Health Information Systems Program

HISP & DHIS 2: Past, Current, Future

• HISP : global network for HIS
development, Open Source Software,
education and research
• DHIS 2 open source software : reporting,
analysis and dissemination of health data
& tracking individuals
• Started in South Africa in the 1990’s
- Now 40+ countries using DHIS 2
• DHIS 2: core funding from Norad and
PEPFAR.
• Global Fund: Country implementations
• Partners: WHO, Global Fund, GAVI,
UNICEF
DHIS2 country systems & PEPFAR
Early phase / pilots
Early implementation / many states in India
Nation-wide
PEPFAR
DHIS – District Health information Software
HISP – Health Information Systems Program

Background:
• HISP started 1994 in “New” post apartheid South Africa
• Development DHIS started 1997 & 2002 National Standard
• DHIS v1 & HISP to India from 2000
• DHIS v1 spread to many countries in Africa from 2000
• 2000-2013 - Develop Masters Programs in Mozambique,
South Africa, Malawi, Tanzania, Ethiopia & Sri Lanka
• PhD program, 40 students from Asia and Africa
…… who are later running the Masters programs
Background in ‘NEW’ post apartheid South Africa 1994-2000

HISP approach – from South Africa:

•Local use of information;
•Maximise end-user control;
•Local empowerment &
•bottom-up design and system development

Focus: Integration and use of data

1) standardisation of primary health care data &
2) ‘flexible’ – easy to change and adapt new data sets
•1998/99: implementation in two provinces
•1999/2000 - onwards: National implementation
HISP / DHIS timeline (2):
From ‘Stand alone’ MS Access – to DHIS2
Web & global footprint
• 2004 – 2010: New technological paradigm:
o Web based open source – Java frameworks
o 2006 Kerala; 2009 Sierra Leone
• 2011 – 2013: ‘Cloud’ and online
o ‘Cables around Africa’:
o Kenya, Ghana, Uganda, Rwanda, …
• 2014 – 2016: 40+ countries in Asia and Africa use
DHIS2 as national HIS
 HISP Approach to information systems –
Background

• Information for decision making

• Data use – culture of information
• ‘Power to the users’ – Empower health workers, local levels,
communities
• Training & education
• Participatory design
• Focus on important data & indicators:
• Data standardisation, harmonisation of data sets
• ‘Less is better’
 Data Use, for what

Data:
• Where?
• What?
• When?

Analysis
& decisions:
• Why?
• How to?
‘When, What, Where’:
Basis for DHIS2 data model

When Dates, time period,

National
e.g. August 2011,
Period
Quarter 3 2011
State /
1 Province
N Where
1
Data Value Location (Organisation Unit) District
N
N Organised in an Sub-
1 Organisational hierarchy District

Data Element Disaggregated by

Health
Dimensions, e.g. sex, age facility
What Organised in
Data sets
Data collection, analysis, action
 TALI Tool: Tool for Measuring levels of
Information USAGE & The DHIS2
Level 0: The DHIS2 may be in various stages of development,
but not yet fully functional

Level 1: System is functioning technically : data reporting

completeness as a key indicator

Level 2: Data is analysed, disseminated and used. Data quality

(accuracy, timeliness, completeness) and feedback reports
and graphs on the wall are key indicators

Level 3: Data used for planning and decision making:

Indicators: evidence of use of data to measure achievements
in reaching targets in e.g. annual planning process
Motivation for ‘Standardisation’:
South Africa 1994 /95 – Problems & challenges:
• Inequity between blacks & whites, rural & urban, urban & “peri-
urban”, former “homelands”, etc.
• “Equity” main target
– Need data to know whether targets are achieved
• Need standard data from across the country on
– Health status & Health services provision
• Problem: No coordinated data system – no standards
• HISP key actor in developing the new unified Health Information
System in South Africa

–‘
 Example South Africa, Atlantis District 1994:
First Architecture approach: From fragmentation to integration;

Health Higher
programs levels
Cape Town DNHPD
RSC Western Cape

Cape Town
PAWC Family Planning
Clinic Clinic
RSC RSC Malmesbury Clinic Clinic
PAWC
Clinic
PAWC
Hospital Mother Clinic
Private PAWC Child Database
Info. office
School NGO
Health MOU School Hospital
PAWC Health
Private
A NGO
Private
B
A) Post-apartheid centralised, vertical and B) Decentralised integrated district model
fragmented structure in Atlantis (simplified). As according to the ANC Health Plan

Intergation: Still the same challenge !!

