each and every level in health system is required to understand the health
hazards and risks posed on their population and map this using technology
such as Geographic Information System (GIS).
 Guiding principles of PHEM
D. International Health Regulations (IHR2005)

 The PHEM process considered and encompassed international

obligations that Ethiopia ratified.

 IHR 2005 is to prevent, protect against, control and provide public

health response to the international spread of disease in ways that are
relevant and restricted to public health risks, and which avoid
unnecessary interference with international traffic and trade.
 Diseases under surveillance in Ethiopia
 It is clear that surveillance could not be carried out for all diseases and
conditions due to many reasons.

 Therefore, priority should be given to those diseases that are of

interest at national and international levels.

 In Ethiopia context 20 diseases (13 are immediately reportable

whereas 7 are weekly reportable) are selected to be included into
the routine surveillance.
 Diseases under surveillance cont…

Diseases and conditions selected based on one/more of the following criteria:

I. Diseases which have high epidemic potential:
1. Anthrax,
2. Avian Human Influenza,
3. Cholera,
4. Measles,
5. Meningococcal Meningitis,
6. Pandemic Influenza,
7. Smallpox,
8. Severe Acute Respiratory Syndrome (SARS),
9. Viral Hemorrhagic Fever (VHF)
10.Yellow Fever
 Diseases under surveillance cont…

II. Required internationally under IHR2005:

1. Smallpox,

2. Poliomyelitis due to wild-type Poliovirus,

3. Human Influenza caused by a new subtype,

4. SARS
 Diseases under surveillance cont…

III. Diseases targeted for eradication or elimination:

1. Poliomyelitis due to wild-type Poliovirus,

2. Dracunculiasis,

3. Neonatal Tetanus (NNT)

 Diseases under surveillance cont…

IV. Diseases which have a significant public health importance:

1. Rabies,
2. Dysentery,
3. Malaria,
4. Relapsing Fever,
5. Typhoid Fever,
6. Typhus And
7. Severe Malnutrition

V. Diseases that have available effective control and prevention measures for
addressing the public health problems they pose.
 Immediately and Weekly reportable disease
Table: The current list of reportable diseases / conditions in Ethiopia context, 2018
Immediately reportable disease Weekly reportable disease
1. Acute Flaccid Paralysis 1. Dysentery
2. Anthrax 2. Malaria
3. Avian Human Influenza 3. Meningitis
4. Cholera 4. Relapsing fever
5. Dracunculiasis/Guinea worm 5. Typhoid Fever
6. Measles 6. Typhus
7. Neonatal tetanus 7. Severe Acute Malnutrition
8. Pandemic Influenza A(H1N1)
9. Rabies
10.Small pox
11.SARS
12.Viral Hemorrhagic Fever (VHF)
13.Yellow Fever
Cases/ conditions Case definition
Acute Febrile Illness Any person with fever, severe headache and /or diarrhea
Bloody diarrhea Any person with diarrhea and visible blood in the stool

Malaria Any person with fever OR fever with headache, back pain,
chills, rigor, sweating, muscle pain, nausea and vomiting OR
suspected case confirmed by RDT

Meningitis Any person with fever, severe headache and neck stiffness
Severe acute Children age 6 months to 5 years with MUAC less than 11cm
Malnutrition and bilateral leg edema OR Children age 6 months to 5 years
with bilateral leg edema.

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 Standard Case Definitions of surveillance in Ethiopia

A case definition: is a set of criteria used to decide if a person has a

particular disease, or if the case can be considered for reporting and
investigation.

Standard case definition: is a case definition that is agreed upon to be

used by everyone within the country.

 Standard case definition can be classified as:

 Confirmed,
 Probable
 Possible or suspected
 Standard Case Definitions of surveillance in Ethiopia

 Confirmed: a case definition by appropriate laboratory test

 Probable: a case with typical clinical features of the disease without

laboratory confirmation

 Possible/ Suspect: a case with few of the typical clinical features

 Standard Case Definitions of surveillance in Ethiopia

Importance of case definition

 Facilitate early detection and prompt management of cases

 Useful in areas where there is no laboratory

 Facilitate comparison more accurately from area to area

 Facilitates observation of trends within specified geographic areas

Read the case definition of diseases in PHEM Guideline

Target population can be:
 Individuals at specific institutions

 Residents of a community

 Residents of a nation, etc.

