Routine health

information
system
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 THE INFORMATION CYCLE
• As shown in the figure below the information cycle starts with data
collection.
• The collected data are then processed, analyzed, presented and interpreted
to become information.
• Then finally this information will be used for action.

Use COLLECT

Interpret PROCESS

Present Analyze
 Data Collection Tools
Why is Data Collection Important?
 To track changes/stability of health over time
 What is influencing changes
 To evaluate the impact of prevention/health promotion, and
health care interventions
 To monitor resource allocation

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Standardized, Integrated, and Simplified Data Collection and Reporting
 An integrated data collection and reporting system provides the
foundation for harmonizing the requirements of internal
information consumers like the MOH and external consumers
such as other ministries, development partners, and civil
society.
 An integrated data collection and reporting system requires :
1. Cascaded Indicators for performance monitoring
2. Standardized data collection tools for service delivery and
administrative records
3. Standardized reporting instruments
4. An integrated reporting channel that supplies all
information to consumers.
 All HMIS information generators and consumers will use these
tools, so their introduction requires consensus from all.
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 Standardized Data Collection Tools
These tools capture medical, demographic, and
financial transaction information on clients and
patients.
They may be:
 Registers,
 Cards,
 Files retained at the facility, or
 Cards retained by the client.
Must include the data required for the HMIS
indicators
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Important Consideration In Designing Data Collection Tools
These tools must respond to patterns of
service delivery in a facility.
It is essential that the HMIS be flexible
enough to adapt to new service delivery
norms.
A register should help to trace care and
responds to the need for financial
accountability.

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 Important Consideration In Designing Data Collection
Tools…
 In the case of simple services, such as immunization, A
REGISTER can be used because the service information
required can be predicted in advance;
 In the case of complex services, such as curative care,
AN OPEN-ENDED CARD is needed because the service
information requirements cannot be predicted.
 For services that become more complex if a
complication is detected, recording can begin on a
register, with SUPPLEMENTATION by a card in the
infrequent cases when it is needed .

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 Essentials For Data Instruments
Clear instructions for entering the information.
 A continuous supply of these instruments must
be assured so that data will be consistently
recorded and
Should and must be easily reported over time
and across locations.
Care providers must be thoroughly trained,
using both pre-service and in-service modalities.

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Standardized Reporting Instruments
Standardized reporting formats,
including tally sheets, must be
designed to collect the HMIS data
from the client / patient records.
Assurance of stationary supply and
training are crucial for improving and
maintaining data quality, and
thereby meeting HMIS performance
standards. 9
 What Is Standardization?
 Standardization refers to the process of employing
best practice, principles and guidelines for the
collection and storage of healthcare data in a uniform
manner across various facilities, levels, and programs.
 Standardization applies for the data collecting
instruments and practices for collection of data, its
analysis and transmission.
 Standards serve as guidelines, principles or gateways
for communication among health workers and health
hierarchies such as woredas, regions and a nation.

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 Why is Standardization Important?
To define all the data elements according to
international standard
 To make sure that data are comparable
across countries/regions/woredas/zones.
• For this purpose user’s guide or manual
defining the data elements should be
developed to ensure the data collected in one
facility means the same in the others.

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 Standardizing the Data Elements
 There is a need to define all the data elements and cases
according to a standard.
 For example: one may diagnose malaria purely on clinical
symptoms while others may strictly depend on laboratory
exams.
 In such cases it will be difficult to compare cases across
different health facilities and across different healthcare
providers.
 Hence, defining cases is of paramount importance in
order to make sure that we are saying the same thing.

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Standardizing the Data Collection Tools
All the data collection tools such as registers,
tally sheets and formats should be developed
according to a standard.
Doing so helps in maintaining the data quality
as well as in making reports comparable across
all the health sector hierarchical levels, i.e. :
‘consistency of the data items’ requires the
need to standardize the data collecting
instruments well.

