International Journal of Medical Informatics (2005) 74, 733744

Evaluation of existing District Health Management Information Systems A case study of the District Health Systems in Kenya
George W. Odhiambo-Otieno
Department of Health Management, Faculty of Health Sciences, Moi University, P.O. Box 6142, Eldoret, Kenya
Received 9 May 2005; accepted 10 May 2005 KEYWORDS
Evaluation; District Health Management Information System; District Health System

Summary Introduction: This paper discusses some of the issues and challenges of implementing appropriate and coordinated District Health Management Information System (DHMIS) in environments dependent on external support especially when insufcient attention has been given to the sustainability of systems. It also discusses fundamental issues which affect the usability of DHMIS to support District Health System (DHS), including meeting user needs and user education in the use of information for management; and the need for integration of data from all health-providing and related organizations in the district. Methods: This descriptive cross-sectional study was carried out in three DHSs in Kenya. Data was collected through use of questionnaires, focus group discussions and review of relevant literature, reports and operational manuals of the studied DHMISs. Results: Key personnel at the DHS level were not involved in the development and implementation of the established systems. The DHMISs were fragmented to the extent that their information products were bypassing the very levels they were created to serve. None of the DHMISs was computerized. Key resources for DHMIS operation were inadequate. The adequacy of personnel was 47%, working space 40%, storage space 34%, stationery 20%, 73% of DHMIS staff were not trained, management support was 13%. Information produced was 30% accurate, 19% complete, 26% timely, 72% relevant; the level of condentiality and use of information at the point of collection stood at 32% and 22% respectively and information security at 48%. Basic DHMIS equipment for information processing was not available. This inhibited effective and efcient provision of information services.

Tel.: +254 720716770; fax: +254 532033041. E-mail address: gwo-otieno@multitechweb.com.

1386-5056/$ see front matter 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijmedinf.2005.05.007

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G.W. Odhiambo-Otieno
Conclusions: An effective DHMIS is essential for DHS planning, implementation, monitoring and evaluation activities. Without accurate, timely, relevant and complete information the existing information systems are not capable of facilitating the DHS managers in their day-today operational management. The existing DHMISs were found not supportive of the DHS managers strategic and operational management functions. Consequently DHMISs were found to be plagued by numerous designs, operational, resources and managerial problems. There is an urgent need to explore the possibilities of computerizing the existing manual systems to take advantage of the potential uses of microcomputers for DHMIS operations within the DHS. Information system designers must also address issues of cooperative partnership in information activities, systems compatibility and sustainability. 2005 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Health Management Information Systems (HMISs) are important support tools in the management of health care services delivery [1]. In 1983, the Government of Kenya (GoK), decentralized the Ministry of Healths (MoH) decision-making process to the districts [2]. This was in line with World Health Organization (WHO) resolution calling on all WHO member states to strengthen District Health Systems (DHS) [3]. For this decentralization to be effective, there was a need to establish information systems to support the DHS managers in their planning, implementation and evaluation functions. The establishment of effective Health Information Systems to support decision-making by district health personnel was an essential component of the DHS [4]. The GoK recognized that without an effective and appropriate information system, the MoHs capacity to cope with its planning and management needs would be severely compromised [5]. These information systems were to provide the DHS managers who were members of District Health Management Team (DHMT) and District Health Management Board (DHMB) with the information they require. The DHMT members including among others the District Medical Ofcer of Health (DMOH) as Chairman, the District Health Administrative Ofcer (DHAO), the District Public Health Nurse (DPHN), the District Public Health Ofcer (DPHO,) and the Medical Records Ofcer, were responsible for among other things, developing a strategy for the district health service, monitoring the health problems that occurred in the district, and coordinating the activities of all health care providers in the district. The DHMB on the other hand, which consisted of the area DMOH, local community and Non-Governmental Organization (NGO) representatives, among others, played an advisory role in relation to DHMT and worked with DHMT to coordinate and monitor the implementation of government and

