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HealtH metrics network
Assessing the National Health Information System
An Assessment ToolVERSION 4.00
HealtH metrics network
Assessing the National Health Information SystemAn Assessment Tool
VERSION 4.00
© World Health Organization 2008
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WHO Library Cataloguing-in-Publication Data
Assessing the national health information system : an assessment tool. – version 4.00.
1.Public health informatics – methods. 2.Data collection – standards. 3.Vital statistics. 4.Information systems – standards. I.World Health Organization. II.Health Metrics Network.
ISBN 978 92 4 154751 2 (NLM classification: W 26.5)
Contents
1. Introduction 1
2. Assessment of the national health information system (HIS) 4
2.1 What are the objectives of assessment? 4
2.2 Who should assess? 4
2.3 How can assessment be organized and facilitated? 6
2.4 How can final consensus be reached and findings disseminated? 9
2.5 How can the assessment findings be built upon? 10
3. Scoring and interpretation of results 12
The HMN Assessment And Monitoring Tool: Version 4 15
I. Assessing national HIS resources 17
Table I.A National HIS information policies 19
Table I.B National HIS financial and human resources 20
Table I.C National HIS infrastructure 22
II. Assessing national HIS indicators 25
Table II.A Assessing national HIS indicators 27
III. Assessing national HIS data sources 29
Table III.A Censuses 33
Table III.B Civil registration 35
Table III.C Population surveys 37
Table III.D Individual records 38
Table III.E Service records 40
Table III.F Resource records 42
IV. Assessing national HIS data management 47
Table IV.A Assessing national HIS data management 48
V. Assessing national HIS data quality 49
Table V.A Under-5 mortality 51
Table V.B Maternal mortality 52
Table V.C HIV prevalence 53
Table V.D Measles vaccination coverage 54
Table V.E Attended deliveries 55
Table V.F Tuberculosis treatment 57
Table V.G General government health expenditure (GGHE) per capita 58
Table V.H Private expenditure 59
Table V.I Workforce density 61
Table V.J Smoking prevalence 62
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VI. Assessing national HIS information dissemination and use 63
Table VI.A Demand and analysis 66
Table VI.B Policy and advocacy 66
Table VI.C Planning and priority-setting 67
Table VI.D Resource allocation 67
Table VI.E Implementation and action 68
Annex I. Glossary of terms 69
Annex II. Abbreviations and acronyms 72
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1. Introduction
The Health Metrics Network (HMN) was launched in 2005 to help countries and other partners improve global health by strengthening the systems that generate health-related information for evidence-based decision-making. HMN is the first global health partnership that focuses on two core requirements of health system strengthening in low and low-mid-dle income countries. First, the need to enhance entire health information and statistical systems, rather than focus only upon specific diseases. Second, to concentrate efforts on strengthening country leadership for health information production and use.
In order to help meet these requirements and advance global health, it has become clear that there is an urgent need to coordinate and align partners around an agreed-upon “framework” for the development and strengthening of health information systems. It is intended that the HMN Framework1 shown in Fig.1 will become the universally accepted standard for guiding the collection, reporting and use of health information by countries and global agencies. Through its use, it is envisaged that all the different partners working
1 World Health Organization. Framework and Standards for Country Health Information Systems. Geneva, World Health Organization, 2007. http://www.healthmetricsnetwork.org
Fig. 1 the Hmn Framework
Components and Standards of a Health Information System
Indicators
Data sources
Data management
Information products
HIS resources
Dissemination and use
Strengthening Health Information Systems
HMN Goal
Increase the availability, accessibility, quality and use of health information vital for
decision-making at country and global levels.
Principles
Processes
• Leadership, coordination and assessment • Priority-setting and planning • Implementation of health information system strengthening activities
Tools
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within a country will be better able to harmonize and align their efforts around a shared vision of a sound and effective national health information system (“national HIS”).
As shown in Fig.1, the HMN Framework consists of two major parts:
n Components and Standards of a Health Information System (left-hand column of Fig. 1) – which describes the six components of health information systems and provides normative standards for each.
n Strengthening Health Information Systems (right-hand column of Fig. 1) – which describes the guiding principles, processes and tools that taken together outline a road-map for strengthening health information systems.
A crucial early step in this roadmap is the need for an effective assessment of the existing national HIS – both to establish a baseline and to monitor progress. In order to assist coun-tries in this key activity HMN has developed this assessment tool1 which describes in detail how to undertake a first baseline assessment. An overriding aim of any statistical system assessment is to arrive at an understanding of:
…users’ current and perceived future requirements for statistical information; their assessment of the adequacy of existing statistics and of where there are gaps in existing and planned data; their priorities; and their ability to make effective use of statistical information.2
Such an assessment is complex, as overall system performance depends upon multiple determinants – technical, social, organizational and cultural. Assessment therefore needs to be comprehensive in nature and cover the many subsystems of a national HIS, including public and private sources of health-related data. It should also address the resources avail-able to the system (inputs), its methods of work and products (processes and outputs) and results in terms of data availability, quality and use (outcomes). Important “inputs” to assess include the institutional and policy environment, and the volume and quality of financial, physical and human resources, as well as the available levels of information and commu-nications technology (ICT). In terms of “outputs” the integrity of data is also determined by the degree of transparency of procedures, and the existence of well-defined rules, terms and conditions for collection, processing and dissemination. Assessing “outcomes” should include quantitative and qualitative approaches, such as document reviews and interviews with in-country stakeholders at central and peripheral levels, and with external actors.
As described in section 2.2 all major stakeholders should participate in assessing the national HIS and planning for its strengthening. Stakeholders will include the producers, users and financiers of health information and other social statistics at various national and subnational levels. These include officials in government ministries and agencies; donors and development partners such as multilateral and bilateral agencies; NGOs; academic institutions; professional associations; other users of health-related information such as parliamentarians; civil society (including health-related advocacy groups); and the media. In countries with decentralized systems, the assessment process should be clearly articu-lated and involve managers and representatives of care providers at peripheral levels (dis-tricts) as well as stakeholders at the central level. Once produced the assessment report and its recommendations for action should be made accessible to all stakeholders, includ-ing health professionals and civil society.
Establishing a broad-based coordinating mechanism with links to all relevant ministries, research institutions, NGOs, technical support agencies and donors is a crucial step in the assessment process. It should be the body charged with the goal of reaching agreement on how best to achieve the standards set out in the HMN Framework and developing a
1 This and other tools may also be downloaded from: http://www.who.int/healthmetrics/tools/en/2 PARIS21 Secretariat. A Guide to Designing a National Strategy for the Development of Statistics (NSDS), 2004.
http://www.paris21.org/pages/designing-nsds/NSDS-reference-paper/
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national strategic plan (section 2.5). If a suitable body does not exist, a coordination steer-ing committee under high-level leadership should be constituted to ensure coordination. It should convene regularly, mobilize technical advice, provide guidance and oversight, and disseminate progress reports to all stakeholders. The precise nature of the operational arrangements for taking action will vary depending upon the individual national context.
During the assessment process, workshops must be conducted to build broad-based con-sensus among key stakeholders in the following three stages:
n First, a workshop is held to mark the launch of national HIS reform, the first stage of which is leadership, consensus-building and assessment activities.
n A second workshop then follows to initiate assessment of the health information sys-tem, supplemented by follow-up visits to key stakeholders. Another key function of the second workshop is to assess, and open dialogue on, the strengths and challenges of the existing system.
n The third workshop coincides with the end of the assessment phase and is used to share and discuss findings, highlight existing weaknesses and map a way forward for the planning process.
The coordination steering committee should draw up terms of reference for the baseline assessment, identify the composition of the assessment team, and mobilize the required human and financial resources needed to properly assess the extent to which the national HIS and its various subsystems currently meet the needs of all users.
This HMN assessment tool is intended to achieve more than simply assess the strengths and weaknesses of the elements and operations of a national HIS. The mere process of con-ducting the assessment reaches and engages all stakeholders in the system. Some of these will interact for the very first time through the assessment process, which is intended to be both catalytic and synergistic. It should move stakeholders towards a shared and broader vision of a more coherent, integrated, efficient and useful system. The gap between the existing system and this new vision will be an important stimulus for moving to the next stage of planning national HIS reform. At this stage, stakeholders are now better prepared to articulate and argue for a new vision of how a national HIS would benefit the country, lead to stronger health system performance, and ultimately to improved public health. Such an assessment process can also be a mechanism for directly engaging stakeholders and for reinforcing broad-based consensus-building.
In many settings, assessments of the national HIS or its individual components may already have been conducted and should be built upon, not duplicated. The findings should provide the foundation for an analytical and strategic assessment of current strengths and weak-nesses. Once endorsed, assessment provides the baseline against which future progress in health information system strengthening should be evaluated.
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2. Assessment of the national HIS
2.1 what are the objectives of assessment?
National HIS strengthening must start with a broad-based assessment of the system’s own environment and organization, responsibilities, roles and relationships; and of the technical challenges of specific data requirements in order to:
n allow objective baseline and follow-up evaluations – assessment findings should there-fore be comparable over time;
n inform stakeholders – for example, of aspects of the HIS with which they may not be familiar;
n build consensus around the priority needs for health information system strengthening; and
n mobilize joint technical and financial support for the implementation of a national HIS strategic plan – with indications of the priority investments in the short term (1–2 years), intermediate term (3–9 years) and long term (10 years and beyond).
Stakeholders may decide to repeat the comprehensive assessment exercise at appropriate intervals. HMN is working to develop a separate monitoring tool that will permit the moni-toring of progress over time.
2.2 who should assess?
Another initial step in planning an assessment of the national HIS is to identify who should be involved. One basic principle of the HMN approach is that all major stakeholders should participate in assessing the national HIS and planning for its strengthening. Stakeholders will include the producers, users and financiers of health information and other social sta-tistics at various national and subnational levels.
As described in section iii, essential HIS data are usually generated either directly from populations or from the operations of health and other institutions. This produces a range of data sources with numerous stakeholders involved in different ways with each of these sources. For example, ministries of health are usually responsible for data derived from health service records. National statistics offices are usually responsible for conduct-ing censuses and household surveys. Responsibility for vital statistics including births and deaths may be shared between the national statistics office, the ministry of home affairs and/or local government, and the ministry of health. An illustrative list of appropriate rep-resentatives of relevant stakeholders would include:
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1. Central statistics office
a) Officials and analysts responsible for:
n the national population census; and
n household surveys such as the Demographic and Health Survey (DHS), Living Stand-ard Measurement Study (LSMS) household surveys, and Multiple Indicator Cluster Sur-veys (MICS).
b) Other leading demographers and statisticians.
2. Ministry of health
a) Senior advisors as well as members of the ministry cabinet and those within the ministry responsible for or coordinating:
n the HIS;
n acute disease surveillance and response;
n disease control, immunization and maternal and child/family planning programmes;
n noncommunicable disease control programmes;
n management of human resources, drugs and other logistics and health finances;
n planning;
n annual monitoring and evaluation and performance reviews; and
n facility-based surveys.
3. Other ministries and governmental agencies
a) Those within the finance and other ministries or agencies responsible for:
n the planning, monitoring and evaluation of social programmes;
n civil registration – typically the ministry of the interior or home affairs or local govern-ment;
n planning commissions;
n population commissions; and
n commissions for developing social statistics.
4. Institutes of public health and universities
a) Researchers and directors of the Demographic Surveillance System (DSS) and those in other institutes and universities.
5. Donors
a) Major bilateral and multilateral health sector donors.
b) Global health partnerships such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and the Global Alliance for Vaccines and Immunization (GAVI).
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c) Donors who finance specific activities of relevance including:
n the national population census;
n large-scale national population-based surveys (DHS, MICS, LSMS);
n the sample vital registration system;
n Demographic Surveillance System (DSS);
n Strengthening of the health management information system
n strengthening of surveillance and Integrated Disease Surveillance and Response (IDSR);
n the national health account (NHA);
n mapping of health risks and health services;
n health facility surveys – for example, Service Provision Assessment (SPA);
n annual health sector performance reviews; and
n systems for the monitoring and evaluation of major disease control programmes in areas such as HIV/AIDS, malaria, tuberculosis and vaccine-preventable diseases.
6. United Nations organizations
a) United Nations organizations active in development and the monitoring of progress towards the Millennium Development Goals (MDGs) include UNICEF, UNDP, UNFPA, WHO and the World Bank.
7. Representatives of key nongovernmental organizations (NGOs) and civil society
a) NGOs and other health-advocacy groups.
b) Private health-professional associations.
c) Associations of faith-based health providers.
To mobilize and coordinate these and other stakeholders it is very useful to identify a high-level and influential country “champion” with decision-making powers. This could be someone within the ministry of health, the national statistics office or from a major pro-gramme area involved in health systems. The champion can help ensure that stakeholders understand fully the objectives of the assessment and how it fits into the overall process of national HIS development. In particular, stakeholders should be aware that assessment will rapidly be followed by a comprehensive strategic planning process to which they will also be asked to contribute.