 A surveillance system remains effective when it is continuously

assessed.

 Periodically updating information about the catchment area is

necessary
 Time period of data collection
 It is useful to identify problems and solve timely
 There are three periods of reporting
1. Immediate reporting:
A. For diseases considering presence of a single case to result to a suspicion for
an epidemic.
B. Suspected epidemic when a threshold is crossed
2. On weekly basis: For epidemic prone diseases. Eg. Malaria, meningitis
3. On monthly basis: For Routine surveillance. Eg. Tuberculosis, Leprosy, AIDS
cases
 Information Flow in Surveillance System

WHO

Federal MOH (Central Referral Hospitals EPHI)

 

Supervision and feedback

Data collection, analysis,

Regional Health Bureau (Regional hospitals and

action & reporting

Regional laboratories)
 
Zonal Health Department (General hospital, PHCUs)

 
 
Woreda Health Office (Primary hospital, PHC facilities)
 

The community
Reporting diseases under surveillance, Type of reports and tools
 Reporting
• The routine flow of surveillance data is usually from reporting sites to the
next level up to the central level.
• The community and health facilities especially health posts are the main
source of information.
• The information collected from this site is compiled in standard forms,
analyzed and then forwarded, to the woreda health office.
• Woreda level uses standard formats to compile aggregate, and send the data
to zone/region, from which the central level receives.
• Feedback and information sharing will follow the same route.
• Electronic Reporting: Ethiopia is introducing DHIS2 for reporting PHEM
diseases
Reporting diseases under surveillance, Type of reports and tools

 Type of reports

 Disease and conditions are classified in to two reporting periods as:

1. Immediately and

2. Weekly

 It’s depending on their epidemic potential, diseases targeted for

elimination and eradication
Reporting diseases under surveillance, Type of reports and tools

1. Immediate reporting:

 Currently 13 diseases are identified to be reported immediately to next

reporting level.

 For the immediately reportable diseases, a single suspected case is

considered as a suspected outbreak.
Reporting diseases under surveillance, Type of reports and tools
1. Immediate reporting:
Therefore, suspected outbreak of these diseases should be notified from level to level
within 30 minutes of identifications as follows:
 From community or health post or health center to Woredas health office within
30 minutes,
 From Woreda health office to zone/region within another 30 minutes,
 From zone to regional office within another 30 minutes,
 From region health bureau to federal level within another 30 minutes,
 MOH to WHO within 24 hours of detection.
Reporting diseases under surveillance, Type of reports and tools

2. Weekly reporting:

 Currently 7 diseases and conditions are identified to be reported weekly to

the next reporting level.

 Reporting of the total number of cases and deaths seen within a week
(Monday to Sunday) and should be reported to the next level as follows:
 Health facilities report data to Woreda every Monday till midday;
 Woredas report to zone/region every Tuesday till midday;
 Zone (if applicable) report to region every Wednesday till midday;
 Region report to EHNRI /PHEM every Thursday;
 EHNRI /PHEM report to stakeholders every Friday
Reporting diseases under surveillance, Type of reports and tools
 Reporting tools
Different reporting tools are developed to facilitate the reporting. These includes:
1. Weekly reporting form for health post / HEW
2. Weekly reporting format for other levels
3. Daily epidemic reporting format for Woreda (DERF-W)
4. Daily epidemic reporting format for Region (DERF-R)
5. Case based reporting format (CRF) for many diseases
6. AFP case investigation form
7. Guinea worm case-based reporting format
8. Guinea worm line list
9. Influenza case-based reporting format
10. Line list (for all diseases)
11. Rumor log book for suspected epidemics (for any type of public health rumors)
12. Case based laboratory reporting form (CLRF).
Activity-10
1. Observe all current list of immediately and weekly reportable diseases in Ethiopia
and discuss why each disease assigned as immediately and weekly reportable?
2. Discuss about how surveillance for Covid-19 conducted and the case definition for
Covid-19
3. Observe all disease surveillance reporting tools and discuss in groups on the
following points:
a) Data elements to be reported
b) Reporting hierarchy and periods
c) Who are responsible bodies for recording and reporting
363
 CHAPTER 11:
BASICS OF LOGISTICS INFORMATION SYSTEM
LEARNING OUTCOMES

At the end of this chapter participants will be able to:

 Describe overview of logistic management
 Identify the challenges in logistic management information system
 Define logistics management information system
 Demonstrate report generation in logistics management information system
 Overview of Logistic Management
 Logistics management: Is part of the supply chain that plans, implements
and controls the efficient, effective forward and reverse flow and storage of
supply related information between the point of origin and the point of
consumption.