non-government health programs in the district [5]. The DHMIS was to provide both the DHMT and DHMB with accurate, reliable and up-to-date information for the management of the DHS. Following this decentralization, Health Information Systems (HISs) at the district level in Kenya have undergone fundamental changes that have resulted in the introduction of different types of information systems. A quick survey of Kenyas MoH reveals that it operates different versions of District Health Management Information Systems (DHMISs) at the DHS level [5]. The rst DHMIS was introduced in Muranga DHS in 1988 and was funded by UNICEF. This system introduced a total of 26 data collection forms, 11 of which were for collecting health service data and 15 for collecting administrative/management data [6]. Subsequent to the introduction of the Muranga DHMIS, the following DHSs introduced various versions of DHMISs: Kitui, Embu, Baringo, Nakuru, Nyandarua, Nyamira, Kisumu, Kwale, Uasin Gishu, Bungoma and Mombasa [5]. Reasons advanced for the introduction of these systems were: (a) health facilities collected information haphazardly and irregularly; (b) information collected was incomplete and unreliable with limited analysis and use at the point of collection; (c) too much data was collected rendering analysis impossible. The objective of this system was to facilitate the use of selected existing information to support operational decision-making and planning. Relevant information compiled at the District HIS Ofce was to be extracted, processed and made available regularly to the DHMT and DHMB for action planning, supervision and impact assessment [6]. These systems operated along side with the routine HISs which are operational in all DHSs in Kenya. All these systems within the DHSs in Kenya are characterized by a lack of integration, and are disjointed and widely dispersed, with no effective central co-ordination to ensure that the information which they contain is readily available to those

Evaluation of existing District Health Management Information Systems who need it [5]. To-date, there has been no formal comprehensive evaluation of these systems by their designers to determine their strengths and weaknesses ever since their introduction in the DHSs in Kenya. The research question is: To what extent are the information systems in the DHSs in Kenya supportive of the operational management of the health services? This paper attempts to provide an answer to this question and at the same time identies and discusses some of the obstacles to the smooth operation of the existing systems.

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2. Objective of the study

The broad objective is to evaluate the extent to which existing information systems have supported the operational management of health services at the district level in Kenya. The specic objectives are to: identify the processes undertaken in designing and implementing the existing DHMISs; identify DHMIS operation and resource requirements; identify DHMIS users and their information requirements.

3. Methodology
This exploratory and descriptive, cross-sectional study was undertaken to unearth the real problems faced by existing DHMISs in the MoH, Kenya. Both qualitative and quantitative approaches were used to explore, describe and explain why things happened the way they did [7]. The qualitative method permitted the researcher to study selected issues in depth and detail thereby producing a wealth of detailed information from a small sample [8]. These methods permitted subjects full opportunity to express themselves and behave in a naturalistic way [9]. In-depth studies of 3 of the 13 DHMISs introduced in the Kenyas DHSs were made. Interviews were conducted with system designers, DHMIS operators (staff) and users (health workers). These interviews were conducted on an individual basis. In addition, document analysis of literature on these systems was carried out. Finally, day-today observation of the operations of these systems was conducted. As a result, a set of constraints to the operations of these systems was evident. This study used a combination of purposeful/judgmental and snowball/chain sampling procedures [10]. The logic and power of purposeful sampling lies in selecting information-rich cases for

study in depth [8]. Since DHMISs were implemented in 13 selected DHSs in Kenya, this study used purposeful sampling procedures for selecting the three DHSs of study, namely, Muranga, Uasin Gishu and Bungoma. Muranga was selected because it was the rst DHS to pilot and implement a DHMIS. The Muranga design was supposed to be used as a blueprint for other DHSs, hence the justication to study in detail the original system and assess how it was actually operating in comparison with those in other DHSs. Sample size in this study depended mainly on what could be done with available time and resources [8]. There were two categories of samples for this study whose sizes were: study areas n = 3 (based on purposeful/judgmental sampling procedures) and, respondents n = 30 (based on outcome of snowball sampling procedures). Snowball sampling was used for locating information-rich key informants (interviewees). The process began by identifying the rst key informant who then helped in identifying subsequent key informants for the study [7,8,10]. Rationale for using this strategy was to get information-rich respondents; those who had actually been involved in one way or another in either the design or implementation of the DHMISs that were being evaluated. This strategy enabled the researcher to identify information-rich respondents whose knowledge of the system helped in providing the crucial information sought by the study.