2.3 How can assessment be organized and facilitated?
Once the key stakeholders have been identified a steering committee should be formed to provide ongoing oversight, direction and coordination of national HIS strengthening activi-ties. These will include the planning and implementation of initial and ongoing assessment efforts. Although it must be inclusive, not all stakeholders need to be active on the steering committee. For example, a group of bilateral donors, each financing a different aspect of HIS strengthening, may wish to designate a single representative, possibly on a rotational basis. The stakeholder group and its steering committee should then designate an existing agency (such as the national HIS unit or section within the ministry of health) to carry out certain of the communications, procurement and other administrative tasks required to conduct an assessment.
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An assessment may be conducted during a large dedicated national workshop and/or dur-ing smaller meetings of several groups. In some countries, individual interviews with key individuals and groups have been used but this does not allow for the stimulation of open discussions with all relevant stakeholders in an open forum. HMN recommends that the assessment be done during large workshops and/or smaller meetings of several groups where all relevant stakeholders are present. A combination of these two approaches is most likely to be effective and time-efficient in obtaining inputs from all key stakeholders. Many participants may not be familiar with certain aspects of the national HIS, and par-ticipating in broad discussions of all 197 items included in this assessment tool would be highly time-consuming. Hence, it is usually best if participants are divided into small groups that can work either sequentially or simultaneously (for example, at a national workshop) to reach consensus on a subset of items. However whenever assessment is conducted by only a subset of meeting participants, efforts must be made to ensure feedback and discus-sion of the findings takes place among all key stakeholders. This will be necessary to meet the objective of informing and building consensus among all stakeholders.
Note 1: It is NOT advisable to administer the assessment as a “questionnaire” to be completed by separate, individual informants. It is important that groups of informants discuss together the assessment items. Even if the individuals in the group end up scoring the items differently, they will learn from the group discussion and the results will better reflect a consensus about the meaning of each item.
Note 2: Persons who are not technically qualified to assess a given item should be asked to NOT score the item. Use of the Group Builder tool helps to reduce the chance that someone who is poorly informed will score a given assessment item.
The HMN Group Builder tool1 has been designed to help those organizing the national HIS assessment to group together the individuals and representatives best qualified to assess particular assessment items. Each group should be composed of key participants in the aspect under consideration with the maximum number of items to be considered by any one group not greatly exceeding 100.
The proposed groupings and an estimation of the number of items that each will contribute are as follows:
1. Members of the national HIS unit or section of the ministry of health – even without fur-ther members, this is a key group for assessing almost 100 items.
2. Senior planners and policy-makers with the ministry of health – such senior officials alone are an important group for assessing approximately 75 items.
3. Central statistics office staff together with other available demographers – key in the assessment of approximately 75 items.
4. Programme managers (including coordinators of public health programmes in areas such as maternal and child health, immunization, tuberculosis, HIV/AIDS and disease surveillance) – can assess almost 80 items.
5. Subnational personnel (including managers and national HIS staff at provincial, district and hospital levels) – by assessing about 60 items would complete a subnational assess-ment.
6. Finance monitoring experts – a specialized group for assessing approximately 30 items.
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1 Health Metrics Network (2006). Group Builder, version 1.5. Internal document for grantees.
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7. Resource tracking – another specialized group composed of those who manage the databases that track human resources, supplies and infrastructure, and who should assess about 20 items.
8. Non-project donors (including the World Bank and those contributing to a “common basket” for funding Sector-Wide Approaches) – about 70 items have been identified for assessment by these partners if they are not already participating in other groups. Donors supporting public health programmes (for example in immunization or surveil-lance), the population census or national household surveys should be invited to join the group that includes the respective programme manager.
Group Builder allows the membership of each of these groups to be customized by adding or removing members based upon local circumstances and preferences. Care is required to avoid adding too many optional members to groups as this may also increase the number of items that must be assessed. Once group members are identified, a spread-sheet automatically indicates the best items for each group to assess. A separate spread-sheet (“ungrouped”) lists key individuals who have not been included in any of the groups and the items for which key participants are lacking. Ungrouped participants may then be invited to join one of the groups, or alternatively separate interviews may be scheduled to gather their assessment inputs.
In addition to a printout of this assessment tool, relevant key documents for each of the groups should be provided in advance to all participants. At present, these key documents include:
n The HMN Framework;1
n Fundamental principles of official statistics;2
n A Guide to Designing a National Strategy for the Development of Statistics;3
n OECD Guidelines for data protection;4 and
n IMF Data Quality Assessment Framework.5
Assessment of certain items may also be supported by external findings such as statistics used in global databases. For example, vital statistics practices may in part be assessed on the basis of statistics compiled by the United Nations Statistics Division or available in the WHO global mortality database.6
Certain key individuals (such as senior policy-makers and planners within the ministry of health, the central statistics office, the ministry of finance, and the vital registration author-ities) may not be able to attend the entire assessment workshop. If this is the case, then individual appointments should be scheduled by the assessment organizers in order to obtain these key inputs.
It is also essential that one or more facilitators or resource people are available to support the workshops or meetings where this assessment tool is being used. Facilitators should be thoroughly familiar with the complete assessment tool and with the HMN Framework on which it is based. In addition to helping to lead the plenary sessions, the facilitator should
1 World Health Organization. Framework and Standards for Country Health Information Systems. Geneva, World Health Organization, 2007. http://www.healthmetricsnetwork.org
2 United Nations. Fundamental principles of official statistics. New york, United Nations Statistics Division, 1994. Principles include impartiality, scientific soundness, professional ethics, transparency, consistency and effi-ciency, coordination and collaboration. http://unstats.un.org/unsd/goodprac/bpabout.asp
3 PARIS21 Secretariat. A Guide to Designing a National Strategy for the Development of Statistics (NSDS), 2004. http://www.paris21.org/pages/designing-nsds/NSDS-reference-paper/
4 For example, the OECD Guidelines for data protection at: http://www.oecd.org/document/18/0,2340,en_2649_34255_1815186_1_1_1_1,00.html
5 International Monetary Fund Data Quality Assessment Framework (DQAF), 2003. http://dsbb.imf.org/Applications/web/dqrs/dqrsdqaf/
6 http://www.who.int/healthinfo/morttables/en/index.html
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circulate among the smaller groups, helping to clarify the meaning of particular items and answering questions. The facilitator can also explain how to the composite scores for each aspect of the national HIS can be compiled and the findings summarized in the assessment report.
A large number of items will need to be assessed by members of the national HIS unit or section within the ministry of health. Hence, it may support the assessment process if these key participants also met in advance of the workshops and other meetings. Groups that meet subsequently may then be provided with a record of the scores generated by national HIS staff. These same individuals could then play a key role in organizing and facili-tating the assessment workshops, meetings and interviews with key personnel as outlined above.
However, the major advantage of a self-assessment approach is that it engages all partners in a shared learning experience. Facilitators may help to speed up the assessment and make the findings more comparable but it is important that they do not interfere with the process of self-discovery among country stakeholders. Self-assessment can often lead to a genuine desire to significantly improve the national HIS.
2.4 How can final consensus be reached and findings disseminated?
Irrespective of the approach used to conduct the initial assessment (interviews with key people, small-group discussions of subsets of items, and so on) efforts should be made to involve all the relevant stakeholders in analysing the findings and identifying the next steps. After all the items have been scored, a plenary session of at least 3 hours should be organized to review and reach consensus on the key assessment findings. Even if some key stakeholders have not been able to participate in earlier meetings during which items were scored, they should be encouraged to join in this final plenary. Ideally the final plenary should be held at a time when participants are well rested and able to reflect on the assess-ment findings.
If items have been assessed by multiple small groups, a good way to begin the final plenary session is to invite a rapporteur from each group to present the most important findings or insights. Examples of possible key findings include:
n The legal and policy framework for the national HIS is outdated and poorly imple-mented.
n The health information system is quite fragmented between different health programmes and directorates, and between the ministry of health and the national statistics office.
n Insufficient feedback is provided to those who collect data and submit reports.
n Many health information officers at subnational level are not well qualified for the tasks they are asked to carry out.
n Investments are needed in ICT.
n As a top priority, statistics from multiple sources should be pulled together into an inte-grated data warehouse.
The remainder of the final plenary might then consist of presenting the scores both of over-all national HIS components and of key individual assessment items, followed by discussion of how such scores positively or negatively impact on the key findings. The assessment tool automatically generates summary scores and graphs to assist in this process. In this way the meeting outcomes will go beyond individual item scores to include the comments recorded for each item, and the important points made during subsequent plenary discus-sions.
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A special task force should be established to produce a draft report of the assessment meeting and its results. This should then be distributed for review and comment by a broad range of stakeholders prior to its finalization. In support of this important stage of the assessment process it will be necessary to budget not only for the national workshop itself, but also for the subsequent costs of editing, printing and disseminating the finalized meeting and assessment reports. Once completed, this process should help considerably in identifying the next steps, and should provide a bridge between the assessment findings and strategic planning.
2.5 How can the assessment findings be built upon?
The findings contained in the assessment report should provide information for the devel-opment of a comprehensive strategic plan for national HIS strengthening with the following characteristics:
n The plan specifies what is to be done over the coming decade to increase the availability, quality, value and use of timely and accurate health information.
n The plan is based upon consultation with all key constituencies including those support-ing the population census, vital statistics, household health surveys, disease surveillance, health service statistics (including those from the private sector), health resource records and health accounts.
n The plan is also based upon the assessment and additional findings regarding the human and financial resources currently available, and likely to be required for the achievement of priorities.
n The various constituencies (those producing, using and financing such health infor-mation) should be asked to identify investment priorities and strategies for national HIS strengthening.
n Priority investments in the short term (1–2 years), intermediate term (3–9 years) and long term (10 years and beyond) are identified, sequenced and costed.
n The plan discusses how these investments will be financed and identifies appropriate funding sources at country level including ministry budgets, HIPC debt relief, concessional loans, bilateral and multilateral development agencies and global health partners.
n Consensus on the plan is reached at a national workshop. The plan is subsequently endorsed by the national HIS coordinating committee.
HMN is currently developing guidelines to support the development of strategic plans for national HIS strengthening. A few general principles to keep in mind when preparing for this process are:
n A task force may be established to review findings from the assessment, conduct or commission additional studies and draft the strategic plan. As with the steering committee for organizing and facilitating the assessment meetings, the task force should be repre-sentative of all appropriate technical and other stakeholders. To improve coordination and partnership:
— a range of views and expertise will be essential to reach a consensus that will ulti-mately be endorsed by a broader range of stakeholders, including those in the minis-try of health, the national statistics office and financing partners; and
— too large a group may make it difficult to reach consensus – essential participants should be identified.
n Decisions on the timing of different activities included in the workplan depend upon sev-eral factors such as their perceived urgency; the extent of the gap identified (i.e., assess-
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ment scores of 0 or 1); ease of implementation with existing health system and resources; and availability of financing. The assessment process may identify some data sources for which the country has good capacity but has problems with the content of the informa-tion produced (for example, a good-quality census is regularly conducted every 10 years but questions on mortality have not been included in the census questionnaire). This may suggest areas where important advances can be made in the short term or with modest resources.
n It is however essential that the strategic plan is not limited only to those activities that are feasible in the short term. More-ambitious or longer-term objectives may be met by mobilizing financial, organizational and technical commitment around a compelling strate-gic vision. Hence, it is also possible to address problems of weak capacity over the longer term.
n Achievement of the more-ambitious objectives (for example, development of human resources for the national HIS; and strengthening civil registration) depend upon the broader policies, plans and budgets of the ministry of health, the national statistics office and the national government in general. Thus it is essential that the national HIS strategic plan be consistent with these broader policies and plans. It is also important for the advocates of national HIS strengthening to engage in discussions on the reform or development of these broader policies and plans. Implementation of important components of the national HIS strategic plan depends upon continued advocacy, lobbying and negotiation, and participa-tion in related policy formulation and planning processes.
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3. Scoring and interpretation of results
For each item included in this assessment tool, a range of possible scenarios is provided allowing for objective and quantitative rating. The highest score (3) is given for a scenario considered Highly adequate compared to the gold standard as defined by the HMN Frame-work. The lowest score (0) is given when the situation is regarded as Not adequate at all in terms of meeting the gold standard. The total score for each category is aggregated and compared against the maximum possible score to yield a percentage rating. Each of the questions can potentially be rated by multiple respondents and the replies aggregated to obtain an overall score. The more varied the (informed) respondents involved, the lower the risk of bias in the end results. In some cases, a particular item may be judged as inap-plicable. If so, it should be omitted from the scoring process and the reasons for doing so recorded.
For the purposes of the overall report, scores are converted into quartiles. Thus items with scores falling in the lowest quartile are classified as Not adequate at all. Scores falling into the next lowest quartile are classified as Present but not adequate, followed by Adequate, and Highly adequate for those in the third and fourth quartiles respectively.