Different levels of the health system
– different needs for information

Level of health Quantity of data

system
Information needs
Data granularity

Less data Summary indicators

Global/Region
General, e.g. MDG

Countries/ Indicators
Health Programs National /program

Indicators district
District
management

Facility
Facility
management

Patient records,
Patient
tracking & care
More data
Hierarchy of data standards:
• Balancing national need for standards with local need for
flexibility to include additional indicators
• All levels – province, district, facility – can define their own
standards as long as they adhere to the standards of the level above

Hierarchy of Indicator Standard

Indicators,
& Data Standards Regional Level & datasets:

National Level Patient

Facility
Sub-National Level
Sub National

National
Health Facility Level
Regional -
ECOWAS
Patient – individual client Level
3 components of the HISP ‘Network of Action’

Health Information Systems Free & Open Source Software

Integration, standards, architecture Distributed DHIS2 development
Use of information for action – Sharing across the world
Health management knowledge & support

Mozambique
South Africa Building Capacity,
Vietnam Academies, Education, Research
Uganda Training of health workers
Norway
Nigeria Graduate courses, Masters, PhD
India Sharing teaching /courses
Kenya Sri Lanka
Rwanda Bangladesh
Ghana Phillipines
Indonesia
others Laos
 Regional approach:
Implementing DHIS2 through HISP nodes
Early phase / pilots / preparation
Under implementation / many states in India
Nation-wide
PEPFAR

HISP
Kenya
Tanzania
HISP Uganda
West Africa Rwanda HISP India & Vietnam
Nigeria,
& HISP Sri Lanka!
Ghana, ..
HISP South Africa
 HISP – DHIS2 Community: principles
• Free and Open Source Software &
training / educational materials, etc.
• Development and implementation of
sustainable & integrated Health
Information Systems
• Empower communities, healthcare
workers and decision makers to
improve the coverage, quality and
efficiency of health services
• Developmental approach to capacity
building & research
– Research based development
– Engage HISP groups and health
workers in action research!
WHY SUCH EXPANSION ?
And how to continue to
build the network and open source
platform
Mobile subscribers per 100 persons, Africa

Source: World Bank

Internet: Total bandwidth of communication
cables to Africa South of Sahara

Source: AFRINIC
 DHIS2 implementations /initial projects
correlated with increase in bandwidth
DHIS 2
implementations
DHIS = 1/1000

2014 2015
Source: AFRINIC
Improved Internet & mobile network – ‘cloud’ infrastructure
Rapid scaling – from ‘hundreds’ of installations to 1
Online system – one server
Easier to integrate / interoperability with other systems
which are also online: web API
& central server

Interoperability
with Other systems
Improved Internet and mobile network: Rapid scaling
Implementation Using central server & “cloud” infrastructure

Online data use; web pivot

reports, charts, maps
Online
Data capture
100.0

90.0
Measles under 1 year coverage by district 2006
(Measles doses given to children < 1 year / total population < 1 year)

89.5
94.4 93.6 93.8

DHIS2
81.3 80.7 80.0 79.9
79.0
80.0 74.7

70.0
Annual measles coverage %

60.0

50.0

40.0

30.0

20.0
10.0

0.0
Chake Micheweni Mkoani Wete Central North A North B South Urban West
Chake District District District Dis trict District Distric t District District District
Dis trict

Pemba Zone Unguja Zone

District

Mobile Data Use

Mobile
Data
Capture Online / / Offline
Offline data use
BCG: 12 Browser application
PENTA1:10
PENTA2: 7 Datamart
PENTA3:11
- pivot tables
Offline Archive
Data Capture -reports,
- Charts, maps
HMN architecture (2007) – Integrated National data warehouse:
 DHIS2 Country platform: Integrating health programs & data
sources
Web Portal

Data
from capture
form paper
s

-Data mart Dashboard

Data from Data -Meta data
Mobile devises warehouse
Measles under 1 year coverage by district 2006

-Visualising
(Measles doses given to children < 1 year / total population < 1 year)