4. Results and discussions

4.1. The processes undertaken in designing and Implementing existing DHMISs
The study revealed that the DHMISs studied were designed at the MoH headquarters and implemented in the DHSs with no participation of those who were to ultimately operate them. Neither was there involvement of those who were to use the information generated by these systems. Another feature common to all of them was that they were all donor driven. This had implication for their eventual operation upon donor pullout. There was a considerable variation in the degree to which DHSs studied and their information support evolved. Whereas the Muranga system used a total of 26 report forms for collecting data, Bungoma and Uasin Gishu systems used a total of 17 and 49 report forms respectively. The study indicated that these DHMIS were highly fragmented with no linkages with other health care providers at various levels. The design and implementation of these DHMIS did not

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G.W. Odhiambo-Otieno

Fig. 1 A fragmented District Health Management Information System: NGO HQ: Non-Govermental Organization Headquaters; PHMT : Provincial Health Management Team; DHMB: District Health Management Board; DHMT: District Health Management Team; HCMT: Health Centre Management Team; HCDC: Health Centre Development; Committee; VHC: Village Health Committee; () current information channel; ( ) bypassed points (levels).

facilitate integration of different sources of health information within the DHSs studied. Consequently, there was no sharing of information among health care providers in the DHSs studied (Fig. 1). The basic premise to be adopted in the development of any information system model is that a DHMIS should be designed with a focus on improving the health status of the community. Meaningful improvements can only come about as a result of provision of information generated by all health care providers in the DHS. Only health interventions based on such information stand a chance of having desired effects on improving the health status of the DHS community.

4.2. The DHMISs operations and resource requirements

The DHMISs in the studied DHSs were mainly concerned with the collection of health service (patient) data with none of them collecting management/administrative data. This needed to change as these systems must concentrate also on managerial aspects for the better use of health care resources. DHMISs should strive to collect both health service (patient) data and administrative data. The information required by both DHMTs and DHMBs to plan and manage the DHS ranges from the broad and qualitative data, which is often

Evaluation of existing District Health Management Information Systems in the realm of general knowledge, to specic demographic, epidemiological and administrative data. Not a single information system studied was found to be computerized. The existing manual systems for collection, storage and retrieval were not facilitating timely availability of information for decision-making. Despite coming up with their own unique designs, none of the DHMISs were found to be operating as designed. The inability to implement the systems in Bungoma and Uasin Gishu DHSs as per the Muranga DHS design which was supposed to be the blueprint for all other DHSs in Kenya, resulted in the variations in the type and quantity of information collected. Each of the DHMIS studied was found to be using its own unique set of forms which varied in numbers from one system to the other. Given the fact that some of these forms were to be lled by the already overburdened clinical staff and nurses in the facilities, it resulted in most data not being captured as these staff saw their rst priority as being the provision of medical care to the patient and only turning to the forms when there was time to spare for this activity. This variation in the data collection tools (forms) did not facilitate meaningful comparison with other DHSs in terms of performance. One of the major complaints by DHMIS personnel interviewed was that the number of forms used in data collection was too large. They felt that there was an urgent need to reduce the number of forms to a reasonable number. Some of the forms were found to be redundant in that they were collecting information already collected by other forms. Inadequacies in access to and availability of information call for the creation of partnership and shared vision in health information management. The lack of common vision and of coherent policies within the MoH arise partly because of the lack of adequate and shared information. The goal is for all partners in health care to share their information. The DHSs studied were based on the WHO Model, with the district as the main operational unit that supports the Primary Health Care (PHC) strategy [3]. The most important PHC strategies are intersectoral co-ordination and community involvement, coupled with bringing together all relevant parties (including government, private health providers, NGOs and traditional healers) as partners in work related to health. The DHS through the PHC is inherently multidisciplinary. Findings indicated that these DHMISs neither collected nor received data or information from other health care providers like the private hospitals, local authority facilities or NGOs providing health care in their respective DHSs (Fig. 1). Particular attention needs to be paid to collecting informa-