 The supply chain not only includes the manufacturer and its suppliers but
also transporters, warehouses, retailers, service organizations and
consumers.

 Supply chain management encompasses the planning and management of

all activities involved in sourcing and procurement and all logistics
management activities.
 Overview of logistics management
 Supply chain management integrates supply and demand management
within and across companies.
 Supply chain management includes the logistics activities plus the
coordination and collaboration of staff, levels and functions.
 A well-functioning supply chains benefit public health programs by

 Increasing program impact

 Enhancing quality of care

 Improving cost effectiveness and efficiency

 Logistics management information system (LMIS)
 LMIS is collecting, organizing and reporting logistic related data to enable
managers to make logistics decisions.
 LMIS data elements includes:
 Stock on hand,
 Losses and adjustments,
 Consumption,
 Demand,
 Issues,
 Shipment status and
 Information about the cost of commodities managed in the system
 Purpose of LMIS
 The primary purpose of the LMIS is to ensure smooth supply chain management

 The Six rights for LMIS data:

 The right data
 At the right time
 At the right place
 In the right quantity
 The right quality
 At the right cost
 Types of logistic records

 Three Types of Logistics Records

1. Stock keeping records: Holds information about products in storage.

2. Transaction records: Holds information about products being moved.

3. Consumption records: Holds information about products being consumed or

used.
Computerized logistics management information system

 Automation of LMIS can greatly facilitates supply chain managers by

enabling faster collection, transmission and aggregation of data.

 eLMIS is a revolutionary and cost-effective system of data management

that ensures greater commodity security and better health outcomes.

 Computers take the place of humans in aggregating logistics data

performing calculations and producing reports and graphs for analysis.
Computerized logistics management information system

Benefits of computerized over manual LMIS:

 No mathematical errors

 Rapid aggregations and calculations

 Rapid production of reports and graphs

 A computerized LMIS also provides functionalities such as alert

mechanisms to assisting decision making.
 Basic Modules in eLMIS Registering and Tracking
The common module of LMIS includes:

 Record keeping

 Back-up

 Logistic data analysis

 Data importing, exporting,

 Reporting

 Information visualizing and others

 eLMIS Operations

Operation of a computerized LMIS includes the following key tasks:

 Collecting, entering, and validating routine LMIS data.

 Distributing routine LMIS reports

 Identifying and reporting software defects

 Identifying improvements for the next version of the software

 Challenges of LMIS

The main LMIS challenges in developing countries also include:

 Inadequate resources for structural, resource and organizational support
 Inadequate knowledge and skill on designing and implementation of LMIS
 Difficulty of measuring logistic related performance indicators
 The shortage of professionals
 Poor infrastructure
 eLMIS needs affordable, comprehensive, user friendly, flexible and reliable
system to allow quick and easy data exchange between all its nodes
 Reporting in LMIS

 Reports move information up and down through a logistics system

 A reporting system must be in place to ensure that this information flows
correctly and consistently.
 A reporting system in a supply chain may include levels outside storage and
distribution points.
 For example, a District Health Office might not hold stock or be involved in
the distribution of products but this office still needs to receive LMIS reports to
ensure that facilities are stocked appropriately to determine if the District Health
Office needs to invest additional funding and or resources into training, staffing,
commodity quantities
 Reporting in LMIS

 Logistics managers use them for evidence-based decision-making and high-

level managers may rely on them to implement policies affecting the
national supply chain.
 Logistics management information system reports are first and foremost
used for logistics transactions, particularly determining how much of each
medicine, vaccine, reagent or consumable to supply to each facility to meet
service delivery needs
 These data may flow at regular or irregular intervals often have to be
evaluated longitudinally to make a resupply decision for a single period or
event and are typically incorporated into transactional workflows.
Activity 11

1. Discuss common challenges and alternative solutions for Logistic

Management Information System in Ethiopia.

2. Search and evaluate open-source Logistic Management Information

System software for health care.

377