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Standardizing the Data Collection Tools...
In standardizing data collecting tools, it is important
to make the data collection tools:
S- Simple- easy to use (layout)
O- Overlap less- no duplication of data elements
U- Useful for calculating indicators
R- Relevant for making decisions and plans
C- Clear- easily understandable (terms used)
E- Effective in making decisions

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 Standardizing the Data Collection Procedures
 Again there is a need to standardize the way in which data
are collected.
 For example: in some of the hospitals in Addis recording
and reporting of the inpatients’ data is made on discharge
while on the others it is made on admission.
 The diagnosis that is made on admission may change after
investigating the patient thoroughly and hence the true
diagnosis of the patient is the one that is recorded on
discharge.
 However, if the diagnosis that is made on admission is taken
on the routine health data then the information might be
wrong.
 Hence, there is also a need of standardizing the data
collection procedures taking the best practice.

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 Standardizing Data Set by Developing Essential Data Set
 At the health Sector of most developing countries, there is a
tendency of collecting all possible data.
 Most healthcare providers are supposed to fill in data in
endless forms that are not relevant to the task they perform
and without understanding the meaning and importance of
the data.
 Overburdens health professionals who have to collect health
data in addition to their primary task, which is giving health
service for their community.
 Collecting excess data affects the quality of data inhibiting the
utilization of relevant information. It should be noted that
the ultimate objective of health information is not only to
‘gain information’ but to ‘improve action’.
 The collection and use of information should not impose
burden on the health system.
 It should be collected as a routine by-product of the
health system
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 The Information Pyramid
 The information pyramid: - is a schematic way of looking
at the number of data items to be collected at each level of
the health system, allowing each level to gather data of
importance and relevance to their daily work while avoiding
reporting of excessive data where no action is taken.
 Only the information that leads to action must be reported to
the health facility and all the activities taking place in the
health facility can be recorded for local action but for the
woreda only relevant information is to be provided.
 It is only the information that is needed for decision making
process at this level should be reported.

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We can classify health data according to their usefulness as:
1. Must know: E.G. Percentage of children under one year fully
immunized
2. Useful to know: E.G. Drop out rate Penta1-Penta 3
Penta 1
3. Nice to know: other vaccines given
4. Dangerous to know: all the doses of vaccines like Penta 2,
polio2, TT3….
 Dangerous to know is so called because it distracts health
workers from the essential work of seeing patients and
diverts attention to data that is of no use in making
decisions.
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 The common problem in most developing countries is that data
elements to be collected are mostly decided by international and
national requirements as well as by donors and funding agencies
rather than by local needs.
 This leads to a situation where most of the data collected at the
local level are not relevant to local management needs, and is
therefore not used effectively.
 In such conditions, health professionals will collect information only
for the sake of reporting to the higher officials and not to use it for
their own action.
 This may also contribute to a reporting of data of a poor quality as
the possibility of correcting gross errors while using the information
is lost in such cases.
 One should note that systems that are not found to be useful locally
tend to be less useful at higher levels.
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 Integrating Health Information Systems
 Another factor which leads to the collection of excess data is the
persistence of vertical programs.
 Such vertically oriented health program managers tend to
prioritize their programs insisting on the inclusion of many data
elements related to their service.
 For the development of a single integrated reporting system,
careful selection of essential data elements by each program is
needed.
 Health managers of the different programs should have an open
mind and should be ready to accept change in such processes.
 In addition, facilitating the sharing of data across vertical program
managers helps in integrating the information system and in
reducing the data elements to be collected.
 Defining HMIS unit at all levels of the health sector where all
collected data will be available for each program manager may
help in realizing the integration process

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 Factors that affect Data Collection Methods
1. Resource (human and financial)
2. Ethical issues
3. Sensitivity of the information gathered
4. Geographic accessibility
5. Time
6. Language
7. Study design
8. Type of study participants (eg. Educational status)

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 Control for Reliability
• Use redundancy
– Ensures reliability
– Duplication of data collection item
Parallel
• Repetition of a question with slight modification
Series
• Repeating the whole/ part of the instrument at
different times
– Eg. selected sub-samples of the clients