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tion from non-governmental sources with a view to strengthening co-ordination and collaboration to improve health in the DHS. To complement the facility-based sources of information, surveys could be used to collect information from the community in the facilitys catchment area. Data for a district health prole, for example, could be obtained through routine reporting. These two sources would then enable the DHS managers to have a more complete and comprehensive picture of the health situation in the DHS and would help them to come up with appropriate interventions. All institutions in a DHS should be seen to be having an important contribution to make to the DHMIS and to improving health in the DHS. The partnership between information users and collectors helps to avoid embarrassing errors and greatly reduces external criticism of the DHMIS. Making information users partners in the design and implementation of a DHMIS has the opportunity to unify its goals with users goals. Ideally, the partnership between information producers and information users should be formed as early as possible in the data collection process. Successful design and implementation of a DHMIS requires the full and active participation of all stakeholders (DHMIS designers, donors, operators and users) during all the stages of developing a DHMIS. Institutionalization, ownership and commitment can only come about as a result of active involvement of all stakeholders. There is need for integration of data from all health-providing and related organizations in the DHS. Health care workers in the studied DHMISs studied spend a signicant proportion of their working time collecting large amounts of patient data that was rarely analyzed and used at the point of collection. They were found to be merely collecting, aggregating and dutifully passing over this data to the next level. This information is rarely ever used to guide local action at the level at which the data is collected [11]. Data collected was not compiled and presented into summaries useful for decisionmaking. There were no wall charts or graphs summarizing information collected in any of the systems studied. Very little collected information reached the DHS managers, the DHMTs and DHMBs (Fig. 1). This was despite the fact that the DHMIS was introduced to facilitate the operations of these two bodies. Information produced by these systems rarely matched the requirements of the DHS managers. This could possibly be explained by lack of involving information users in the design of these systems. Given the manual nature of these systems, their information was not delivered in time as it was not easily

738 physically accessible mainly due to type of storage system used. The most frequent problem is the lack of feedback to local districts and health care workers [11]. When feedback was nally received from the headquarters in the form of MoH Annual Report, it inevitably came too late, sometimes after 2 years, to impact on operational management decisions. At the grassroots level, the health centre development committees (HCDCs), health centre management teams (HCMTs) and the village health committees (VHCs), where they existed, were usually isolated from their health centres and dispensaries (Fig. 1). They were rarely provided with processed information from these facilities or from the district health committees that were supposed to assist them in better understanding the health problems of their localities. Data captured varied from one system to another depending on the design and number of forms introduced in each system, which eventually determined the type and amount of data collected by each DHMIS. These DHMISs had no information on access to and coverage of health services. None of these systems studied had management/administrative information about such resources as personnel, nances, physical facilities, equipment and transport. To get any of this information it has to be specically collected for the purpose as it is neither routinely collected nor stored by the studied systems. Only Uasin Gishu DHS had information on the size of the catchment population it was attempting to serve. In the absence of such information it
Table 1

G.W. Odhiambo-Otieno becomes very difcult to relate health resources to populations. Without such population-based information, it is impossible to do even the most basic types of monitoring of DHS activities. All the systems studied had adequate information on common causes of morbidity and mortality. However, these systems could be improved by collecting data on important underlying factors inuencing health status such as food availability, housing, water supply and sanitary facilities. Knowledge of occupational groups at high risk of diseases such as malnutrition may point to areas of promotive and preventive action. The information systems studied were found to be lacking key resources necessary for information processing, reecting low managerial priority. These DHMISs were handicapped in all their work by the lack of basic typing, duplicating, and ling equipment. All Health Information Systems require resources and adequate long-term funding for such necessities as trained staff, computers, stationery, communication equipment, systems and staff development, reports and communication costs (Table 1). The three DHMISs were all initially developed with considerable support from international donor agencies. All the systems collapsed as soon as the donor agencies withdrew their nancial and technical support. For purposes of sustainability, there is need for provision of adequate funding by beneciary DHSs. This will ensure that these systems are provided with adequate resources for their operations. Sustainability can be enhanced by active