A nn ual m easles co verag e %

100.0 94.4 93.6 93.8
89.5
90.0 81.3 79.0 80.7 80.0 79.9
80.0 74.7

tools
70.0
60.0

50.0
40.0

DHIS 2
30.0

20.0
10.0
0.0
Chake Michew eni Mkoani Wete Central North A North B South Urban West
Chake District District District District District District District District District
District

act rm
Pemba Zone Unguja Zone

District

LMIS tr
Ex nsfo Graphs
Tra ad
Lo
HR EMR
Mobile Maps

Getting data in - Data warehousing Getting data out - Decision support systems –
‘Business intelligence (BI)
 Integrated Health Information Architecture (“Horizontal integration”)
- integrating sub-systems, technologies, health services & programs
Users of processed & integrated data

Aggregate & Data

indicator data Warehouse
Int
l ity e ro
bi per
pe ra a bili
ero ty
Int Paper
Performance reports
Electronic SDMX -HD Based financing
Medical reporting
Records
HR
Management Paper based systems:
Logistics OPD, EPI, RCH,
Mobile other programs
Users of & drugs reporting
primary data Finance
Users of primary data
& data providers & data providers

Integration of technologies,
systems, data & health programs
Integration and interoperability

DHIS : Data Data transfer

Data transfer
warehouse from iHRIS to
from OpenMRS
DHIS, e.g.:
To DHIS, e.g.: Statistical #midwifes
#deliveries data @health centre X
@health centre X
for month of May
for month of May
DHIS is calculating
the indicator:
Interoperability Deliveries per midwife Interoperability
Per facility per month

OpenMRS : Integration iHRIS: Human

Medical records Resource records
 Extending the reach through mobiles
• User friendly & ’close’ data entry individual level/aggregate data
• Tracking clients in programs
– sending reminders, e.g. for ANC visits & vaccination
• Feedback – simple reports, text & calls
• Communication – ‘social media’ for both health staff and community
(support, chat,
• Integration with DHIS data warehouse & backbone infrastructure
• Support wide range of technologies

SMS Java Browser Android PC/laptop/tablet

 All devises integrated in

e
ix bl
fl e
e
or
M
SMS

PC/laptop
Lightweight
Browser
Android app
or browser Tablet
Enterprise architecture: 3 Levels (each serving the level above)
Level 1:
Information
Needs, Users, Usage
Across Organisations

“Business level” Institutional use of information

Level 2:
Patient Data warehouse
Software applications records
DHIS Aggregate data
& Information
Systems iHRIS
Open
“Application level” MRS Applications supporting use
of information

Level 3: “Data Data & indicator dictionary /standards

Facility register
exchange level” OpenHIE
Provider register
“Technical level” Health Information Exchange

Interoperability & ADX

standards, technical Data Standards and infrastructure supporting the applications
infrastructure
 Indonesia Data Warehouse & Dashboard

National level: Dashboard

Electronic data
sources
BKKBN
BPJS (Family
(Social Security Planning
Provider) Board)
DHIS2
Data warehouse

E-Sismal
SITT (TB) SIHA (HIV) NCD NIHR&D Logistics
(Malaria)
Integrated National HTM Dashboard
National TB Dashboard
National Malaria Dashboard
 TB + rate 2014
By Province

By District TB +Ve cases by facilities

Location of Hospital and Puskesmas
Yogyakarta Hospital and
Puskesmas
Yogyakarta Dashboard
 NATIONAL PROVINCE: All programs
receive reports aggregated by
district –from district programs
KOMDATA
DISTRICT:
District
Each program
TB AIDS MCH IDSR
manage own data
Vaccine Others Malaria -Limited
coordination
Data flow across programs

TB AIDS MCH IDSR PUSKESMAS:

Each Program
Vaccine Others Malaria
Reports to Program in
Puskesmas – Health facility
District
Dataflow – Districts with few patient records (Malang)
Pilotitis in Uganda: mHealth mapping
Map of mHealth pilots in Uganda (Sean Blaschke , Unicef Uganda)
Shared Facility codes Integrating data sources
Mapping Family
Planning
Facility codes MCH
DHIS : Data Malaria
warehouse Same
Statistical EPI