Scores may be awarded by individuals or by groups. On the spreadsheet version of this assessment tool1 there are spaces for recording the scores awarded by up to 14 individu-als, with an adjacent space for recording any detailed comments made about major gaps, constraints, possible solutions and intervention priorities. Early experience of using this assessment tool suggests that it is important to capture these detailed qualitative remarks. If responses are recorded on a paper copy of the assessment tool rather than the spread-sheet version, it is advisable to insert blank rows after each item or to provide several blank pages after each table to capture qualitative remarks.
On the spreadsheet, separate rows are also provided for additional assessment items. The insertion or deletion of rows from the spreadsheet is not recommended as this may lead to errors in the formulae used to sum the scores and colour-code the results. Instead of deleting an item, it should be skipped so that it does not affect the final scores. New items may be added in the blank rows provided in each section of the assessment tool. Assess-ment scores entered into the cells to the right of these additional items are then averaged, and the results displayed along with the results for the standard items. If such an approach does not meet the needs for adaptation of the tool, assessment organizers are encouraged to contact HMN2 for assistance. Table 1 shows the total number of questions in each of the assessment categories.
12
1 http://www.healthmetricsnetwork.org2 [email protected]
13
table 1. number of questions in the assessment tool
CATEGORIES NUMBER OF QUESTIONS
I. Resources 25 A. Policy and planning 7 B. HIS institutions, human resources and financing 13 C. HIS infrastructure 5
II. Indicators 5
III. Data sources 83
A. Census 10 B. Vital statistics 13 C. Population-based surveys 11 D. Health and disease records (incl. surveillance) 13 E. Health service records 11 F. Resource records 25 i. infrastructure and health services 6 ii. human resources 4 iii. financing and expenditure for health service 8 iv. equipment, supplies and commodities 7
IV. Data management 5
V. Information products 69
VI. Dissemination and use 10
Total 197
3.
SC
OR
ING
AN
D I
NT
ER
PR
ETA
TIO
N O
F R
ES
ULT
S
The HMN Assessment and Monitoring ToolVersion 4
17
I. Assessing national HIS resources[Tables I.A–C]
national His coordination, planning and policies
Developing and strengthening health information systems will depend upon how key units and institutions function and interact. These include the ministry of health’s central health information unit, disease surveillance and control units, and the central statistics office. Institutional analysis can therefore be useful in identifying constraints that undermine policy or hamper the implementation of key strategies for developing the information sys-tem. Constraints include those related to reporting hierarchies or relationships between different units responsible for monitoring and evaluation. The national HIS strategic plan outlined in section 2.5 is an essential requirement for effective coordination as it will guide HIS investments, and provide agreed-upon approaches to the maintenance, strengthening and coordination of all the key HIS components.
The legal and regulatory contexts within which health information is generated and used are also highly important as they enable mechanisms to be established to ensure data availability, exchange, quality and sharing. Legal and policy guidance is also needed, for example, to elaborate the specifications for electronic access and to protect confidenti-ality. Legislation and regulation are particularly significant in relation to the ability of the national HIS to draw upon data from both the private and public health services, as well as non-health sectors. Particular attention to legal and regulatory issues is needed to ensure that non-state health-care providers are integral to the national HIS, through the use of accreditation where appropriate. The existence of a legal and policy framework consist-ent with international standards, such as the Fundamental principles of official statistics,1
enhances confidence in the integrity of results. A legal framework can also define the ethi-cal parameters for data collection, and information dissemination and use. The health infor-mation policy framework should identify the main actors and coordinating mechanisms, ensure links to programme monitoring, and identify accountability mechanisms.
national His financial and human resources
Improvements in the national HIS cannot be achieved unless attention is given to the train-ing, deployment, remuneration and career development of human resources at all levels. At national level, skilled epidemiologists, statisticians and demographers are needed to oversee data quality and standards for collection, and to ensure the appropriate analy-sis and utilization of information. At peripheral levels, health information staff should be accountable for data collection, reporting and analysis. Deploying health information offic-ers within large facilities and districts (as well as at higher levels of the health-care system) results in significant improvements in the quality of data reported and in the understanding of its importance by health-care workers.
1 United Nations. Fundamental principles of official statistics. New york, United Nations Statistics Division, 1994. Principles include impartiality, scientific soundness, professional ethics, transparency, consistency and effi-ciency, coordination and collaboration.
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
18
Appropriate remuneration is essential to ensure the availability of high-quality staff and to limit attrition. This implies, for example, that health information positions in ministries of health should be graded at a level equivalent to those of major disease programmes. Within statistics offices, measures should be taken to retain well-trained staff. Establishing an independent or semi-independent statistics office should allow for better remuneration and subsequent retention of high-level staff.
Targeted capacity development is needed, and training and educational schemes should be used to address human resource development in areas such as health information man-agement and use, design and application, and epidemiology. Such training should be for all levels of competency, ranging from the pre-service training of health staff and continuous education, to public health graduate education at the Masters and PhD levels.
national His infrastructure
The infrastructural needs of the national HIS can be as simple as pencils and paper or as complex as fully integrated, web-connected, ICT. At the level of the most basic record keeping, there is a need to store, file, abstract and retrieve records. However, ICT has the potential to radically improve the availability, dissemination and use of health-related data. While information technologies can improve the amount and quality of the data collected, communications technology can enhance the timeliness, analysis and use of information. A communications infrastructure is therefore needed to fully realize the potential benefits of information that may already be available.
Ideally, at national and subnational levels, health managers should therefore have access to an information infrastructure that includes computers, e-mail and Internet access. All facilities should have such connectivity, but this is a long-term objective in many countries. Similarly, national and regional statistics offices should be equipped with transport and communications equipment to enable the timely collection and compilation of data at the subnational level.
In many settings, computers are already used in discrete vertical health information pro-grammes and electronic medical records systems, resulting in many non-compatible sys-tems being used within countries. This often aggravates rather than alleviates duplication and overlap. Coherent capacity building in electronic and human resources throughout the health system is a far more effective and cost-efficient approach.
19
I. A
SS
ES
SIN
G N
AT
ION
AL
HIS
RE
SO
UR
CE
S
taBl
e i.a
– a
sses
sinG
nat
iona
l His
res
oUrc
es: c
oord
inat
ion,
pla
nnin
g an
d po
licie
s
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
3 2
1 0
I.A.1
Th
e co
untr
y ha
s up
-to
-dat
e le
gisl
atio
n pr
ovid
ing
the
fram
ewor
k fo
r he
alth
Le
gisl
atio
n co
veri
ng
Legi
slat
ion
cove
ring
Le
gisl
atio
n ex
ists
Th
ere
is n
o su
ch
info
rmat
ion
cove
ring
the
follo
win
g sp
ecifi
c co
mpo
nent
s: v
ital
reg
istr
atio
n;
all a
spec
ts e
xist
s so
me
aspe
cts
exis
ts
but
is n
ot e
nfor
ced
legi
slat
ion
no
tifia
ble
dise
ases
; pri
vate
-sec
tor
data
(inc
ludi
ng s
ocia
l ins
uran
ce);
an
d is
enf
orce
d an
d is
enf
orce
d
confi
dent
ialit
y; a
nd fu
ndam
enta
l pri
ncip
les
of o
ffici
al s
tati
stic
s
I.A.2
Th
e co
untr
y ha
s up
-to
-dat
e re
gula
tion
s an
d pr
oced
ures
for
turn
ing
the
ye
s, r
egul
atio
ns a
nd
Reg
ulat
ions
and
R
egul
atio
ns a
nd
No,
the
re a
re n
o
fund
amen
tal p
rinc
iple
s of
offi
cial
sta
tist
ics
into
goo
d pr
acti
ces,
and
for
pr
oced
ures
exi
st a
nd
proc
edur
es e
xist
and
pr
oced
ures
exi
st,
wri
tten
reg
ulat
ions
en
suri
ng t
he in
tegr
ity
of n
atio
nal s
tati
stic
al s
ervi
ces
(by
ensu
ring
ar
e fu
lly im
plem
ente
d.
are
wid
ely
bu
t ar
e no
t ye
t an
d pr
oced
ures
for
pr
ofes
sion
alis
m, o
bjec
tivi
ty, t
rans
pare
ncy
and
adhe
renc
e to
eth
ical
In
tegr
ity
of n
atio
nal
diss
emin
ated
, but
no
diss
emin
ated
and
en
suri
ng t
he in
tegr
ity
st
anda
rds
in t
he c
olle
ctio
n, p
roce
ssin
g an
d di
ssem
inat
ion
of h
ealt
h-
stat
isti
cal s
ervi
ces
is
regu
lar
asse
ssm
ent
impl
emen
ted
of n
atio
nal s
tati
stic
al
rela
ted
data
) re
gula
rly
asse
ssed
of
the
inte
grit
y of
serv
ices
na
tion
al s
ervi
ces
is
pe
rfor
med
I.A.3
Th
ere
is a
wri
tten
HIS
str
ateg
ic p
lan
in a
ctiv
e us
e ad
dres
sing
all
the
maj
or
yes,
com
preh
ensi
ve
The
com
preh
ensi
ve
The
stra
tegi
c pl
an
Ther
e is
no
wri
tten
da
ta s
ourc
es d
escr
ibed
in t
he H
MN
Fra
mew
ork
(cen
suse
s, c
ivil
H
IS s
trat
egic
pla
n st
rate
gic
plan
exi
sts,
ex
ists
, but
it is
not
H
IS s
trat
egic
pla
n
regi
stra
tion
, pop
ulat
ion
surv
eys,
indi
vidu
al r
ecor
ds, s
ervi
ce r
ecor
ds
exis
ts a
nd is
bu
t th
e re
sour
ces
to
used
or
does
not
an
d re
sour
ce r
ecor
ds) a
nd it
is im
plem