Status and quantity of data processing equipment District Uasin Gishu Muranga 2 1 1 3 Bungoma 3 1 1 Uasin Gishu ones are personal; Bungoma using calculators donated by KFPHCP These belong to the MoH Hardly used due to stationery problems Not used for data entry as there was no printer available. Observed staff playing computer games instead of entering data Not available even where there is a computer like in Uasin Gishu All photocopying done commercially outside the facilities Despite its usefulness no single system had one in place Extension of the hospitals main line The available cabinets were far from adequate. Data storage in Uasin Gishu was pathetic. Most data was found lying on the oor 2 1 Remarks

Equipment Pocket calculator Desk calculator Typewriter Computer Printer Photocopier Duplicating machine Telephone Filing cabinets

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Table 2 District Health System

Quantity and quality of information system personnel in study areas Total number in district 50 26 31 107 Level of training received Percentage of personnel None Certicate Diploma Degree trained 8 7 10 25 2 1 1 4 20 31 35.5 27 Percentage of personnel untrained 80 69 64.5 73 Remarks

Uasin Gishu Muranga Bungoma Total

40 18 20 78

20 are temporary

involvement of all parties at all stages of DHMIS development. Data collection in the wards was not coordinated as the nurses and medical records clerks in the same ward collected information from the same patients for different persons and purposes. Both categories of staff (nurses and clerks) had not received adequate training on information activities. In one of the DHSs studied, data was being collected by mainly untrained and temporarily hired workers. The number of DHMIS personnel was found to be inadequate, the majority of them were untrained in DHMIS operations (Table 2). The deployment of untrained staff in information activities is likely to compromise the quality of information produced. Lack of a co-ordinated data collection strategy was a recurrent problem in the DHMISs studied which led to duplication of effort and competition among data collecting units and health care providers. The poor quality, incompleteness and lack of timeliness of much of the data being generated by existing institutional record-based Health Information Systems were found to be the main problems. Information produced was 30% accurate, 19% complete, 26% timely, 72% relevant; the level of condentiality and use of information at the point of collection stood at 32% and 22% respectively and information security at 48%. Condentiality and security of the information was compromised by the nature of storage as most records were found lying on some oors due to either inadequate storage facilities or lack of space. The study revealed that almost all of the key resources needed for the functioning of the DHMISs were in inadequate supply. Information systems personnel interviewed on adequacy of resources produced the following results: The number of personnel was found adequate by 47% of the interviewed persons, working space 38%, storage space 32% and stationery 18%. Findings also revealed that a dismal 13% of the interviewed persons found management support for information activities to be adequate. Management follow-up/supervision

Fig. 2 Resources and managerial support.

stood at 7% and feedback from above was 13%. All the respondents interviewed indicated that all the studied systems seriously lacked nances, transport and equipment (Fig. 2). DHMIS personnel interviewed indicated that these systems were faced with numerous operational problems. These identied problems had greatly affected the smooth operations of the implemented DHMISs to the extent that they were barely functional. Responses of DHMIS staff mainly focused on the inadequacies in the supply of information system resources as shown in Table 3. For the same DHMISs to produce their desired effects, personnel operating the three DHSs studied made suggestions on what they thought needed to be done to address the problems they identied in their respective DHMISs (Table 3). For a DHMIS to be supportive of the DHS activities, it must have access to functioning equipment for developing forms, communication to the eld and replies to user inquiries. Storage of collected data and generated information must be handled with the condentiality and security they deserve. This calls for the provision of adequate