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 Control for Validity
• Insure Validity
– The right Response should be filled in the right
respondent column.
– Ambiguous responses should be re-checked at the
field level

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 Quality Control at Facilities
 Ensure appropriate administration of the data collection
instrument
 Monitoring and supervision of facilities is the key to
ensure quality
 Questionnaires should be manually edited before entering
data into computer software
 Correction of errors
 Coding and recoding of questions (if needed)
 Checking completeness
 Proper design of the data entry template
 The template should reflect the actual report

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 The Role Of Data Entry Clerk
The data entry clerk must simply type
what is written on the questionnaire
The clerk must not do
 Coding and recoding
 Calculation
 Interpretation
 Assumption

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 Quality Check During Data Entry

Double entry to check consistency

Preparing Data dictionary is mandatory to
easily understand the data base
Data cleaning must be done by a different
person
Always save the master database on a
separate file before doing any coding and
categorizing

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 Domains of Health Data

1. Health Determinants

2. Health System Inputs

3. Health System Outputs
4. Health System Outcomes
5. Health Status.

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 Figure 2 Typology of measurement domains

Health
determinants

Risk factors
Behaviours Health
Genetics status
Environment
Health
Mortality
Socio-economic & system
demographic outcomes Morbidity /
disability
Health Health Well-being
system system Service
inputs outputs utilization

Policy Information
Financing Service
Human availability and
resources quality
Organization

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 Types of Data Commonly Collected Under Each Domain

Health Determinants Indicators:

 Prevalence and level of poverty
 Education levels
 Water and sanitation coverage
Health Status Indicators:
 Infant mortality rate
 1-4 year old mortality rate
 maternal mortality
 life expectancy at birth
 prevalence/incidence of infectious diseases

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 Data Collected on Health Care Resource & health Care Utilization

Health Care Resource allocation Indicators (Per Capita):

distribution of qualified health personnel
 distribution of health services, by level
 distribution of health expenditure on personnel, supplies and
facilities

Health Care Utilization Indicators:

 immunization coverage
 antenatal coverage
 proportion of births attended by a skilled attendant
 use of modern contraceptives

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 Frequency of Data Collection
 ROUTINE or continuous data collection
– Health facility-based (patient information and service statistics)
– Community-based (service-statistics)
– Program-based (administrative)
– Vital registration
– Sentinel reporting/demographic surveillance
 NON-ROUTINE or periodic data collection
– Household or facility-based surveys
– Population census
– Rapid assessment procedures (RAP)
– Special studies/research

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 Data Quality and Accuracy
 Since data are the basis for information
adequate attention should be given to maintain
its quality in order for it to be useful.
 Data quality/Accuracy can be defined as the
distance between the actual and the
measured.
 The shorter the distance, the more accurate
the data will be.
 The level of accuracy required depends on the
importance of the decision to be made.
 If a decision has important consequences,
accuracy should be higher.
 Data Quality and Accuracy…
However, it should be noted that higher
accuracy usually means higher cost. In
other words, when one tries to get data of a
high quality, there is a risk of compromising
the primary task, the health service delivery.
Therefore, the level of accuracy required
depends also on the cost of getting the stated
accuracy level.
there is a need of focusing only on
essential (minimum) data elements.
 Data Quality Measures
 The health information system should ensure that the
data meet standards of reliability, transparency and
completeness.
 It is important to assess the strength of the source data
and the statistical techniques and estimation methods
used to generate indicators.
 The following criteria are used to assess the quality of
health related data and indicators:
 Timeliness:-The gap between when data are collected
and when they become avail- able to a higher level or are
published.
 Periodicity:-The frequency with which an indicator is
measured.
 Data Quality Measures…
 Consistency and transparency of revisions:
Internal consistency of data within a data- set as well
as consistency between datasets and over time;
extent to which revisions follow a regular, well-
established and transparent schedule and process.
 Representativeness: The extent to which data
adequately represent the population and relevant
subpopulations.
 Disaggregation: The availability of statistics
stratified by sex, age, socioeconomic status, major
geographical or administrative region and ethnicity,
as appropriate.
 Confidentiality and data security guidelines
There should be guidelines for data protection
and other established standards for:
 Storage,
 Backup,
 Transport of information and
 Retrieval.
 Aspects of High Quality Data
 Complete
 All Oranges belonging in the data are in the data
 Consistent
 Oranges aren’t confused with mangos
 Correct
 All items defined as oranges are indeed oranges
 Timely
 All oranges listed as fresh are still fresh
 Accessible
 People needing information on oranges can get it
 Relevant (Useful)
 People do in fact need data collected on oranges
 Factors Affecting Data Quality
Correctness