ente
d at
the
nat
iona
l lev
el
impl
emen
ted
impl
emen
t it
are
not
em
phas
ize
av
aila
ble
inte
grat
ion
I.A.4
Th
ere
is a
rep
rese
ntat
ive
and
func
tion
ing
nati
onal
com
mit
tee
in c
harg
e ye
s, a
func
tion
al
Ther
e is
a fu
ncti
onal
Th
ere
is a
nat
iona
l Th
ere
is n
o na
tion
al
of H
IS c
oord
inat
ion
nati
onal
HIS
na
tion
al H
IS
HIS
com
mit
tee,
but
H
IS c
omm
itte
e
co
mm
itte
e ex
ists
co
mm
itte
e, b
ut
it is
not
func
tion
al
wit
hout
res
ourc
es
I.A.5
Th
e na
tion
al s
tati
stic
s of
fice
and
min
istr
y of
hea
lth
have
est
ablis
hed
ye
s, fu
lly o
pera
tion
al,
yes,
but
mee
ts o
nly
yes
in t
heor
y, b
ut
No
co
ordi
nati
on m
echa
nism
s (e
.g.,
a ta
sk fo
rce
on h
ealt
h st
atis
tics
); th
is
mee
ts r
egul
arly
and
oc
casi
onal
ly o
n an
th
ese
mec
hani
sms
m
echa
nism
may
be
mul
tise
ctor
al
mee
ts n
eeds
for
ad
hoc
bas
is o
r ar
e no
t op
erat
iona
l
co
ordi
nati
on
agen
da is
too
full
I.A.6
Th
ere
is a
rou
tine
sys
tem
in p
lace
for
mon
itor
ing
the
perf
orm
ance
of
yes,
it e
xist
s an
d is
ye
s, b
ut it
is s
eldo
m
yes,
but
it is
nev
er
No
th
e H
IS a
nd it
s va
riou
s su
bsys
tem
s us
ed r
egul
arly
us
ed
used
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
20
taBl
e i.a
– C
ontin
ued
It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
3 2
1 0
I.A.7
It
is o
ffici
al p
olic
y to
con
duct
reg
ular
mee
ting
s at
hea
lth-
care
faci
litie
s an
d ye
s, t
he p
olic
y Th
e po
licy
exis
ts, b
ut
The
polic
y ex
its,
but
Th
ere
is n
o po
licy
he
alth
-adm
inis
trat
ion
offic
es (e
.g.,
at n
atio
nal,
regi
onal
/pro
vinc
ial o
r di
stri
ct
exis
ts a
nd is
bei
ng
mee
ting
s ar
e no
t is
not
impl
emen
ted
le
vel)
to r
evie
w in
form
atio
n on
the
HIS
and
tak
e ac
tion
bas
ed u
pon
such
im
plem
ente
d re
gula
r
info
rmat
ion
taBl
e i.B
– a
sses
sinG
nat
iona
l His
res
oUrc
es: F
inan
cial
and
hum
an re
sour
ces
It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
3 2
1 0
I.B.1
Th
e m
inis
try
of h
ealt
h ha
s ad
equa
te c
apac
ity
in c
ore
heal
th in
form
atio
n H
ighl
y ad
equa
te
Ade
quat
e P
arti
ally
ade
quat
e N
ot a
dequ
ate
sc
ienc
es (e
pide
mio
logy
, dem
ogra
phy,
sta
tist
ics,
info
rmat
ion
and
ICT)
I.B.2
Th
e na
tion
al s
tati
stic
s of
fice
has
adeq
uate
cap
acit
y in
sta
tist
ics
H
ighl
y ad
equa
te
Ade
quat
e P
arti
ally
ade
quat
e N
ot a
dequ
ate
(d
emog
raph
y, s
tati
stic
s, IC
T)
I.B.3
Th
ere
is a
func
tion
al c
entr
al H
IS a
dmin
istr
ativ
e un
it in
the
min
istr
y of
H
IS c
entr
al u
nit
is
HIS
cen
tral
uni
t is
H
IS c
entr
al u
nit
has
Ther
e is
no
func
tion
ing
he
alth
to
desi
gn, d
evel
op a
nd s
uppo
rt h
ealt
h-in
form
atio
n co
llect
ion,
fu
ncti
onal
wit
h fu
ncti
onal
but
lack
s ve
ry li
mit
ed fu
ncti
onal
ce
ntra
l HIS
m
anag
emen
t, a
naly
sis,
dis
sem
inat
ion
and
use
for
plan
ning
and
ad
equa
te r
esou
rces
ad
equa
te r
esou
rces
ca
paci
ty a
nd u
nder
- ad
min
istr
ativ
e un
it in
m
anag
emen
t
ta
kes
few
HIS
- th
e m
inis
try
of h
ealt
h
st
reng
then
ing
acti
viti
es
I.B.4
Th
ere
is a
func
tion
al c
entr
al H
IS a
dmin
istr
ativ
e un
it r
espo
nsib
le fo
r
Cen
tral
uni
t is
C
entr
al u
nit
is
Cen
tral
uni
t ha
s ve
ry
Ther
e is
no
func
tion
ing
po
pula
tion
cen
suse
s an
d ho
useh
old
surv
eys
that
des
igns
, dev
elop
s
func
tion
al w
ith
func
tion
al b
ut la
cks
limit
ed fu
ncti
onal
ce
ntra
l adm
inis
trat
ive
an
d su
ppor
ts h
ealt
h-in
form
atio
n co
llect
ion,
man
agem
ent,
ana
lysi
s,
adeq
uate
res
ourc
es
adeq
uate
res
ourc
es
capa
city
and
und
er-
unit
in t
he m
inis
try
of
diss
emin
atio
n an
d us
e fo
r pl
anni
ng a
nd m
anag
emen
t
ta
kes
few
HIS
- he
alth
stre
ngth
enin
g ac
tivi
ties
I.B.5
A
t su
bnat
iona
l lev
els
(e.g
., re
gion
s/pr
ovin
ces
and
dist
rict
s) t
here
are
ye
s –
100
% o
f hea
lth
yes
– m
ore
than
50
%
Less
tha
n 50
% o
f N
o po
siti
ons
de
sign
ated
full-
tim
e he
alth
info
rmat
ion
offic
er p
osit
ions
and
the
y ar
e fil
led
offic
es a
t su
bnat
iona
l of
hea
lth
offic
es a
t he
alth
offi
ces
at s
ub-
leve
l hav
e a
desi
gnat
ed
subn
atio
nal l
evel
hav
e na
tion
al le
vel h
ave
a
an
d fil
led
full-
tim
e
a de
sign
ated
and
fille
d de
sign
ated
full-
tim
e
he
alth
info
rmat
ion
fu
ll-ti
me
heal
th in
for-
he
alth
info
rmat
ion
offic
er p
osit
ion
mat
ion
offic
er p
osit
ion
offic
er p
osit
ion
21
It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
3 2
1 0
I.B.6
H
IS c
apac
ity-
build
ing
acti
viti
es h
ave
take
n pl
ace
over
the
pas
t ye
ar fo
r
Suffi
cien
t ca
paci
ty-
Suffi
cien
t ca
paci
ty-
Lim
ited
cap
acit
y-
No
H
IS s
taff
of t
he m
inis
try
of h
ealt
h (s
tati
stic
s, s
oftw
are
and
data
base
bu
ildin
g ha
s ta
ken
build
ing,
but
larg
ely
build
ing
m
aint
enan
ce, a
nd/o
r ep
idem
iolo
gy) a
t na
tion
al a
nd s
ubna
tion
al le
vels
pl
ace
as p
art
of a
long
- de
pend
ent
upon
te
rm g
over
nmen
t-
exte
rnal
(e.g
., do
nor)
dr
iven
hum
an re
sour
ces
sup
port
and
inpu
t
de
velo
pmen
t pl
an
I.B.7
C
apac
ity-
build
ing
acti
viti
es h
ave
take
n pl
ace
over
the
pas
t ye
ar fo
r st
aff o
f Su
ffici
ent
capa
city
- Su
ffici
ent
capa
city
Li
mit
ed c
apac
ity-
N
o
the
nati
onal
sta
tist
ics
offic
e (s
tati
stic
s, a
nd s
oftw
are
and
data
base
bu
ildin
g ha
s ta
ken
build
ing,
but
larg
ely
build
ing
m
aint
enan
ce) a
t na
tion
al a
nd s
ubna
tion
al le
vels
pl
ace
as p
art
of a
long
- de
pend
ent
upon
term
gov
ernm
ent-
ex
tern
al (e
.g.,
dono
r)
driv
en h
uman
reso
urce
s s
uppo
rt a
nd in
put
deve
lopm
ent
plan
I.B.8
H
IS c
apac
ity-
build
ing
acti
viti
es h
ave
take
n pl
ace
over
the
pas
t ye
ar fo
r
Suffi
cien
t ca
paci
ty-
Suffi
cien
t ca
paci
ty-
Lim
ited
cap
acit
y-
No
he
alth
-fac
ility
sta
ff (o
n da
ta c
olle
ctio
n, s
elf-
asse
ssm
ent,
ana
lysi
s an
d
build
ing
has
take
n bu
ildin
g, b
ut la
rgel
y bu
ildin
g
pres
enta
tion
) pl
ace
as p
art
of a
long
- de
pend
ent
upon
term
gov
ernm
ent-
ex
tern
al (e
.g.,
dono
r)
driv
en h
uman
reso
urce
s s
uppo
rt a
nd in
put
deve
lopm
ent
plan
I.B.9
A
ssis
tanc
e is
ava
ilabl
e to
hea
lth
and
HIS
sta
ff a
t na
tion
al a
nd s
ubna
tion
al
Exce
llent
A
dequ
ate,
usu
ally
Li
mit
ed, d
oes
not
Not
ava
ilabl
e
leve
ls in
des
igni
ng, m
anag
ing
and
supp
orti
ng d
atab
ases
and
sof
twar
e
avai
labl
e fo
r oc
casi
onal
m
eet
the
need
s of
as
sist
ance
and
bac
k-up
st
aff f
or a
ssis
tanc
e
an
d su
ppor
t
I.B.1
0 A
ccep
tabl
e ra
te o
f hea
lth-
info
rmat
ion
staf
f tur
nove
r at
nat
iona
l lev
el in
Lo
w t
urno
ver,
not
a M
oder
ate
turn
over
Tu
rnov
er r
ate
is
Turn
over
rat
e is
th
e m
inis
try
of h
ealt
h pr
oble
m
but
man
agea
ble
prob
lem
atic
un
acce
ptab
ly h
igh
I.B.1
1 A
ccep
tabl
e ra
te o
f hea
lth-
info
rmat
ion
staf
f tur
nove
r at
nat
iona
l lev
el in
Lo
w t
urno
ver,
not
a M
oder
ate
turn
over
Tu
rnov
er r
ate
is
Turn
over
rat
e is
na
tion
al s
tati
stic
s of
fice
prob
lem
bu
t m
anag
eabl
e pr
oble
mat
ic
unac
cept
ably
hig
h
I. A
SS
ES
SIN
G N
AT
ION
AL
HIS
RE
SO
UR
CE
S
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
22
taBl
e i.B
– C
ontin
ued
It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
3 2
1 0
I.B.1
2 Th
ere
are
spec
ific
budg
et-l
ine
item
s w
ithi
n th
e na
tion
al b
udge
t fo
r va
riou
s
yes,
the
re a
re s
peci
fic
Nat
iona
l HIS
bud
get-
N
atio
nal H
IS b
udge
t-
Ther
e ar
e no
nat
iona
l
sect
ors
to p
rovi
de a
dequ
atel
y fo
r a
func
tion
ing
HIS
for
all r
elev
ant
data
bu
dget
-line
item
s w
ith-
lin
e it
ems
are
limit
ed
line
item
s ar
e lim
ited
H
IS b
udge
t-lin
e it
ems
so
urce
s in
the
min
istr
y of
hea
lth
in t
he n
atio
nal b
udge
t bu
t al
low
for
adeq
uate
an
d do
not
allo
w fo
r an
d th
e fu
ncti
onin
g of
to p
rovi
de a
dequ
atel
y fu
ncti
onin
g of
all
adeq
uate
func
tion
ing
mos
t re
leva
nt d
ata
for
a fu
ncti
onin
g H
IS
rele
vant
dat
a so
urce
s of
all
rele
vant
dat
a so
urce
s is
inad
equa
te
fo
r al
l rel
evan
t da
tas
so
urce
s
so
urce
s
I.B.1
3 Th
ere
are
spec
ific
budg
et-l
ine
item
s w
ithi
n th
e na
tion
al b
udge
t fo
r va
riou
s
yes,
the
re a
re s
peci
fic
Nat
iona
l sta
tist
ics
Nat
iona
l sta
tist
ics
Ther
e ar
e no
nat
iona
l
sect
ors
to p
rovi
de a
dequ
atel
y fo
r a
func
tion
ing
stat
isti
cs s
yste
m fo
r al
l dat
a
budg
et-l
ine
item
s w
ith-
bu
dget
-lin
e it
ems
are
budg
et-l
ine
item
s ar
e st
atis
tics
bud
get-
line
so
urce
s in
the
nat
iona
l sta
tist
ics
offic
e in
the
nat
iona
l bud
get
lim
ited
but
allo
w fo
r lim
ited
and
do
not
item
s an
d th
e
to
pro
vide
ade
quat
ely
ad
equa
te fu
ncti
onin
g al
low
for
adeq
uate
fu
ncti
onin
g of
mos
t
fo
r a
func
tion
ing
of
all
rele
vant
dat
a fu
ncti
onin
g of
all
rele
vant
dat
a so
urce
s
st
atis
tics
sys
tem
for
all
sour
ces
rele
vant
dat
a so
urce
s is
inad
equa
te
re
leva
nt d
ata
sour
ces
taBl
e i.c
– a
sses
sinG
nat
iona
l His
res
oUrc
es:in
fras
truc
ture
It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
3 2
1 0
I.C.1
R
ecor
ding
form
s, p
aper
, pen
cils
and
oth
er s
uppl
ies
that
are
nee
ded
for
ye
s, r
ecor
ding
form
s,
Occ
asio
nally
the
re a
re
Ther
e ar
e “s
tock
-out
s”
The
heal
th s
ervi
ce is
re
cord
ing
heal
th s
ervi
ces
and
dise
ase
info
rmat
ion
are
avai
labl
e pa
per,
penc
ils a
nd
“sto
ck-o
uts”
of
of r
ecor
ding
form
s,
not
able
to
mee
t
ot
her
supp
lies
are
re
cord
ing
form
s, p
aper
, pa
per,
penc
ils a
nd
repo
rtin
g re
quir
emen
ts
al
way
s av
aila
ble
for
pe
ncils
and
oth
er
othe
r su
pplie
s w
hich
du
e to
a la
ck o
f
re
cord
ing
requ
ired
su
pplie
s bu
t th
is d
oes
affe
ct t
he r
ecor
ding
of
reco
rdin
g fo
rms,
pap
er,
info
rmat
ion
no
t aff
ect t
he r
ecor
ding
re
quir
ed in
form
atio
n pe
ncils
and
oth
er
of r
equi
red
info
rmat
ion
su
pplie
s
23
It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
3 2
1 0
I.C.2
R
ecor
ding
form
s, p
aper
, pen
cils
and
sup
plie
s th
at a
re n
eede
d fo
r re
port
ing
ye
s, r
ecor
ding
form
s,
Occ
asio
nally
the
re a
re
Ther
e ar
e “s
tock
-out
s”
Hea
lth
serv
ice
is n
ot
vita
l sta
tist
ics
are
avai
labl
e pa
per,
penc
ils a
nd
“sto
ck-o
uts”
of
of r
ecor
ding
form
s,
able
to
mee
t re
port
ing
othe
r su
pplie
s ar
e
reco
rdin
g fo
rms,
pap
er,
pape
r, pe
ncils
and
re
quir
emen
ts d
ue t
o a
alw
ays
avai
labl
e fo
r
penc
ils a
nd o
ther
ot
her
supp
lies
whi
ch
lack
of r
ecor
ding
form
s,
reco
rdin
g re
quir
ed
supp
lies
but
this
doe
s af
fect
the
rec
ordi
ng o
f pa
per,
penc
ils a
nd
in
form
atio
n
not a
ffec
t the
rec
ordi
ng
requ
ired
info
rmat
ion
othe
r su
pplie
s
of r
equi
red
info
rmat
ion
I.C.3
C
ompu
ters
are
ava
ilabl
e at
the
rel
evan
t of
fices
at
nati
onal
, reg
iona
l/
yes,
all
rele
vant
offi
ces
Som
e re
leva
nt d
istr
ict
Som
e re
leva
nt
No,
onl
y re
leva
nt
prov
inci
al a