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Table 3 DHS Muranga

DHMIS operational problems in each DHS and suggested solutions by DHMIS personnel interviewed DHMIS operational problem Financial constraints Manual system Lack of transport Inadequate skills Heavy workload Lack of feedback Lack of working and storage space Lack of equipment Existing system limited to MoH facilities activities Manual operations Reluctance by some members to give full information Lack of clear understanding between HIS and DHMIS staff (fear of takeover) Financial constraints resulting in shortages of equipment, stationery transport, working and storage space Some DHS Mangers dont appreciate the value information Limited DHMIS personnel skills Lack of reporting guidelines/feedback Lack of integration of information activities in the DHS Ignoring DHMIS personnel in the design Manual system System activities too narrow Lack of nances for the provision of: equipment and furniture; working and storage space; stationery; transport; adequate staff and training Lack of management support Lack of co-ordination Lack of appreciation of DHMIS staff work Suggested solution by DHMIS personnel Create a budgetary line item for DHMIS operations Computerize for ease of analysis, storage and retrieval Provide motor-bikes to staff for eld supervision Train new staff and further train old staff Reduce number of forms currently used Encourage feedback in both upwards and downwards Provide adequate working and storage space Procure modern equipment calculators and photocopiers Expand existing system to collect information from other health care providers in the DHS Minimize work by computerization Training in information systems activities for new members of staff and refresher courses for old staff Proper interpretation of what DHMIS is all about Adequate nancial support create a budget item for DHMIS operations Train DHS Mangers on the value of DHMIS and its products and them to recognize DHMISs contribution in care delivery Encourage further training and refresher courses Issue clear policy guidelines for reporting Modify and expand existing system to involve community and other health care providers in the DHS Involve ultimate users in the design of such systems Computerize to enhance DHMIS operation to facilitate data analysis, storage and retrieval of information Expand the system and collect information from central government and local authorities, public, mission, and private clinics Provide adequate funding through creation of a budget line in the Districts budgetary allocation from the MoH for the provision of these identied services Provide the necessary nancial and moral support Co-ordinate with other health care providers in the DHS Demonstrate appreciation of the contribution of HMIS staff

Bungoma

Uasin Gishu

physical storage and working space. To deliver expected information outputs, the information systems require strong central management and support by major decision makers within the DHS.

4.3. DHMIS users and their information requirements

The health care panorama is diverse and complex. Major differences are observable among DHSs activities and even among different levels of the same

DHS. No single information system will support this diversity of information generation and management needs. DHMIS users (health workers) complained about untimeliness, inaccuracies, irrelevance and incompleteness of information produced (Table 4). Various DHMIS users are not getting the type of information they need. In such a case there is need for conducting an information audit to identify user requirements. The information audit is a managerial tool for the examination of information used to make decisions. The information identied

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Table 4 User

DHMIS users and their information requirements Type of Information Information from all other health care providers in the DHS Outcome/impact General socio-economic Catchment population Demographic Access and coverage Resource mobilization, allocation and utilization Administrative information (personnel, nances, facilities) Information from all other health care providers in the DHS Preventive and therapeutic strategies Outcome and impact Environmental and social determinants of health Options for their on-going care Reasons Information needed for formulation of comprehensive policies and intervention Information provides a district health prole necessary for the planning and management of the DHS Information needed for effective and efcient allocation of health resources

HIS dept. personnel (MoH Hq) DHS managers

PHC providers Institutions and organizations General public Patients

Need to know which strategies achieve the best outcomes Need to know how best to ensure the health and productivity of their employees Need to know how to avoid illnesses and improve life expectancy For effective decision-making for better care

as relevant to current decision-making and to what might be used in some future system is ordered by priorities according to the resources allocated on the basis of the decisions being made. The role of the DHMIS in the DHS should not just be routine collection of facility-based health service data and dutiful conveyance of the same to higher levels of the health care system. The underlying rationale for a DHMISs efforts is improvement in health status of the population within a DHS. Information collection, analysis and presentation should be organized in such a way that the most needy groups and individuals are identied. Subsequent health planning should be based on such information and strategies should be designed to redress any identied inequalities. It is important that the DHS managers have current information on the impact of its service activities. The information on target populations is quite essential for understanding the impact of health services rendered. This information is necessary for monitoring the impact/outcome of DHS interventions. DHS managers need information on an interventions relevance, progress, effectiveness, impact and efciency. Information output from the systems studied is of statistical nature, inappropriate and outdated that only a relatively small group of health infor-

mation personnel and researchers are capable of using it. In this respect, the very format, composition and availability of the information products have become formidable barriers to the potential users. No DHMIS can afford to discourage the successful use of its information resources by producing information products that are not aligned with the needs of the user in the forefront. It is important for existing DHMISs to produce information that is user-friendly. If the DHMIS personnel are willing (and technically able) to tailor information to specic user needs, then that information is likely to be utilized to a greater extent than would otherwise be the case. No information system should be developed without a careful assessment of the levels of the information generation and use. Information should be the basis for improving the administration of health resources, as quickly and efciently as possible, in the pursuit of national and district health priorities. DHMISs must place greater emphasis on providing DHS Managers with information that will be genuinely useful in improving health status. The goal should be to reduce morbidity, disability and premature mortality and improve efciency in health care delivery. Information has the potential to unite the health sector in the pursuit of better community health, but studied sys-