•Training/skill
Layout of forms
Standardized instruction
Local use of information
Perceived relevance of the information gathered
Incentive/feedback
Validation technique
Time in relation to data set and work load
Consistency of the data items

Timeliness Completeness
Incentive/feedback
Perceived relevance of the
•Infrastructure
information gathered
Incentive/feedback Data Training/skill
•Time in relation to Quality Standardized instruction
data set and work load Local use of information
Time in relation to data set and
work load
 Factors Affecting Data Quality…
1. Training/skill: - In order to obtain data of a high accuracy,
data collectors must receive training on how to collect data and
on how to calculate indicators.
2. Local use of information: - Use of data at the site where it is
collected can lead to detection of errors and inconsistencies, so
that correction is made easily.
It is mainly at this level that information use can have the
greatest impact on the efficiency and effectiveness of h-
services.
When information is used by people who collect it then it
tends to be more accurate.
The improved quality following extensive use of data leads to
further confidence to use the data at all levels forming a
positive spiral.
 Factors Affecting Data Quality…
3. Perceived relevance of the information:- Health care
providers will be inspired to collect and maintain the data
quality if they consider the selected data set to be relevant for
the task they perform.
If in contrary excessive quantities of data that are not
relevant to the h professionals responsible for data recording,
then the quality of data often suffers and data use at collection
level becomes minimal.
Involving all potential users in the selection of the data
elements to be included in the essential data set has proved
fruitful in increasing ownership and perceived relevance of the
information system.
 Factors Affecting Data Quality…
4. Providing incentives: - Incentives are acknowledged to
be one of the important factors in maintaining data quality
and improving data use.
Offering incentives and feedback for performance helps in
keeping the quality of data and data use.
However, incentives offered for high performance as
revealed by information generated by health care providers
may also lead to ‘cooked figures’ and regular supervision
and validation techniques by managers is imperative.
For example, if incentives are provided for the h facility
with the highest vaccination coverage, some people may be
tempted to report higher coverage. Hence, one should be
cautious enough to verify the reported data are representing
reality.
 Factors Affecting Data Quality…
5. Validation technique: - Cross checking mechanisms for
the health data helps in identifying errors and hence in taking
corrective measures.
 For example, cross checking number of deliveries to the
number of BCGs delivered may also be used as a
validation technique as the number of BCGs delivered in
an institution can not be more than the attended
deliveries in the institution.
6. Time in relation to data set: - As the routine h data are
collected at the expense of h workers’ time whose primary
task is to deliver h care for their community, as much as
possible the data elements in the essential data set should
be limited.
 Only the data which lead to useful information should be
collected routinely.
 Data that are needed for research purposes can be
collected on ad hoc basis as a survey and used to
supplement the routine data.
 Factors Affecting Data Quality…

7. Consistency of the data items: - Unless the data items used

across different hierarchical levels are consistent, the records
will not be comparable and may further lead to error if the
record in one is used to fill the other.

For example, the inconsistency of the data elements for ANC

service in the formats of the ANC unit and the zone could cause
the poor quality of data.
 Factors Affecting Data Quality…

8. Layout of forms: - The layout of formats can have

a great impact on the accuracy of data.
The order of the data fields on the record forms
and registers should take into account the sequence
of procedures h workers will perform.
For example: If there was difference in the layout
of the tetanus toxoid Amharic and English version
formats, where the order of the data elements
‘pregnant women’ and ‘non-pregnant women’ were
interchanged, this would cause wrong information to
be conveyed.
 Factors Affecting Data Quality…

9. Standardized instructions:-Establishment of standard

procedures for collection and use of data is vital to maintain
the quality of the collected data.