nd d
istr
ict
leve
ls t
o pe
rmit
the
rap
id c
ompi
lati
on o
f sub
nati
onal
at
dis
tric
t, r
egio
nal/
of
fices
and
mos
t re
gion
al/p
rovi
ncia
l na
tion
al o
ffice
s ha
ve
data
pr
ovin
cial
and
nat
iona
l na
tion
al a
nd r
egio
nal/
of
fices
and
the
co
mpu
ters
for
this
le
vels
hav
e co
mpu
ters
pr
ovin
cial
offi
ces
have
m
ajor
ity
of n
atio
nal
purp
ose
for
this
pur
pose
co
mpu
ters
for
this
of
fices
hav
e co
mpu
ters
pu
rpos
e
for
this
pur
pose
I.C.4
A
bas
ic IC
T in
fras
truc
ture
(tel
epho
nes,
inte
rnet
acc
ess
and
e-m
ail)
is in
ye
s, b
asic
ICT
infr
a-
Bas
ic IC
T in
fras
truc
ture
B
asic
ICT
infr
astr
uctu
re
Bas
ic IC
T in
fras
truc
ture
pl
ace
at n
atio
nal,
regi
onal
/pro
vinc
ial a
nd d
istr
ict
leve
ls
stru
ctur
e is
in p
lace
at
is
in p
lace
at
nati
onal
is
in p
lace
at
nati
onal
is
in p
lace
onl
y at
nati
onal
, reg
iona
l/
leve
l; m
ore
than
50
%
leve
l; bu
t le
ss t
han
nati
onal
leve
l
pr
ovin
cial
and
dis
tric
t
at r
egio
nal/
prov
inci
al
50%
at
regi
onal
/
le
vels
le
vel;
but
less
tha
n
prov
inci
al a
nd d
istr
ict
50
% a
t di
stri
ct le
vel
leve
ls
I.C.5
Su
ppor
t fo
r IC
T eq
uipm
ent
mai
nten
ance
is a
vaila
ble
at n
atio
nal,
regi
onal
/ ye
s, t
here
is s
uppo
rt
Ther
e is
sup
port
for
Ther
e is
sup
port
for
Ther
e is
sup
port
for
pr
ovin
cial
and
dis
tric
t le
vels
fo
r IC
T eq
uipm
ent
IC
T eq
uipm
ent
ICT
equi
pmen
t IC
T eq
uipm
ent
mai
nten
ance
at
m
aint
enan
ce a
t m
aint
enan
ce a
t m
aint
enan
ce a
t
na
tion
al, r
egio
nal/
na
tion
al le
vel;
mor
e na
tion
al le
vel;
but
less
na
tion
al le
vel o
nly
prov
inci
al a
nd d
istr
ict
th
an 5
0%
at
regi
onal
/ th
an 5
0%
at
regi
onal
/
le
vels
pr
ovin
cial
leve
l; bu
t
prov
inci
al a
nd d
istr
ict
le
ss t
han
50%
at
le
vels
di
stri
ct le
vel
I. A
SS
ES
SIN
G N
AT
ION
AL
HIS
RE
SO
UR
CE
S
25
II. Assessing national HIS indicators[Table II]
The boundaries of a national HIS are not confined to the health sector alone and overlap with information systems in other fields. In addition, data is required for various needs, including information for improving the provision of services to individual clients, statistics for planning and managing health services, and measurements for formulating and assess-ing health policy. For each of the three major domains of measurement shown in Fig. 3, core indicators are required to track progress and assess change.
Fig. 3 Domains of measurement for health information systems
Determinants of health
• Socioeconomic and demographic factors • Environmental and behavioural risk factors
Health system
Health status
• Mortality • Morbidity/ disability • Well-being
Inputs • Policy • Financing • Human resources • Organization and management
Outputs • Information • Service availability and quality
Outcomes • Service coverage • Utilization
n Determinants of health – indicators include socioeconomic, environmental, behavioural, demographic and genetic determinants or risk factors. Such indicators characterize the contextual environments in which the health system operates. Much of the information is generated through other sectors, such as agriculture, environment and labour.
n Health system – indicators include inputs to the health system and related processes such as policy, organization, human and financial resources, health infrastructure, equip-ment and supplies. There are also output indicators such as health service availability and quality, as well as information availability and quality. Finally there are immediate health system outcome indicators such as service coverage and utilization.
n Health status – indicators include levels of mortality, morbidity, disability and well-being. Health status variables depend upon the efficacy and coverage of interventions and deter-minants of health that may influence health outcomes independently of health service coverage. Health status indicators should be available stratified or disaggregated by vari-ables such as sex, socioeconomic status, ethnic group and geographical location in order
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
26
to capture the patterns of health in the population and to permit analysis of inequities in health.
The core indicators selected should reflect changes over time in each of the three domains. As with any indicator, health indicators should be valid, reliable, specific, sensitive and feasible/affordable to measure. They must also be relevant and useful for decision-making at data-collection levels, or where a clear need exists for data at higher levels. The precise indicators used and their number will vary according to the epidemiological profile and development needs of individual countries.
If carefully selected and regularly reviewed, the use of core indicators are a vital part of national HIS strengthening and can be viewed as the backbone of the system, providing the minimum information package needed to support macro and micro health system func-tions. All countries therefore need a nationally defined minimum set of health indicators used regularly in national programme planning, monitoring and evaluation.
Although health indicators are needed to monitor local and national priorities, indicator definitions must also meet international technical standards. Moreover, national indicators should be consistently linked and harmonized with key indicators in major international and global initiatives, such as the MDGs,1 GFATM and GAVI. Core health indicators and related data-collection strategies should also be linked to a broader national statistics strategy, and notably a poverty-monitoring master plan in countries with a poverty-reduction strat-egy paper (PRSP). National and international stakeholders should therefore take part in defining core indicators, and targets set for the number of indicators that match national plans or international goals.
1 http://www.who.int/mdg/publications/mdg_report/en/index.html
27
taBl
e ii
– as
sess
inG
nati
onal
His
inDi
cato
rs
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
3 2
1 0
II.1
Nat
iona
l min
imum
cor
e in
dica
tors
hav
e be
en id
enti
fied
for
nati
onal
and
ye
s, m
inim
um c
ore
Min
imum
cor
e P
roce
ss in
itia
ted
–
Pro
cess
not
init
iate
d –
su
bnat
iona
l lev
els,
cov
erin
g al
l cat
egor
ies
of h
ealt
h in
dica
tors
in
dica
tors
are
in
dica
tors
are
D
iscu
ssio
ns a
re u
nder
N
o m
inim
um in
dica
tors
(d
eter
min
ants
of h
ealt
h; h
ealt
h sy
stem
inpu
ts, o
utpu
ts a
nd o
utco
mes
; and
id
enti
fied
at n
atio
nal
iden
tifie
d at
nat
iona
l w
ay t
o id
enti
fy
nor
data
set
iden
tifie
d
heal
th s
tatu
s)
and
subn
atio
nal l
evel
s
and
subn
atio
nal l
evel
s es
sent
ial i
ndic
ator
s
an
d co
ver
all
but
they
do
not
cove
r
ca
tego
ries
al
l cat
egor
ies
II.2
Ther
e is
a c
lear
and
exp
licit
offi
cial
str
ateg
y fo
r m
easu
ring
eac
h of
the
ye
s, a
ll th
e ap
prop
riat
e N
ot a
ll, b
ut a
t le
ast
At
leas
t on
e bu
t le
ss
Non
e of
the
MD
G
heal
th-r
elat
ed M
DG
indi
cato
rs r
elev
ant
to t
he c
ount
ry
heal
th-r
elat
ed M
DG
50
% o
f the
hea
lth-
th
an 5
0%
of t
he
heal
th-r
elat
ed
in
dica
tors
are
incl
uded
re
late
d M
DG
indi
cato
rs
appr
opri
ate
MD
G
indi
cato
rs a
re in
clud
ed
in
the
min
imum
cor
e
are
incl
uded
in t
he
indi
cato
rs a
re in
clud
ed
in t
he m
inim
um c
ore
indi
cato
r se
t m
inim
um c
ore
in
the
min
imum
cor
e in
dica
tor
set
in
dica
tor
set
indi
cato
r se
t
II.3
Cor
e in
dica
tors
are
defi
ned
in c
olla
bora
tion
wit
h al
l key
sta
keho
lder
s
yes,
all
the
rele
vant
R
elev
ant
min
istr
ies
Col
labo
rati
on
No,
eac
h pr
ogra
mm
e
(e.g
., m
inis
try
of h
ealt
h (M
oH),
nati
onal
sta
tist
ics
offic
e (N
SO),
othe
r
stak
ehol
ders
an
d th
e N
SO a
re
betw
een
the
MoH
, the
re
ques
ts d
ata
re
leva
nt m
inis
trie
s, p
rofe
ssio
nal o
rgan
izat
ions
, sub
nati
onal
exp
erts
and
co
llabo
rate
d in
the
in
volv
ed b
ut m
ore
subn
atio
nal l
evel
and
ac
cord
ing
to o
wn
m
ajor
dis
ease
-foc
used
pro
gram
mes
) se
lect
ion
of t
he c
ore
ex
tern
al p
arti
cipa
tion
so
me
dise
ase
requ
irem
ents
indi
cato
rs
wou
ld b
e de
sira
ble
prog
ram
mes
but
no
invo
lvem
ent
of t
he N
SO
II.4
Cor
e in
dica
tors
hav
e be
en s
elec
ted
acco
rdin
g to
exp
licit
cri
teri
a in
clud
ing
ye
s, t
he c
ore
indi
cato
rs
Mos
tly
– bu
t no
t al
l Th
ere
are
guid
elin
es
Ther
e ar
e no
gui
delin
es
usef
ulne
ss, s
cien
tific
sou
ndne
ss, r
elia
bilit
y, r
epre
sent
ativ
enes
s, fe
asib
ility
ha
ve b
een
sele
cted
cr
iter
ia fo
r se
lect
ion
but
they
do
not
or e
xplic
it c
rite
ria
for
an
d ac
cess
ibili
ty
acco
rdin
g to
exp
licit
w
ere
clea
r an
d ex
plic
it
incl
ude
expl
icit
cri
teri
a th
e se
lect
ion
of
cr
iter
ia in
clud
ing
for
the
sele
ctio
n of
in
dica
tors
usef
ulne
ss, s
cien
tific
indi
cato
rs
so
undn
ess,
rel
iabi
lity
repr
esen
tati
vene
ss,
feas
ibili
ty, a
nd
acce
ssib
ility
II.5
Rep
orti
ng o
n th
e m
inim
um s
et o
f cor
e in
dica
tors
occ
urs
on a
reg
ular
bas
is
Rep
orti
ng is
reg
ular
Rep
orti
ng is
irre
gula
r R
epor
ting
is v
ery
limit
ed
(e
.g.,
annu
al o
r bi
annu
al)
and
inco
mpl
ete
II.
AS
SE
SS
ING
NA
TIO
NA
L H
IS I
ND
ICA
TO
RS
29
III. Assessing national HIS data sources[Tables III.A–F]
The national HIS should draw upon a set of key data sources. The role and contribution of each source will vary due to overlap in the type of information best collected by each source. In many cases, measurement of the same indicators with data from multiple sources may contribute to better-quality information while maintaining efficiency. In other cases, it is more efficient to avoid duplication. The optimal choice will depend upon a range of factors including epidemiology, specific characteristics of the measurement instrument, cost and capacity considerations, and programme needs. In addition, each source may generate data on a range of indicators. The frequency and mode of data collection will depend upon the likelihood of change and the ability of the indicator to detect this change over time. In all settings an appropriate combination of data sources should be used to provide the priority information required.
The selection of data sources should also be based upon assessments of feasibility, perio-dicity, cost-effectiveness and sustainability. Periodicity of measurement depends on the likely speed of change of the indicator and the costs of generating it. Determining which items of information are most appropriately generated through routine health information systems – and which require special surveys – should be a central feature of the national HIS strategic plan.