742 tems do not seem to serve this purpose particularly well. Other than health service (patient) data which is being collected fairly adequately, a DHMIS also needs to collect administrative data. Table 4 identies DHMIS users and their information requirements. The DHMIS staff must analyze this data and disseminate information produced to all stakeholders to assist them in their decision-making. Not only academic institutions, health policy-makers and health care providers need access to information; accurate and up-to-date information on health is required by the entire district community and other individual information consumers such as researchers.

G.W. Odhiambo-Otieno For a comprehensive planning of health services, the DHS managers need information on quantity, capacity and distribution of governmental and nongovernmental/private health facilities, personnel and programs in their districts. Equally important is the readily available information on sources and ows of health nances, budgetary allocations and expenditure, availability and performance of the transport system, supplies, stafng, training, deployment and distribution of categories of health staff and their remuneration. This information was not available in the DHS studied. Very limited demographic data important for the DHS strategic planning and general socio-economic and environmental information essential for the long-term planning

Table 5 District Muranga

DHMIS problems identied by users and proposed solutions Identied problem Dispersed manual data collection and information generation Delays in accessing data due to poor storage Limited DHMIS personnel technical skills Lack of funds for effective operation of the system Delays in getting the right information Scattered location of information generated Incomplete collection of information from health care providers Information storage problems Inappropriate information format Lack of adequate storage space Lack of condentiality and security of data collected Data not well kept Dispersed information systems Unqualied information personnel collecting data Proposed solution Centralize information generation through computerization Computerize the system to facilitate the ease of storage and retrieval of information Provide adequate and continuous technical training Provide adequate funding from both the MoH headquarters and cost-sharing funds Computerize the system to speed up analysis and retrieval of information Centralize information collected by the HMIS by storing all the information in a computer located in a central place Ensure effective collaboration in the collection of information from al care providers in the DHS Improve the situation through: Matching form with user needs through user-collector partnership Provide shelves and cabinets Locking up condential information in cabinets and seal off information zone to unauthorized persons Train staff to store data in a systematic manner to facilitate ease of retrieval to save on time Computerize and centralize information activities through Local Area Networking (LAN) Avoid using casuals to collect information by recruiting trained staff form Medical Training Colleges (MTCs) Collect comprehensive data from all health system departments Build effective collaboration among all health care providers and encourage information sharing Provide adequate funding for supplies and equipment

Bungoma

Inadequate collection of administrative data from non-clinical departments No sharing of information generated Lack of adequate supply of stationery

Evaluation of existing District Health Management Information Systems was collected in the DHSs studied. It was doubtful if the DHS managers in the study areas were able to understand their districts health situations in the absence of such key information. Measures must be implemented to ensure that information is shared widely and synthesized into forms suitable for use by various information system users. This prevailing situation raises disturbing questions about the relevance and efciency of the studied DHMISs activities. DHMIS users identied several DHMIS operational problems and suggested measures that needed to be taken to alleviate them (Table 5). No information system should be developed without a careful assessment of the levels of information generation and use. DHMIS needs to provide at least some information in each of the following categories: general socio-economic and environmental information; demographic information; health status patterns and trends; access, utilization, coverage and quality of health care; resource mobilization, allocation and utilization; and District Health System management process. Information systems designers must also address the issues of co-operative partnership in information activities, systems compatibility and sustainability [5]. In the absence of this information, the DHMISs were not able to help health managers to efciently and effectively allocate resources and monitor the functional status of resources at their disposal. In the way they are collecting, processing and disseminating information, DHSs studied are, indeed operating fragmented systems which are not supportive of the operational management of the DHS (Fig. 1).