For example: development of specific instruction manual

for the first-level care workers, explaining the meaning and
use of each indicator in the h information system was found
to be effective in the FMOH of Pakistan.
 Factors Affecting Data Quality…
10. Availability of infrastructure
 road and computer play significant role in maintaining the
quality of data.
 Greater use of computer improves use of information
through rapid processing,
 Improved data presentation, and improved
communication and dissemination.
 Information technologies offer many clear opportunities
for h care management in developing countries.
 Computers are necessary if not imperative for information
system to be timely, correct, reliable and adequate for
planning and monitoring h service performance.
 Factors Affecting Data Quality…
Computers are not the final answer by their own!
 Their affordability, in the face of limited resources available
for the h sector and in places :
 labor costs are comparatively low, will rarely match
developing countries context not to mention,
 the lack of trained staff in computer skills seen in such
countries.
 The potential of computers can only be realized if HMIS can be
successfully developed and implemented.
 Experience has showed that improving paper-based systems
should go hand in hand with development of digital systems
especially in developing countries context, where recording at
the facility is basically done manually.
 Maximizing Data Quality
 Data Quality should be as high as possible
 Inaccuracies should be minimized
 Lower the possibility for data errors
 Protect data from intentional manipulation
 Workload for quality assurance should be balanced
against relative benefit
DATA MANAGEMENT
 Database
 A database is a collection of tables.
 Each table may be considered to be similar to a
spreadsheet with columns (data elements or
fields) and rows (records) of data.
 A "relational structure" can be established
among tables by using columns that have the
same definition.
 This relational structure can be used to combine
data from different sources.
 The metadata dictionary is essential to
understand the data and ensure that consistent
definitions are followed so that the relational
structure is valid.
 Data Managing Approaches
 Data management is a set of procedures for the
collection, storage, analysis and distribution of
data.
 Firstly, a metadata dictionary should be
developed.
 Next, sound data storage procedures require a
well-designed logical structure which permits data
retrieval and analysis.
 Data analysis and presentation include
calculating indicators and the preparation of
tables and graphs.
 Finally, the data should be made available to all
who can use them and act on them.
 Data Collection
 Accurate and complete data collection is the foundation of the
data management plan.
 All other efforts are ineffective if the data are not of good quality.
 The first of procedures for ensuring data quality is to reduce the
amount of data to the minimum necessary.
 This "minimum data set" will reduce the burden of data
collection.
 Other management actions which can improve data quality are:
 Regular local quality control and use of data,
 Clear definitions of data elements,
 Up-to-date training, and
 Frequent feedback to those collecting and using data. When
electronic communications facilities are available, data can be
entered into a data warehouse at decentralized locations and thus
provide immediate reporting to all levels.
 HMIS/M&E Reporting Flow Diagram

Council of Ministers International Bodies

FMOH
Other Ministries WHO, UN, etc
Development Partners
Federal and Regional Hospitals
Regional Council Regional Health Bureau report to the appropriate levels

Zonal Hospital
Zonal Health Department (MOH, NGO, private, etc)

Woreda Council
Woreda Health Office Woreda Hospital
(MOH, NGO, private, etc)