As shown in Fig. 4, national HIS data are usually generated either directly from populations or from the operations of health and other institutions.
n Population-based sources generate data on all individuals within defined populations and can include total population counts (such as the census and civil registration) and data on representative populations or subpopulations (such as household and other population surveys). Such data sources can either be continuous and generated from administrative records (such as civil registers) or periodic (such as cross-sectional household surveys).
n Institution-based sources generate data as a result of administrative and operational activities. These activities are not confined to the health sector and include police records (such as reports of accidents or violent deaths), occupational reports (such as work-related injuries), and food and agricultural records (such as levels of food production and distribu-tion). Within the health sector, the wide variety of health service data includes morbidity and mortality data among people using services; services delivered; drugs and commodi-ties provided; information on the availability and quality of services; case reporting; and resource, human, financial and logistics information.
A. Censuses – ideally carried out at least once every 10 years with results made available within 2 years of the data being collected. Unfortunately, only a small number of questions may be included on a census questionnaire, and the data are often of variable quality. To assess census-data quality, it is standard practice to conduct a post enumeration survey (PES) during which the census questionnaire is re-administered to a small sample of the population. If civil registration captures less than 90% of deaths, then including fertility and mortality topics in a population census is particularly important.
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
30
B. Civil registration – refers to the comprehensive ongoing monitoring of births and deaths by age and sex, and with attribution of the cause of death. The gold standard is a system that provides a complete record of all births and deaths with medically certified causes of death. Achieving the gold standard may not be attainable in many developing countries for the foreseeable future. The use of a sample registration system (SRS) has been shown to be effective in bringing about improvements in the relatively short term. In the near future, packages such as sample vital registration with verbal autopsy (SAVVy) could considerably improve knowledge about basic health statistics in a population. A Demographic Surveil-lance System (DSS) may also provide a data source for continuous surveillance of births and cause-specific mortality. Novel approaches use a hybrid set of consolidated methods based on demographic surveillance; sample registration; and the periodic use of sample cause-of-death modules using verbal autopsy within household surveys.
C. Population surveys – the gold standard is a well-integrated demand-driven household survey programme that is part of the national HIS, and which generates regular essen-tial high-quality information on populations, health and socioeconomic status. Whether national or part of an international survey programme, international standards and norms must be adhered to. More recently, population-based surveys have also been the vehi-cle for biological and clinical data collection (health examination surveys), providing much more accurate and reliable data on health outcomes than self-reports.
D. Individual records – include individual health records (for example, growth monitoring, antenatal, delivery outcome) and disease records (consultation, discharge) routinely pro-duced by health workers as well as by special disease registries. One of the most important functions of these records is to support the quality and continuity of care of individual patients.
E. Service records – capture information on the number of clients provided with various services and on the commodities used. To the extent possible, the national HIS should capture service statistics from the private sector as well as communities and civil society organizations. Such records also include reports of notifiable conditions, diseases or health events of such priority and public health significance that they require enhanced reporting through surveillance systems and an immediate public health response. Integrating report-ing for disease surveillance and monitoring of focused public health programmes reduces
Fig 4. Health information data sources
Institution-based Population-based
Censuses
PopulationSurveys
Resource Records
Service Records
Civil Registration
Individual Records
31
the burden on those completing or reviewing reports and increases the likelihood that information will be acted on.
F. Resource records – a related component of service records concerned with the qual-ity, availability and logistics of health service inputs and key health services. This includes information on the density and distribution of health facilities, human resources for health, drugs and other core commodities and key services. The minimum requirement is a data-base of health facilities and the key services they are providing. The next level of develop-ment of this aspect of the national HIS involves the mapping of facilities, human resources, core commodities and key services at national and district levels. Mapping the availability of specific interventions can provide important information from an equity perspective, and can help promote efforts to ensure that needed interventions reach peripheral areas and do not remain concentrated in urban centres. For the purposes of policy develop-ment and strategic planning, financial information is compiled using the National Health Account (NHA) methodology. The NHA provides information on the financial resources for health, and on the flow of these resources across the health system. In the case of resource records (Table III.F) there are four subgroups:
n Infrastructure and health services;
n Human resources;
n Financing and expenditure for health; and
n Equipment supplies and commodities.
criteria for assessment of data sources
Tables III.A–F respectively provide the assessment criteria and standards for each of the six types of data source (A–F) outlined above and shown in Fig. 4. For all sources, a set of common principles applies. These include the need for procedures to ensure data quality (such as standard definitions, appropriate data-collection methods, metadata and data audit trail, use of routine procedures to correct bias and confounding, and the availability of primary data). In addition, standards for obtaining consent and ensuring confidentiality in data collection and use must be maintained.1
As shown in Tables III.A–F each of the six types of data source are assessed against the following four key criteria of data collection and use:
1. Contents
n events or measures of public health importance identified explicitly and captured by the data source;
n data elements defined (for example, case definitions of notifiable conditions) and defini-tions consistent with global standards used (for example, with HMN standards);
n appropriate data-collection method used; and
n cost-efficiency and effectiveness issues considered.
1 Guidance available in this area includes the OECD Guidelines on the Protection of Privacy and Transborder Flows of Personal Data. http://www.oecd.org/document/18/0,2340,en_2649_34255_1815186_1_1_1_1,00.html
III.
AS
SE
SS
ING
NA
TIO
NA
L H
IS D
ATA
SO
UR
CE
S
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
32
2. Capacity and practices
n country capacity exists to collect data and manage and analyse the results;
n standards applied to data collection; and
n documentation available, accessible and of high quality.
3. Dissemination
n analysis of results available and disseminated;
n microdata available for public access; and
n metadata available.
4. Integration and use
n the number of reports required and surveys conducted are kept to an optimal level through agreements on indicators and the harmonized design of formats and question-naires;
n results from different data-collection methods are compared; and
n appropriate methods are used to estimate need and coverage.
33
III.
AS
SE
SS
ING
NA
TIO
NA
L H
IS D
ATA
SO
UR
CE
S
taBl
e iii
.a –
ass
essi
nG n
atio
nal H
is D
ata
soUr
ces:
cen
suse
sco
re d
imen
sio
ns
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
3
2 1
0
III.A
.1
A.1
.1: M
orta
lity
ques
tion
s w
ere
incl
uded
in t
he la
st c
ensu
s:
Que
stio
ns t
o es
tim
ate
Que
stio
ns t
o es
tim
ate
Onl
y qu
esti
ons
to
No
mor
talit
y qu
esti
ons
Co
nte
nts
•
ques
tion
sto
est
imat
ech
ildm
orta
lity
–ch
ildre
nev
erb
orn
ch
ildm
orta
lity
and
child
mor
talit
yan
des
tim
ate
child
and
child
ren
still
aliv
e;
ques
tion
s to
est
imat
e qu
esti
ons
to e
stim
ate
mor
talit
y, o
r on
ly
•qu
esti
ons
toe
stim
ate
adul
tm
orta
lity
–ho
useh
old
deat
hsin
ad
ult
mor
talit
y,p
aire
dad
ult
mor
talit
yqu
esti
ons
toe
stim
ate
the
past
12
(or
24) m
onth
s in
clud
ing
sex
of d
ecea
sed
and
by
que
stio
ns
ad
ult
mor
talit
y
ag
e-at
-dea
th
conc
erni
ng in
jury
and
pr
egna
ncy-
rela
ted
N
ote
: Ski
p th
is q
uest
ion
if ci
vil r
egis
trat
ion
cove
rs a
t le
ast
90%
of
deat
hs
deat
hs
III.A
.2
A.2
.1: T
he c
ount
ry h
as a
dequ
ate
capa
city
to
: (1)
impl
emen
t da
ta
Ade
quat
e ca
paci
ty fo
r A
dequ
ate
capa
city
for
Ade
quat
e ca
paci
ty
Ade
quat
e ca
paci
ty fo
r C
apac
ity
&
colle
ctio
n; (
2) p
roce
ss t
he d
ata;
and
(3) a
naly
se t
he d
ata
all 3
2
of t
he 3
fo
r on
ly 1
of t
he 3
no
ne o
f the
3p
ract
ices
A
.2.2
: A c
ensu
s w
as c
arri
ed o
ut in
the
pas
t 10
yea
rs
yes
No
A
.2.3
: A P
ost
enum
erat
ion
surv
ey (P
ES) h
as b
een
com
plet
ed a
nd
PES
und
erta
ken
and
PES
und
erta
ken
and
PES
und
erta
ken
but
No
PES
und
erta
ken
a
wri
tten
rep
ort