MAPPING
code
data Komdat
Diff /HMIS
cod erent
es Nutrition

Facility TB
Codes BPJS
Register
HIV/
AIDS
Human Resource
Dashboard records LMIS
Indonesia
Integration PROVINCE/NATIONAL:
DHIS2 Integrated data warehouse
- District system & dashboard used by all

TB AIDS
Vaccine DISTRICT:
IDSR MCH Integrated data
DHIS2
warehouse &
Malaria
dashboard
Others

TB AIDS MCH IDSR PUSKESMAS:

Programs use DHIS2,
Vaccine Others Malaria
both data use and
Puskesmas – Health facility
reporting
Integration PROVINCE/NATIONAL:
DHIS2 Integrated data warehouse
- District system & dashboard used by all

Data access
TB AIDS
& use
Vaccine DISTRICT:
IDSR MCH Integrated data
DHIS2
warehouse &
Malaria
dashboard
Others

TB AIDS MCH IDSR PUSKESMAS:

Programs use DHIS2,
Vaccine Others Malaria
both data use and
Puskesmas – Health facility
reporting
OpenHIE Architecture Design
OpenHIE / DHIS Architecture
- Evolving through use Facility Registry
Data Dictionary

DHIS 2

HMIS
Community
 Dashboard projects in Indonesia

Pusdatin – University of Oslo – UGM

•National data warehouse & dashboard project
• Integration national programs: data by Puskesmas
• Creation of health program-based dashboards (TB,
HIV/AIDS, Malaria, ..)
• Creation of integrated dashboards: indicators
across programs TB-HIV/AIDS, ..
•Yogyakarta province data warehouse
• Province & district based dashboards
• Applying & aligning national data warehouse with
province data warehouse
 Initial plans: HSS – Pusdatin – Oslo –UGM
Selection on 5 provinces for DHIS2 implementation
•Provinces where HSS district located
•Identification of data sources and reporting flows in
districts and province
•Applying & aligning national data warehouse with
province and district data
• Including selected district & province specific data
• Electronic data: (semi) automate data transfer
• Manual data capture
•Design and develop of district and province dashboards
Initial plans (2) : HSS – Pusdatin – Oslo –UGM

Capacity building
•Train & develop national expert DHIS2 team –Pusdatin
&UGM
•Train all HSS staff
•Training of Trainers (TOT): Key people from provinces
& districts
•Training & data review and data use in districts
•Continuous hands-on training and support
Challenge:
Capture data from Puskesmas in Districts

Data only by districts at national leve –need to be

captured in the dstricts
•Malaria: Only Excel
•Morbidity data; districts and Puskesmas have different
systems – sending to districts
• Different methods and systems between districts
•MCH data: e.g. excel sent to district
•Vaccination: Jogja has system, different in other
provinces
 E-SISMAL to Komdat 2 – Integrated
Data Warehouse (dhis2 at Pusdatin)
Komdat 2

Approved data by
DHIS2 : Data
E-SISMAL 2 Malaria department warehouse
DHIS2 Statistical
data

E-SISMAL Excel file at Data check and Approval at

District Level by National / Province Level
Puskesmas Malaria based dashboard
BACK TO THE GLOBAL: Way Forward
Challenge:
•‘Success’ = large number of countries,
organisations, systems & use cases
•Disease surveillance, malaria, TB,
HIV/AIDS, registers, tracker, etc.
•Large number of new requirements

•Central development team becoming

bottleneck !
‘Technical Solution’: DHIS2 - app platform

• How to respond to large amounts of new

requirements?
Enable users & local groups to make
their own apps!
• Web api
• SDK for Android (Software Development
Kit)
• App store for distribution of apps
‘Organisational solution’:
Build strong HISP – DHIS2 community!!

Build network of DHIS2 projects,

countries &universities
• Organise country HISP nodes (Sri Lanka!)
&
• Regional hubs – centres of excellence
• Focus on research and education
•Masters & PhD program critical
 From vertical reporting systems
… towards a common data platform
Progress:
More and more programmes &
countries moving towards single
country platform (e.g. DHIS 2)
Partners working on joint
investment & core functional
requirements

But .. much more required:

−to establish sound governance at
country level
−To integrate public health
surveillance into routine systems
−To build adequate capacity in
analysis and use
 W H O / I n t e r n a t io n a l s t a n d a r d s fo r D H I S 2
Click here t o g o t o t h e W H O s t a n d a r d s w e b p o r t a l, w i t h d e t a ile d
in f o r m a t io n a n d in s t a l la t i o n in s t r u c t i o n s f o r u s i n g t h e s e t e m p l a t e s a n d t o o ls .