Health Center /
Clinic

Kebele Council Health Post

Routine supervisory (fixed) channel – monthly / quarterly / annual

Priority epidemic alert (fixed) channel – immediate / weekly

Partnership (variable) channel – monthly / quarterly / annual

(illustrative destinations – report destinations may be added or reduced)
 THE METADATA DICTIONARY
• In order to relate data from multiple sources, it is
essential to develop common definitions and to
understand the characteristics of each data element.
• The tool to do this is the metadata dictionary.
• The metadata dictionary strictly defines data elements
and their use in indicators, including numerators and
denominators,
• It also specifies the data-collection method,
periodicity, analysis techniques used, estimation
methods and possible biases of the data.
• This is a critical element to ensure quality and data
transparency.
 INTEGRATED DATA STORAGE
• Integrated data storage offers many important benefits.
• Integrating data from multiple sources can make the best use of
data complementarily and synergically.
• The integrated central storage area is known as a data warehouse.
• By developing a data warehouse and a metadata dictionary, it is
possible to create an integrated health information system.
• The data warehouse integrates data from a wide range of sources
including routine service statistics, surveys, surveillance, vital
registration, census, financial, human resource and geographical
information.
• It can be difficult to relate data from this wide variety of sources
and this task is complicated by the fact that data are collected at
different times and may have different field definitions.
 DATA STORAGE
• It is essential to establish a metadata dictionary that will help
provide common data-element definitions and ensure that other
vital information, such as data time periods and geographical
designations and other dimensions, are understood.
• The process of defining metadata and entering data into the
data warehouse through the "extract, transform and load"
procedure can bring order to data chaos.
• The result is a rigorous relational data structure that can be used
for monitoring, evaluation, management and research.
• Extraction is the process of selecting data elements from the raw
data that are available.
• The extraction process takes the data of interest from the source
data tables.
• Not all data from the source tables are taken into the data
warehouse, only data that are selected to fit into the information
structure.
 DATA STORAGE…
• Transformation of the data may include
- aggregation,
- calculation,
- cleaning,
- normalizing or merging tables,
- translating code values, or
- transposing values.
• The transformation process ensures the quality of the data
and puts them into the proper relational structure as defined
by the data warehouse.
• This relational structure ensures that the data can be used
with similar data from other sources.
• The final step is to load the data into the data warehouse
 IMPORTANCE OF DATA STORAGE
• It is vital to improve the use of data at the local and
district levels where it can have the most immediate
impact on service delivery.
• The move to health system decentralization and reform
reinforces the need for local availability of data.
• The data warehouse provides an ideal tool for the
immediate feedback of information to the facility and
district levels.
• It improves data access and use at the local level by
providing immediate access to high-level data-analysis
tools.
• Facilities, districts and programmers can view their own
data and also compare them to data from other sources at
the same level.
 IMPORTANCE OF DATA STORAGE…
• Districts can compare facilities in their area as well as
compare them to facilities in other districts.
• Similarly, information can be aggregated at the
national level to give an overall picture or to compare
regions.
• The data warehouse is an ideal solution to the problem of
providing information to local levels as well as to
higher levels.
• At the national level, the data warehouse provides a
convenient central location where all data are available
for analysis, evaluation and research, so as to influence
policy, planning and management decisions.
DATA ANALYSIS AND PRESENTATION
ANALYSIS- TURNING DATA INTO INFORMATION
 WHAT IS INFORMATION?
• Information is a meaningful collection of
facts/data.
• Information system is a system that provides
specific information that support decision
making process at each level of an
organization.
• The information that is needed at the health
sector can be divided into two main kinds:
1. Patient management information
2. Health management information
THE PATIENT MANAGEMENT INFORMATION