is a
vaila
ble
and
wid
ely
dist
ribu
ted
repo
rt is
ava
ilabl
e on
pr
inte
d re
port
is
no r
epor
t av
aila
ble
th
e w
eb
avai
labl
e
A
.2.4
: Eva
luat
ion
of c
ompl
eten
ess
of a
dult
mor
talit
y da
ta fr
om
Eval
uati
on h
as b
een
Ev
alua
tion
has
bee
n N
o ev
alua
tion
th
e la
st c
ensu
s ha
s be
en u
nder
take
n an
d th
e re
sult
s pu
blis
hed
un
dert
aken
and
the
unde
rtak
en b
ut t
he
alon
g w
ith
the
publ
ishe
d m
orta
lity
stat
isti
cs
resu
lts
publ
ishe
d
resu
lts
have
not
bee
n
alon
g w
ith
the
pu
blis
hed
N
ote
: Ski
p th
is q
uest
ion
if th
e la
st c
ensu
s di
d no
t in
clud
e qu
esti
ons
pu
blis
hed
mor
talit
y
on a
dult
mor
talit
y (h
ouse
hold
dea
ths)
st
atis
tics
III.A
.3
A.3
.1: A
rep
ort
incl
udin
g de
scri
ptiv
e st
atis
tics
(age
, sex
, res
iden
ce
All
dist
rict
s (lo
wes
t A
ll re
gion
s/pr
ovin
ces
Cen
tral
/nat
iona
l N
ot a
vaila
ble
Dis
sem
inat
ion
by
sm
alle
st a
dmin
istr
ativ
e le
vel)
from
the
mos
t re
cent
cen
sus
is
adm
inis
trat
ive
heal
th
(inte
rmed
iate
he
alth
offi
cial
s ha
ve
avai
labl
e an
d w
idel
y di
stri
bute
d (o
nlin
e or
pap
er c
opy)
of
fices
) hav
e
adm
inis
trat
ive
heal
th
imm
edia
te a
cces
s
imm
edia
te a
cces
s of
fices
) hav
e im
med
iate
ac
cess
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
34
taBl
e iii
.a –
Con
tinue
dC
ore
dim
ensi
on
s It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
3
2 1
0
A
.3.2
: Lag
bet
wee
n th
e ti
me
that
dat
a w
ere
colle
cted
and
the
Le
ss t
han
2 ye
ars
2
or 3
yea
rs
4 or
5 y
ears
N
o ce
nsus
res
ults
ti
me
that
des
crip
tive
sta
tist
ics
(age
, sex
, res
iden
ce b
y en
umer
atio
n
av
aila
ble
for
at le
ast
ar
ea) w
ere
publ
ishe
d
10 y
ears
A
.3.3
: Acc
urat
e po
pula
tion
pro
ject
ions
by
age
and
sex
are
A
ccur
ate
proj
ecti
ons
Acc
urat
e pr
ojec
tion
s A
ccur
ate
proj
ecti
ons
No
proj
ecti
ons
for
av
aila
ble
for
smal
l are
as (d
istr
icts
or
belo
w) f
or t
he c
urre
nt y
ear
are
avai
labl
e fo
r th
e ar
e av
aila
ble
for
are
avai
labl
e fo
r cu
rren
t ye
ar, o
r
smal
lest
adm
inis
trat
ive
dist
rict
s re
gion
s/pr
ovin
ces
proj
ecti
ons
are
not
N
ote
: Ski
p th
is q
uest
ion
if no
cen
sus
resu
lts
avai
labl
e fo
r m
ore
le
vel
cons
ider
ed t
o be
th
an 1
0 ye
ars
ac
cura
te
A
.3.4
: Mic
roda
ta a
re a
vaila
ble
for
publ
ic a
cces
s A
vaila
ble
on r
eque
st
Ava
ilabl
e on
req
uest
Not
ava
ilabl
e
w
ith
rest
rict
ions
N
ote
: Ski
p th
is q
uest
ion
if no
cen
sus
resu
lts
avai
labl
e fo
r m
ore
th
an 1
0 ye
ars
III.A
.4
A.4
.1: P
opul
atio
n pr
ojec
tion
s ar
e us
ed fo
r th
e es
tim
atio
n of
P
roje
ctio
ns u
sed
by
Pro
ject
ions
use
d by
P
roje
ctio
ns u
sed
at
Pop
ulat
ion
proj
ecti
ons
Inte
grat
ion
&
cove
rage
and
pla
nnin
g of
hea
lth
serv
ices
m
ost
sub
dist
rict
s m
ost
dist
rict
s na
tion
al a
nd/o
r ar
e no
t us
ed fo
r he
alth
use
re
gion
al/p
rovi
ncia
l
No
te: S
kip
this
que
stio
n if
no c
ensu
s re
sult
s av
aila
ble
for
mor
e
leve
ls
than
10
year
s
35
taBl
e iii
.B –
ass
essi
nG n
atio
nal H
is D
ata
soUr
ces:
civ
il re
gist
ratio
nC
ore
dim
ensi
on
s It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
3
2 1
0
III.B
.1
B.1
.1: T
here
is a
rel
iabl
e so
urce
of n
atio
nwid
e vi
tal s
tati
stic
s: c
ivil
Nat
ionw
ide
civi
l Sa
mpl
e R
egis
trat
ion
Dem
ogra
phic
Th
ere
is n
o re
liabl
e C
on
ten
ts
regi
stra
tion
; Sam
ple
Reg
istr
atio
n Sy
stem
(SR
S); o
r D
emog
raph
ic
regi
stra
tion
Sy
stem
Su
rvei
llanc
e Sy
stem
so
urce
Su
rvei
llanc
e Sy
stem
(DSS
)
B
.1.2
: Cov
erag
e of
dea
ths
regi
ster
ed t
hrou
gh c
ivil
regi
stra
tion
90
% o
r m
ore
70–8
9%
50–6
9%
Less
tha
n 50
%
B
.1.3
: Cau
se-o
f-de
ath
info
rmat
ion
is r
ecor
ded
on t
he d
eath
90
% o
r m
ore
70–8
9%
50–6
9%
Less
tha
n 50
%
regi
stra
tion
form
if c
ivil
regi
stra
tion
is in
pla
ce
No
te: S
kip
this
item
if c
ivil
regi
stra
tion
is n
ot in
pla
ce
III.B
.2
B.2
.1: T
he c
ount
ry h
as a
dequ
ate
capa
city
to
: (1)
impl
emen
t da
ta
Ade
quat
e ca
paci
ty fo
r A
dequ
ate
capa
city
for
Ade
quat
e ca
paci
ty fo
r A
dequ
ate
capa
city
for
Cap
acit
y &
co
llect
ion
; (2)
pro
cess
the
dat
a; a
nd (3
) ana
lyse
the
dat
a fr
om c
ivil
all 3
2
of t
he 3
on
ly 1
of t
he 3
no
ne o
f the
3p
ract
ices
re
gist
rati
on o
r SR
S or
DSS
B
.2.2
: Fre
quen
cy o
f the
ass
essm
ent
of c
ompl
eten
ess
of c
ivil
Ea
ch t
ime
cens
us is
Ea
ch t
ime
cens
us is
Le
ss p
erio
dica
lly
Nev
er c
ondu
cted
or
re
gist
rati
on
cond
ucte
d (e
very
co
nduc
ted
than
cen
sus
do n
ot k
now
5
–10
year
s)
B
.2.3
: The
Inte
rnat
iona
l Sta
tist
ical
Cla
ssifi
cati
on o
f Dis
ease
s an
d
ICD
-10
deta
iled
Tabu
lati
on L
ist
ICD
-10
ICD
-9
No
ICD
use
d or
ICD
-8 o
r
Rel
ated
Hea
lth
Pro
blem
s (IC
D) i
s cu
rren
tly
in u
se fo
r ca
use-
of-d
eath
earl
ier
or t
here
is n
o
regi
stra
tion
caus
e-of
-dea
th
re
gist
rati
on
No
te: S
core
0 if
the
re is
no
caus
e-of
-dea
th r
egis
trat
ion
B
.2.4
: Pro
port
ion
of a
ll de
aths
cod
ed t
o ill
-defi
ned
caus
es (%
) Le
ss t
han
5%
5–1
0%
11
–19%
20
% o
r m
ore
(g
arba
ge c
odes
)
N
ote
: Ski
p th
is it
em if
the
re is
no
caus
e-of
-dea
th r
egis
trat
ion
B
.2.5
: Pub
lishe
d st
atis
tics
from
civ
il re
gist
rati
on o
r SR
S ar
e
All
3
2 of
3
1 of
3
Non
e of
3, o
r th
ere
is n
o
disa
ggre
gate
d by
: (1)
sex
; (2)
age
; and
(3) g
eogr
aphi
cal o
r
ci
vil r
egis
trat
ion
and
ad
min
istr
ativ
e re
gion
(or
urba
n/r
ural
)
no S
RS
N
ote
: Sco
re 0
if t
here
is n
o ci
vil r
egis
trat
ion
or S
RS
III.
AS
SE
SS
ING
NA
TIO
NA
L H
IS D
ATA
SO
UR
CE
S
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
36
taBl
e iii
.B –
Con
tinue
dC
ore
dim
ensi
on
s It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
3
2 1
0
B
.2.6
: Sam
ple
Reg
istr
atio
n Sy
stem
(SR
S) d
evel
oped
and
gen
erat
ing
N
atio
nally
Par
tial
ly
Non
e
tim
ely
and
accu
rate
dat
a re
pres
enta
tive
repr
esen
tati
ve
N
ote
: Ski
p th
is it
em if
the
re is
no
SRS
B
.2.7
: Dem
ogra
phic
Sur
veill
ance
Sys
tem
(DSS
) sit
es d
evel
oped
and
Par
tial
ly r
epre
sent
ativ
e N
on-r
epre
sent
ativ
e N
one
ge
nera
ting
tim
ely
and
accu
rate
dat
a
(at
leas
t 1
urba
n an
d
2
rura
l sit
es)
N
ote
: Ski
p th
is it
em if
the
re is
no
DSS
B
.2.8
: Ver
bal a
utop
sy (V
A) t
ool
VA t
ool v
alid
ated
; VA
too
l val
idat
ed
VA t
ool n
ot v
alid
ated
N
o ve
rbal
aut
opsy
use
d
ques
tion
nair
e pu
blic
ly
by S
RS
and
/or
DSS
N
ote
: Ski
p th
is it
em if
the
re is
no
DSS
or
SRS
avai
labl
e an
d co
nsis
tent
wit
h in
tern
atio
nal
st
anda
rds
III.B
.3
B.3
.1: L
ag b
etw
een
the
tim
e th
at d
ata
wer
e co
llect
ed a
nd t
he t
ime
Less
tha
n 3
year
s 3
year
s 4
or 5
yea
rs
Mor
e th
an 5
yea
rs o
r D
isse
min
atio
n
that
sta
tist
ics
from
civ
il re
gist
rati
on/S
RS/
DSS
wer
e pu
blis
hed
st
atis
tics
not
pub
lishe
d
or
no
vita
l sta
tist
ics
N
ote
: Sco
re 0
if t
here
is n
o ci
vil r
egis
trat
ion
or S
RS
or D
SS
sy
stem
(civ
il re
gist
ratio
n,
SRS,
DSS
) exi
sts
III.B
.4
B.4
.1: I
nfor
mat
ion
from
civ
il re
gist
rati
on/S
RS/
DSS
on
: (1)
mor
talit
y B
oth
mor
talit
y ra
tes
1 of
2 u
sed
Not
use
d or
sta
tist
ics
Inte
grat
ion
ra
tes;
and
(2) c
ause
s of
dea
th is
use
d fo
r na
tion
al a
nd s
ubna
tion
al
and
caus
e-of
-dea
th
not
publ
ishe
d or
no
& U
se
anal
ysis
in
form
atio
n ar
e us
ed
vita
l sta
tist
ics
syst
em
(c
ivil
regi
stra
tion
, SR
S,
No
te: S
core
0 if
the
re is
no
civi
l reg
istr
atio
n or
SR
S or
DSS
DSS
) exi
sts
37
taBl
e iii
.c –
ass
essi
nG n
atio
nal H
is D
ata
soUr
ces:
Pop
ulat
ion
surv
eys
Co
re d
imen
sio
ns
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
3
2 1
0
III.C
.1
C.1
.1: I
n th
e pa
st 5
yea
rs, a
nat
iona
lly r
epre
sent
ativ
e su
rvey
has
ye
s
N
o C
on
ten
ts
mea
sure
d th
e pe
rcen
tage
of t
he r
elev
ant
popu
lati
on r
ecei
ving
key
mat
erna
l and
chi
ld h
ealt
h se
rvic
es (e
.g.,
fam
ily p
lann
ing,
ant
enat
al
ca
re, p
rofe
ssio
nally
att
ende
d de
liver
ies,
imm
uniz
atio
n)
C
.1.2
: In
the
past
5 y
ears
, a n
atio
nally
rep
rese
ntat
ive
surv
ey h
as
yes
No
pr
ovid
ed s
uffic
ient
ly p
reci
se a
nd a
ccur
ate
esti
mat
es o
f inf
ant
and
un
der-
5 m
orta
lity
C
.1.3
: In
the
past
5 y
ears
, nat
iona
lly r
epre
sent
ativ
e po
pula
tion
- ye
s, n
atio
nally
Su
rvey
s ha
ve n
ot
In t
he p
ast
5 ye
ars,
N
o po
pula
tion
-bas
ed
base
d su
rvey
(s) h
ave
mea
sure
d th
e pr
eval
ence
of s
ome
prio
rity
re
pres
enta
tive
sur
veys
m
easu
red
any
popu
lati
on-b
ased
su
rvey
s ha
ve b
een
no
ncom
mun
icab
le d
isea
ses/
heal
th p
robl
ems
(e.g
., di
sabi
lity,
ha
ve m
easu
red
addi
tion
al b
iom
arke
rs
surv
eys
have
not
or
gani
zed
in t
he p
ast
m
enta
l illn
ess,
hyp
erte
nsio
n, d
iabe
tes,
acc
iden
ts, v
iole
nce)
and
bi
omar
kers
and
at
but
have
mea
sure
d m
easu
red
the
5 ye
ars
le
adin
g ri
sk fa
ctor
s (e
.g.,
smok
ing,
dru
g us
e, d
iet,
phy
sica
l ina
ctiv
ity)
le
ast
3 pr
iori
ty n
on-
the
prev
alen
ce o
f at
prev
alen
ce o
f any
co
mm
unic
able
le
ast
1 pr
iori
ty n
on-
prio
rity
non
com
-
“Bio
mar
kers
” –
subs
tanc
e us
ed a
s an
indi
cato
r of
a b
iolo
gic
stat
e.
dise
ases
/hea
lth
com
mun
icab
le d
isea
se/
mun
icab
le d
isea
se/
Th
is in
clud
es s
cree
ning
for
anti
bodi
es in
blo
od a
nd u
rine
sam
ple,
co
ndit
ions
or
risk
he
alth
pro
blem
or
risk
he
alth
pro
blem
or
fo
r ex
ampl
e.
fact
ors
fact
or
risk
fact
or
III.C
.2
C.2
.1: T
he c
ount
ry h
as a
dequ
ate
capa
city
to
: (1)
con
duct
A
dequ
ate
capa
city
for
Ade
quat
e ca
paci
ty fo
r A
dequ
ate
capa
city
A
dequ
ate
capa
city
for
Cap
acit
y &
ho
useh
old
surv
eys
(incl
udin
g sa
mpl
e de
sign
and
fiel
d w
ork)
; al
l 3
2 of
the
3
for
only
1 o
f the
3
none
of t
he 3
pra
ctic
es
(2) p
roce
ss t
he d
ata;
and
(3) a
naly
se t
he d
ata
C
.2.2
: Sur
veys
follo
w in
tern
atio
nal s
tand
ards
for
cons
ent,
ye
s
N
o
confi
dent
ialit
y an
d ac
cess
to
pers
onal
dat
a (e
.g.,
OEC
D g
uide
lines
)
C
.2.3
: The
dat
a al
low
dis
aggr
egat
ion
by a
ge, s
ex a
nd lo
calit
y
All
3 2
1 N
one
(e
.g. u
rban
/rur
al, m
ajor
geo
grap
hica
l or
adm
inis
trat
ive
regi
on)
C
.2.4
: The
dat
a al
low
dis
aggr
egat
ion
by s
ocio
econ
omic
sta
tus:
ye
s, b
oth
O
nly
by e
duca
tion
N
o
(1) i
ncom
e; a
nd (2
) edu
cati
on
III.