S t a n d a r d t o o l s a n d t e m p la t e s
W H O r e c o m m e n d e d i n d i c a t o r s fo r r o u t i n e fa c i l i t y d a t a .
R e f e r e n c e f a c ilit y
Learn m o re… Im p o rt
in d ic a t o r s
I n d ic a t o r s
A p p fo r b r o w s i n g o f D H I S 2 a g g r e g a t e m e t a d a t a , a s w e l l a s to a l i s t o f W H O r e fe r e n c e
D a t a d ic t io n a r y a p p in d ica t o r s. Learn m o re… In st a ll

M o d u l e fo r c o l l e c t i o n o f h o s p i t a l m o r t a l i t y d a t a u s i n g t h e I C D -1 0 s t a r t-u p m o r t a l i t y l i s t.
H o s p it a l m o r t a lit y
In clu d e s d a t a e n t r y t e m p la t e a n d b a s ic o u t p u t s . Learn m o re… Im p o rt
m o d u le
T h e d a t a c o l l e c t i o n fo r m fo r H I V , i n c l u d i n g d a t a e l e m e n t s (w i t h d i s a g g r e g a t i o n s ) a n d
H I V d a t a c o lle c t io n
d a t a v a lid a t io n r u le s .. Learn m o re… Im p o rt
f o rm s
D a t a c o lle c t io n
T h e d a t a c o l l e c t i o n fo r m fo r M a l a r i a , i n c l u d i n g d a t a e l e m e n t s (w i t h d i s a g g r e g a t io n s ) a n d
M a la r ia d a t a c o lle c t io n
d a t a v a lid a t io n r u le s. Learn m o re… Im p o rt
f o rm s
T h e d a t a c o l l e c t i o n fo r m fo r o t h e r p r o g r a m m e s / a r e a s , i n c l u d i n g d a t a e l e m e n t s ( w i t h
O t h e r d a t a c o lle c t io n
d i s a g g r e g a t i o n s ) a n d d a t a v a l i d a t i o n r u l e s , e . g . T B , E P I , M C H e tc . Learn m o re… Im p o rt
f o rm s
A p p fo r p e r fo r m i n g r o u t i n e a n d a n n u a l d a t a q u a l i t y c h e c k s o n a g g r e g a t e h e a l t h fa c i l i t y
D a t a q u a lit y W H O d a t a q u a lit y t o o l d a t a , a c c o r d i n g t o t h e W H O D a t a q u a l i t y r e v i e w t o o l k i t. Learn m o re… In st a ll

D a s h b o a r d s fo r u s e o f r o u t i n e fa c i l i t y -b a s e d H I V d a t a . I n c l u d e s d a s h b o a r d s , a n a l y t i c a l
H IV d a s h b o a rd s o u t p u t s a n d in d ica t o r s . Learn m o re… Im p o rt

D a s h b o a r d s fo r u s e o f r o u t i n e fa c i l i t y -b a s e d m a l a r i a d a t a . I n c l u d e s d a s h b o a r d s ,
D a s h b o a rd s M a la r ia d a s h b o a r d s a n a ly t ica l o u t p u t s a n d in d ica t o r s . Learn m o re… Im p o rt

D a s h b o a r d s a n d d a t a c o l l e c t i o n t e m p l a t e s fo r a d d i t i o n a l p r o g r a m m e s / a r e a s , e . g . T B ,
O th e r d a s h b o a rd s E P I, M C H e t c Learn m o re… Im p o rt

G u id a n c e o n e s t a b li s h i n g a n a t io n a l m a s t e r fa c i lit y lis t .
S y s te m M a s t e r F a c ilit y L is t Learn m o re… Im p o rt
 Status WHO DHIS 2 standards/tools
2016Q1 2016Q2 2016Q3 2016Q4

Data Quality Tool

Data Dictionary
Standards Repository

HIV module RMNCAH module

EPI module
TB module
NTD module(s)
Malaria module

Cause of death (ICD-SMoL)

TB patient tracker
TB-MDR patient tracker

Not started/early phase In progress Done/nearly done