• Consists of all the information provided by

the patient regarding his/her illness that
made him/her seek healthcare which we
call symptoms.
• In addition, all the findings of the physical
examination that the healthcare provider
considers to be relevant for reaching
diagnosis are also included.
• The investigation results including
laboratory findings, radiology or ultrasound
results as well as the treatments provided
for the patient are recorded in this system.
 THE HEALTH MANAGEMENT INFORMATION
• Consists of information that is required for managerial
purpose at the health sector.
• It includes information on the:
- Number of patients seen,
- Type of cases seen in different seasons,
- Number of health professionals available,
- Type and number of drugs available, and the like.
• Hence, HMI is much broader which includes aggregated
data.
• Based on such information, managers will be able to
manage better the health facilities under them or the
health sector in general.
 PROCESSING AND ANALYZING DATA
• In order to be changed into action, data must be
processed and analyzed.
• This is the most important part of the information cycle.
• In analyzing data we use the three epidemiologic analytic
tools:
1. ‘What’ describes a situation by person, place or time,
2. ‘How’ answers how a certain program is running?, And
3. ‘Why’ helps to assess why the figures appear that way
and helps to compare between different seasons and
places.
• Calculating indicators helps in assessing performance
according to these three epidemiologic analytic tools.
 Indicators
• Indicators are variables that help to measure changes and
highlight areas that need intervention.
• Hence, they can give us information that is relevant for
managerial purpose.
• They are mostly calculated based on numerator and
denominator values.
• All the information that should be collected at the health
sector has to be changed into indicators in order to be
useful.
• For example, ‘the number of patients seen is 60’ by itself
will not help us to reach into any form of useful decision.
• But if we compare the number of patients seen with the
number of physicians available, we will be able to analyze
the work load that the physicians are facing and hence,
managers will be able to take action accordingly.
 Use of Indicators
 In facilitating the monitoring & evaluation of objectives
and goals,
• E.g. ‘Infant Mortality Rate’ is one of the indicators that
helps to monitor the progress towards one of the
Millennium Development Goals (MDG 4: Reducing under-
five mortality by two-third between 1990 and 2015).
 Providing meaningful statistics for determining the
health status of the community.
• This includes documentation of inequalities in health
service distribution, the determination of population
groups with the greatest health needs etc…
• E.g. Rural utilization rate may help in assessing the equity
of PHC services.
 Use of Indicators…
 Stratification of epidemiological risk, and identification
of critical areas.
• E.g. Analyzing groups of the community who are highly
affected by HIV/AIDS helps us in identifying the high risk
groups and can guide our intervention.
• Since the principle of Primary Health Care (PHC) is based
on equity, accessibility and quality of health services,
indicators are of paramount importance in monitoring the
delivery of health services according to these parameters.

• In short, valid and reliable health indicators are basic and

important epidemiological tools for health management.
An ideal indicator
 Types of Indicators
1. COVERAGE INDICATORS
• Measure the delivered service in relation to all eligible
• For example, BCG coverage is the number of BCGs delivered divided
by the total number of newborns in the catchment population.
BCG coverage = Total number of BCG delivered x100%
Total number of newborns in the vicinity
• For coverage indicators, we need to know the population data to be
served under that facility and hence, attention has to be paid in
estimating the catchment population under each health facility.
• Coverage indicators help us to know the coverage of major health
services and can be basically affected by availability of resources.
• Therefore, such indicators are useful to measure input as well as
accessibility and appropriateness of services.
 Types of Indicators…
2. QUALITY INDICATORS
• Measure the quality of the health service delivered
• E.g. Inpatient mortality rate is the total number of deaths in a
hospital divided by the total number of admitted patients.
Inpatient mortality rate = Total number of deaths in the hospital x100%
Total number of admitted patients in the hospital
• A higher number may indicate deterioration in the quality of the
health service.
• Quality indicators help to measure the process of the health
service delivery as well as the outcome of the delivered service.
• To realize the full potential of indicators, data that are used for
calculating indicators need to be of a good quality.
• Quality of data used in calculating indicators must be monitored
regularly in order to build and maintain the information users’
confidence in the indicators.
 Indicators Analysis
Based on how they are calculated indicators can also be grouped
as
1. Counts: number of events or frequencies. Certain data are by
themselves informative and do not have to be manipulated.
E.g. Number of health professionals trained in certain period
2. Proportion: numerator is part of the denominator. Most
indicators belong to this category as we mostly compare groups
from the total population in epidemiological assessments.
E.g. 1. Incidence of cholera calculated as
Cases of cholera in a certain place and time x 100%
Total population in the same place and time
• It helps to assess if there is an out-break of cholera in that
vicinity.
 Indicators Analysis…
Proportion E.g. 2. Calculating percentage (per
100)
•At Gulele health center 285 children were
weighed in February. Out of these children
weighed, 26 were found to be underweight.
•To calculate the percentage of children who are
underweight:
Children who are underweight X 100
Children weighed
26 X 100 = 2,600 = 9.1%

285 285
•The Underweight Rate is 9.1%
 Indicators Analysis...