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5. Conclusions
The design of the existing DHMISs studied was done at the ministry headquarters ignoring both those who were to eventually operate them and use the systems products (information). There was a marked difference in the focus of health workers and DHMIS staff. Whereas the health workers complained about the quality of the information produced, DHMIS staff on the other hand concentrated their complaints on inadequate supplies of basic resources necessary for effective operation of the system. The information systems studied were characterized by a lack of integration, and were disjointed with no effective central co-ordination to ensure that the information which they contained was readily available to all who needed it. The DHMISs

were found to be fragmented with no mechanisms for information ow that allowed sharing of information among stakeholders. The information systems were basically data-led which routinely collected large amounts of data that was sent to higher levels without analysis and use at the collection point. The variation in data collection tools did not allow comparison in terms of performance among DHSs. The information requirements of the users were neglected thereby making the systems products (information) irrelevant to potential users. There is need to foster partnership between information producers and users. Without accurate, timely, relevant and complete information, the existing information systems are not capable of facilitating the DHS managers in their day-to-day operational management. Without people who are trained in techniques of both information production and use, the likelihood is small that a DHMIS will enhance the level of health care management in the DHS. There is an urgent need to explore the possibilities of computerising the existing manual systems to take advantage of the potential uses of microcomputers for DHMIS operations within the DHS. Despite the ultimate use of computers, care must be taken in the way data is collected manually. The greatest challenge facing the existing and future DHMISs in Kenya is securing the support of the DHS managers both nancially and morally given their low-key perception on information activities. For long-term internal sustainability, there should be a gradual shift from depending exclusively on donors for nancial and technical support for such initiatives to a fully self-supporting situation. To be supportive, existing systems must have a comprehensive and accurate picture of the health situation in the DHS. The existing DHMISs must collect information from other health care providers within their respective DHSs. Only then can DHS managers receive information necessary for the operational management of the DHS. To the extent that this is not being done, current DHMISs are therefore not supportive of the operational management of health services at the DHS level in Kenya. To improve the current situation, concrete proposals will be made in another publication that will address in more detail the issues raised in this paper. An integrated information system model that involves all district-based health providers which also collects key categories of information from both community- and facility-based sources, with a central management information unit will be proposed.

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[2] Government of Kenya, District Focus Strategy for Rural Development, Government Printer, Nairobi, 1986. [3] World Health Organization, Strengthening of Information Support for Management of District Health Systems: Report on an Inter-regional Meeting, Surabaya, Indonesia, 30 October3 November, 1989, WHO/SHS/Geneva, 1989. [4] L. Hanmer, Criteria for evaluation of the district health information systems, Int. J. Med. Inform. 56 (1999) 161168. [5] G.W. Odhiambo-Otieno, Health management information systems in Kenya: diagnosis and prescriptions, Moi University, Kenya, Unpublished Ph.D. Thesis, 2000. [6] Ministry of Health, Manual for the District Health Management Information System, Health Information System Department, 1991. [7] Earl Babbie, The Practice of Social Research, 5th ed., Wadsworth Publishing Company, Inc., 1989. [8] M.Q. Patton, Qualitative Evaluation and Research Methods, 2nd ed., Sage Publications, 1990. [9] D.F. Polit, B.P. Hugler, Nursing Research: Principles and Methods, 4th ed., JB Lippincott Co., Philadelphia, 1991. [10] World Health Organization Qualitative Research For Health Programmes, Division of Mental Health, WHO, Geneva, 1994. [11] S. Sahay, Special issues on IT and health care in developing countries, Electron. J. Inform. Syst. Dev. Countries 5 (0) (2000) 16.

Summary points What was known before this study: DHMISs are essential components of the DHSs. Evaluation of DHMISs remains the weakest link in their design, implementation and operation. What this study added to our body of knowledge: For effective management of the DHS, the DHMIS must facilitate the integration of data from all health-providing and related organizations in the DHS. Sustainability of the DHMIS requires active participation of all its key stakeholders, namely, the developers, the users and the patients whose management may be affected by the information generated by the DHMIS.

References
[1] M.C. Azubuike, J.E. Ehiri, Health information systems in developing countries: benets, problems, and prospects, Int. J. Med. Inform. 60 (2000) 2128.