Bridging the gaps in the Health Management Information System in the context of a changing health sector

A health management information system (HMIS) is a process whereby health data are recorded, stored and processed for policy-making, planning, implementation and evaluation of health programs. The system is crucial for evidence-based policy and informed decision-making at all levels from national down to the institutional levels. Evidence-based decision making is critically important for the appropriate use of scarce resources particularly in resource limited countries like Tanzania. The HMIS in most developing countries are inefficient and are greatly affected by unreliability of data resulting from underreporting [1]. Reports from sub Saharan Africa indicate that vital health decisions, in this context, are made based on crude estimates of disease and treatment burdens [2, 3]. Findings from this region indicate that the problem of under reporting is huge and is linked to lack of knowledge and practice among the health workers characterized by insufficient analysis skills, training and lack of initiative for using information [4–6].

In Tanzania the first version of the health management information system was launched in 1993 and the second in 1998 [7]. The first version was entirely in English and it was soon realized upon testing that the users had limited commands in this language and was therefore technically changed to Kiswahili, the national language. Thus, the Health Management Information System is called in Kiswahili as Mfumo wa Taarifa za Huduma za Afya (MTUHA). The latest version involves manual data entry into 12 HMIS booklets. The system covers all health programs and health care services, and requires all health facilities, regardless of ownership, to use this system and report to the district health authority on quarterly basis. The overall goal of this system is to optimize the performance of health services at all levels of administration through the timely provision of necessary and sufficient information needed by the health managers to monitor, evaluate and plan their activities [7, 8]. Its success requires a system that is integrated, decentralized, functional and reliable [9].

The conception of this study was based on the concerns about the poor quality data and inadequate integration of the HMIS despite a number of changes it has undergone since inception and the need to bridge the gaps in the on-going changes in health sector. In an attempt to strengthen the health services to meet national and international commitments, the government of Tanzania has developed the Primary Health Service Development Program (PHSDP) whose main goal is to accelerate provision of quality primary health care services to all by 2017. This program is implemented by increasing intakes of trainees for health care, reviewing and standardizing curricula for all medical and paramedical cadres to competence-based [10]. The review of the curricula is spearheaded by the National Council for Technical Education (NACTE) an organ which was empowered by the government through the Act No. 9 of 1997 to coordinate technical education and set qualification standards for the awards. This article explores the gaps and factors for change in HMIS in Tanzania and presents a detailed account on how they could be best bridged in the ongoing changes in country's health sector. It attempts to link the required changes in the HMIS and the evidence-based John Kotter's eight-step process for implementing successful changes in any organizations [11].

Our findings revealed a wide range of interlinked factors responsible for the inefficiency and ineffectiveness of the HMIS in Tanzania. The lack of clear understanding of the purpose, users and flow pattern of health data collection was linked to poor quality of data collection and suggests that decision-making in the country health system may be less than adequately informed. This study has revealed higher proportion (65%) of care providers who failed to define properly what HMIS is than that (47%) reported in previous studies [6]. These findings suggest a declining knowledge on this important system. On the contrary, despite such low knowledge on HMIS, the majority of the care providers (91%) had positive attitude towards the system, indicating substantial acceptability, a positive potential factor for improvement. The existing huge gap of knowledge on such an important system can be linked to lack of training which was as high as 81% of care providers. On the other hand the findings suggest lack of emphasis on HMIS in the pre-service curricula and hence a lack of evidence-based training in medical and paramedical training institutions in the country. Considering the ongoing process to develop and introduce competence-based educational curricula for all medical and paramedical training programs in the country and the government 10 year program to expand training of care providers, incorporation of HMIS in the new curricula is greatly suggested. The government of Tanzania through its 10 year PHSDP (2008 - 2017), intends to train 460,000 health care providers by the year 2017 and improve the provision of health services to the level of every village and ward [10, 15]. The author believes that incorporation of HMIS in the new curricula will improve not only knowledge, skills, culture and efficiency of HMIS but will also cut-down the investment required for on-the-job training for health care providers.

The failure to collect health data as seen in 55% of the health facilities for HMIS delivery booklets, indicates the high degree of poor documentation, underreporting and data inaccuracy from the district up to the national level. The HMIS guidelines require health care providers to complete relevant booklets immediately after provision of health care services before the patients or clients leave the facility. The impact of such poor compliance with this system is worrisome and suggests that vital public health decisions are made based on crude district and national estimates of burden of the problems. The failure to use health data collected at the health facility level as reported by 63% of care providers indicates that the primary purpose of data collection is to report to higher levels suggesting a high prevalence of the "mailbox syndrome". The "mailbox syndrome" is a phenomenon whereby a crucial information generated at the health facility level is mailed rather than used locally for quality care improvement [16]. This syndrome is contrary to the concept of decentralization which is currently implemented in the country. These findings suggest also that the existing HMIS has not been institutionalized in the sense of being integrated into the everyday activities, an important factor for its sustainability and reliability.

Like many other reports the incompleteness and poor use of health data collected at a health facility, found in this study, can be attributed to poor knowledge on HMIS; inadequate financial, human and technological resource capacity; lack of user-friendly systems; lack of coordination and evaluation, as well as inadequate policies to manage the sustainability of the system [17, 18]. Considering the lengthy and laborious HMIS procedural requirements for completion of the booklets and the context of acute shortage of care providers, revision for a more user-friendly system is highly recommended.

The fact that these factors have been documented and remained unattended in Tanzania over many years, indicates a high degree of irresponsiveness and unaccountability in the country health system [19, 20]. These findings suggest in part poor leadership performance. Carrying out "business as usual", a static mindset among the key actors and poor supervision of health systems are progress blocking agents which have been reported as the leading factors for poor performance of health sectors in sub-Saharan Africa [21]. These findings call for more commitment, dedication and accountability within an HMIS organization [22]. Considering these factors and the fact that Tanzania is already off-track in HMIS, evidence-based John Kotter's eight-step process for implementing successful changes is indicated for effective system in this country. These steps are: to create a sense of urgency for change, create powerful group guiding the change, develop and communicate the change vision and strategy, empower others to act, produce short-term wins, press harder and faster after the first successes and create a new culture for sustainability [11].

This article has revealed a state of poor health data collection, lack of data-based decision-making at all levels and the factors for change in the country's HMIS. It calls for new innovations including incorporation of HMIS in the ongoing reviews of the educational curricula for all cadres of health care providers, development of more user-friendly system and use of evidence-based John Kotter's eight-step process for implementing successful changes in this system.