• E.g. 3. Calculating per 1,000 population

Kirkos health center has a population of 3,750 children
less than 5 years of age. In October, 56 children under 5
years came to the clinic with diarrhea.

• Proportion of population with diarrhea can be

calculated as
56 X 1,000 = 56,000 = 14.9 per 1,000 population
3750 1 3750

• The Incidence Rate of Diarrhea in under five children in

Kirkos health center is 14.9 per 1,000 population.
 Indicators Analysis...
3. Ratio: numerator is not part of the denominator
E.g. 1. In calculating maternal mortality ratio we use
total number of live births occurring in that specific
period and place instead of total number of pregnant
mothers. This is done because knowing the exact
number of pregnant mothers in that period and place
is mostly difficult. Therefore, we use a proxy
denominator
i.e. total number of live births. Since the numerator is
not part of the denominator we call this indictor a
ratio.
Total no. of mothers who died during pregnancy and
six weeks after pregnancy in a certain period X 100,000
Total number of live births in the same period
 Indicators Analysis...
E.g. 2. Calculating ratio
• Arada sub-city has four doctors that serve a
population of 15,000.
• To calculate number of people per doctor:
15,000 / 4 = 3,750 people per doctor
E.g. 3. The sub-city has 50 nurses that serve its
population. To calculate number of people per
nurse:
15,000 / 50 = 300 people per nurse
E.g. 4. To calculate number of nurses per doctor:
50 / 4 = 12.5 nurses per doctor
 INFORMATION PRESENTATION
 After the analysis phase, the information should be
presented in a summary statistics, graphs, charts, tables
or maps to facilitate its utilization.
 Tables: useful to present the trend over time where we
can compare and identify outliers.
Table 1.1. The nutritional assessment of the under five
children in Ethiopia over the past 20 years
NUTRITIONAL ASSESSMENT
Nutritional Assessment 1985 1995 2000 2005
Prevalence of stunted children 43 52 52 47
Prevalence of wasted children 19 11 11 10.5
Prevalence of underweight children 38 47 47 38
 INFORMATION PRESENTATION…

Graphs: a pictoral representation of data in

two dimensions. The values of one quantity
will label the vertical axis and the values of the
second the horizontal.
Line graphs: Useful in demonstrating trend of
a disease or health service over time. Can be
useful if more than one data item is used
 INFORMATION PRESENTATION…
Line graphs: Useful in demonstrating trend of a disease or health service
over time. Can be useful if more than one data item is used
 INFORMATION PRESENTATION…
Bar graphs: Useful for illustrating discrete or qualitative data. Helps to
compare services between different facilities and trends over a certain
season.
 INFORMATION PRESENTATION…
Cumulative coverage: Used when targets are set for a year (E.g.
Immunization, antenatal coverage …).
 INFORMATION PRESENTATION…
Pie chart: Is a circle which is split up into segments like a pie cut into pieces
from the centre outwards. Pie chart shows the ‘whole’ at a glance and the size of
each part relates to its importance.
 INFORMATION PRESENTATION…

Population Pyramid: Used to describe the population distribution

in an area. It highlights the difference in age distribution between
male and female and different age categories
 INFORMATION PRESENTATION…

 While using the above forms of information

presentation we should make sure that
 The title is fully descriptive including what the data
talks about, time period when and place of the event
where.
 The columns and rows (in case of table) as well as
the Y and X axis (in case of graphs) should be
labeled
 Key or legend is used if more than one data element
is graphed
 INFORMATION UTILIZATION
 Once information is available then it should be used to make
evidence based decisions and plans.
 Establishing targets and goals before hand helps in
monitoring and evaluating as well as in guiding our action.
 Only if we had predetermined goals and targets we can
assess our performance based on the information that we
have.
 After conducting situational analysis we will be able to
identify health problems and since it is not possible to act on
all the identified problems, we will prioritize the problems
that are affecting our community most and those with
feasible intervention.