AS
SE
SS
ING
NA
TIO
NA
L H
IS D
ATA
SO
UR
CE
S
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
38
taBl
e iii
.c –
Con
tinue
dC
ore
dim
ensi
on
s It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
3
2 1
0
III.C
.3
C.3
.1: M
etad
ata
(des
ign,
sam
ple
impl
emen
tati
on, q
uest
ionn
aire
s)
Pub
licly
ava
ilabl
e
N
ot a
vaila
ble
Dis
sem
inat
ion
ar
e av
aila
ble
from
rec
ent
surv
eys
C
.3.2
: Mic
roda
ta a
re a
vaila
ble
from
rec
ent
surv
eys
Ava
ilabl
e on
req
uest
A
vaila
ble
on r
eque
st
N
ot a
vaila
ble
wit
h re
stri
ctio
ns
III.C
.4
C.4
.1: T
here
are
mee
ting
s an
d a
mul
tiye
ar p
lan
to c
oord
inat
e th
e ye
s, a
coo
rdin
atio
n C
oord
inat
ion
grou
p
Plan
exi
sts
but
is
Nei
ther
a c
oord
inat
ion
Inte
grat
ion
ti
min
g, k
ey v
aria
bles
mea
sure
d an
d fu
ndin
g of
nat
iona
lly
mec
hani
sm a
nd p
lan
and
long
-ter
m p
lan
inco
mpl
ete
and
/or
grou
p no
r a
long
-ter
m&
use
re
pres
enta
tive
pop
ulat
ion-
base
d su
rvey
s th
at m
easu
re h
ealt
h
coor
dina
te a
ll na
tion
ally
coo
rdin
ate
>75%
of
coor
dina
tion
gro
up is
pl
an e
xist
in
dica
tors
re
pres
enta
tive
sur
veys
na
tion
ally
rep
rese
nta-
un
able
to
effe
ctiv
ely
tive
hou
seho
ld s
urve
ys
coor
dina
te s
urve
ys
C
.4.2
: The
hea
lth
and
stat
isti
cal c
onst
itue
ncie
s in
the
cou
ntry
H
ighl
y ad
equa
te
Ade
quat
e P
rese
nt, b
ut n
ot
Not
ade
quat
e at
all
w
ork
toge
ther
clo
sely
on
surv
ey d
esig
n, im
plem
enta
tion
and
dat
a
adeq
uate
an
alys
is a
nd u
se
taBl
e iii
.D –
ass
essi
nG n
atio
nal H
is D
ata
soUr
ces:
indi
vidu
al re
cord
sC
ore
dim
ensi
on
s It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
3
2 1
0
III.D
.1
D.1
.1: F
or e
ach
of t
he k
ey e
pide
mic
-pro
ne d
isea
ses
(e.g
., ch
oler
a,
True
for
all k
ey
True
for
all e
xcep
t 1
or
Ther
e ar
e 3
or m
ore
No
syst
em fo
r C
on
ten
ts
diar
rhoe
a w
ith
bloo
d, m
easl
es, m
enin
giti
s, p
lagu
e, v
iral
hae
mor
- ep
idem
ic-p
rone
2
key
epid
emic
-pro
ne
key
dise
ases
for
whi
ch
noti
ficat
ion
or a
sys
tem
rh
age
feve
rs, y
ello
w fe
ver,
SAR
S, b
ird
flu) a
nd d
isea
ses
targ
eted
for
di
seas
es a
nd d
isea
ses
dise
ases
and
dis
ease
s ca
se d
efini
tion
s re
mai
n th
at d
oes
not
repo
rt o
n
erad
icat
ion
and
/or
elim
inat
ion
(e.g
., po
liom
yelit
is, n
eona
tal t
etan
us,
targ
eted
for
erad
icat
ion
targ
eted
for
erad
icat
ion
to b
e es
tabl
ishe
d or
for
mos
t of
the
key
le
pros
y) a
ppro
pria
te c
ase
defin
itio
ns h
ave
been
est
ablis
hed
and
an
d/o
r el
imin
atio
n an
d/o
r el
imin
atio
n w
hich
the
rep
orti
ng
dise
ases
ca
ses
can
be r
epor
ted
usin
g th
e cu
rren
t re
port
ing
form
at
form
is n
ot a
dequ
ate
D
.1.2
: For
hea
lth
cond
itio
ns o
f sub
stan
tial
pub
lic h
ealt
h
True
for
all l
eadi
ng
True
for
mos
t le
adin
g Tr
ue fo
r so
me
lead
ing
No
good
sur
veill
ance
im
port
ance
oth
er t
han
thos
e lis
ted
abov
e in
D.1
.1 (e
.g.,
lead
ing
ca
uses
of m
orbi
dity
, ca
uses
of m
orbi
dity
, ca
uses
of m
orbi
dity
, sy
stem
exi
sts
othe
r
caus
es o
f mor
talit
y, m
orbi
dity
and
dis
abili
ty s
uch
as p
neum
onia
m
orta
lity
and
disa
bilit
y m
orta
lity
and
disa
bilit
y m
orta
lity
and
disa
bilit
y th
an e
pide
mic
-pro
ne
and
diar
rhoe
a w
ith
dehy
drat
ion
in c
hild
ren
less
tha
n 5
year
s of
age
,
di
seas
es
mal
aria
, tub
ercu
losi
s, H
IV/A
IDS,
sex
ually
tra
nsm
itte
d di
seas
es, a
nd
no
ncom
mun
icab
le d
isea
ses)
a s
urve
illan
ce s
trat
egy
exis
ts
39
Co
re d
imen
sio
ns
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
3
2 1
0
D
.1.3
: Map
ping
of s
peci
fic a
t-ri
sk p
opul
atio
ns in
pla
ce
Map
s ar
e up
to
date
M
aps
are
up t
o da
te
Map
ping
of o
nly
a fe
w
No
map
ping
of p
ublic
(e
.g.,
popu
lati
ons
wit
h hi
gh le
vels
of m
alnu
trit
ion
and
pove
rty)
and
an
d co
mpr
ehen
sive
an
d re
ason
ably
pu
blic
hea
lth
risk
s he
alth
ris
ks
of g
ener
al p
opul
atio
n ex
pose
d to
spe
cific
ris
ks (e
.g.,
vect
ors,
and
an
d th
ere
is c
apac
ity
co
mpr
ehen
sive
en
viro
nmen
tal a
nd in
dust
rial
pol
luti
on)
to p
rom
ptly
add
new
feat
ures
III.D
.2
D.2
.1: T
he c
ount
ry h
as a
dequ
ate
capa
city
to:
(1) d
iagn
ose
and
reco
rd
Ade
quat
e ca
paci
ty fo
r A
dequ
ate
capa
city
to
Ade
quat
e ca
paci
ty t
o A
dequ
ate
capa
city
for
Cap
acit
y &
ca
ses
of n
otifi
able
dis
ease
s; (2
) rep
ort
and
tran
smit
tim
ely
and
all 3
act
ivit
ies
carr
y ou
t ac
tivi
ties
(1)
carr
y ou
t ac
tivi
ty (1
) no
ne o
f the
3 a
ctiv
itie
sp
ract
ices
co
mpl
ete
data
on
thes
e di
seas
es; a
nd (3
) ana
lyse
and
act
upo
n th
e
and
(2)
only
da
ta fo
r ou
tbre
ak r
espo
nse
and
plan
ning
of p
ublic
hea
lth
inte
rven
tion
s
D
.2.2
: Per
cent
age
of h
ealt
h w
orke
rs m
akin
g pr
imar
y di
agno
ses
90
% o
r m
ore
75–8
9%
25–7
4%
Less
tha
n 25
%
who
can
cor
rect
ly c
ite
the
case
defi
niti
ons
of t
he m
ajor
ity
of
no
tifia
ble
dise
ases
D
.2.3
: Per
cent
age
of h
ealt
h fa
cilit
ies
subm
itti
ng w
eekl
y or
mon
thly
90
% o
r m
ore
75–8
9%
25–7
4%
Less
tha
n 25
%
surv
eilla
nce
repo
rts
on t
ime
to t
he d
istr
ict
leve
l
D
.2.4
: Per
cent
age
of d
istr
icts
sub
mit
ting
wee
kly
or m
onth
ly
90%
or
mor
e 75
–89%
25
–74%
Le
ss t
han
25%
su
rvei
llanc
e re
port
s on
tim
e to
the
nex
t-hi
gher
leve
l
D
.2.5
: Pro
port
ion
of in
vest
igat
ed o
utbr
eaks
wit
h la
bora
tory
res
ults
90
% o
r m
ore
75–8
9%
25–7
4%
Less
tha
n 25
%
D
.2.6
: Use
of f
acili
ty-r
etai
ned
pati
ent
med
ical
rec
ords
to
supp
ort
90
% o
r m
ore
of p
atie
nt
Rec
ords
are
usu
ally
Es
sent
ial p
atie
nt
No
syst
em fo
r pa
tien
t
qual
ity
and
cont
inui
ty o
f car
e re
cord
s ar
e co
mpl
eted
co
mpl
eted
ade
quat
ely
info
rmat
ion
is u
sual
ly
med
ical
rec
ords
in
adeq
uate
ly a
nd c
an b
e
and
can
be r
etri
eved
no
t re
cord
ed a
nd/o
r m
ost
heal
th fa
cilit
ies
re
trie
ved
for
90%
or
fo
r th
e m
ajor
ity
of
reco
rds
cann
ot b
e
mor
e of
pat
ient
s in
pa
tien
ts in
tim
e to
re
trie
ved
for
mos
t
time
to p
rom
ptly
info
rm
prom
ptly
info
rm
pati
ents
cl
inic
al d
ecis
ion-
mak
ing
clin
ical
dec
isio
n-m
akin
g
D
.2.7
: Int
erna
tion
al S
tati
stic
al C
lass
ifica
tion
of D
isea
ses
and
IC
D-1
0 de
taile
d Ta
bula
tion
Lis
t IC
D-1
0 IC
D-9
N
o IC
D u
sed
or IC
D-8
R
elat
ed H
ealt
h P
robl
ems
(ICD
) is
curr
entl
y us
ed fo
r re
port
ing
or e
arlie
r
hosp
ital
dis
char
ge d
iagn
oses
N
ote
: Not
app
licab
le if
the
re is
no
ICD
cod
ing
of d
isch
arge
dia
gnos
es
III.
AS
SE
SS
ING
NA
TIO
NA
L H
IS D
ATA
SO
UR
CE
S
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
40
taBl
e iii
.D –
Con
tinue
dC
ore
dim
ensi
on
s It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
3
2 1
0
III.D
.3
D.3
.1: S
urve
illan
ce d
ata
on e
pide
mic
-pro
ne d
isea
ses
are
Bul
leti
n pr
oduc
ed
B
ulle
tin
not
prod
uced
N
o bu
lleti
n pr
oduc
ed
Dis
sem
inat
ion
di
ssem
inat
ed a
nd fe
d ba
ck t
hrou
gh r
egul
arly
pub
lishe
d w
eekl
y,
regu
larl
y du
ring
pas
t
regu
larl
y du
ring
pas
t
mon
thly
or
quar
terl
y bu
lleti
ns
year
and
ava
ilabl
e at
all
ye
ar o
r no
t di
stri
bute
d
dist
rict
hea
lth
offic
es
to
dis
tric
ts
III.D
.4
D.4
.1: I
nteg
rati
on o
f rep
orti
ng fo
r di
seas
e su
rvei
llanc
e an
d ot
her
A s
ingl
e fo
rm is
use
d A
ltho
ugh
ther
e ar
e a
H
ealt
h w
orke
rs a
nd
Inte
grat
ion
fo
cuse
d pu
blic
hea
lth
prog
ram
mes
(e.g
., m
ater
nal c
are,
fam
ily
for
noti
ficat
ion
of k
ey
num
ber
of r
epor
ting
man
ager
s fa
ce a
hea
vy&
use
pl
anni
ng a
nd g
row
th m
onit
orin
g)
dise
ases
. Rep
orti
ng o
f fo
rms,
the
re is
goo
d
burd
en in
com
plet
ing
ot
her
publ
ic h
ealt
h
coor
dina
tion
and
and
revi
ewin
g se
para
te
prog
ram
mes
is a
lso
ef
fort
s to
inte
grat
e th
e
repo
rts
for
num
erou
s
wel
l int
egra
ted
repo
rtin
g re
quir
emen
ts
publ
ic-h
ealt
h
of
pub
lic h
ealt
h
pr
ogra
mm
es
pr
ogra
mm
es
D
.4.2
: Pro
port
ion
of e
pide
mic
s no
ted
at r
egio
nal/
prov
inci
al o
r
At
leas
t 90
% o
f A
t le
ast
75%
of
Le
ss t
han
75%
of
na
tion
al le
vel (
thro
ugh
anal
ysis
of s
urve
illan
ce d
ata)
firs
t de
tect
ed
epid
emic
s no
ted
at
epid
emic
s no
ted
at
ep
idem
ics
note
d at
at
dis
tric
t le
vel
regi
onal
/pro
vinc
ial o
r
regi
onal
/pro
vinc
ial o
r
regi
onal
/pro
vinc
ial o
r
nati
onal
leve
ls a
re fi
rst
na
tion
al le
vels
are
firs
t
nati
onal
leve
ls a
re fi
rst
de
tect
ed a
t di
stri
ct
dete
cted
at
dist
rict
dete
cted
at
dist
rict
le
vel
leve
l
leve
l
taBl
e iii
.e –
ass
essi
nG n
atio
nal H
is D
ata
soUr
ces:
ser
vice
reco
rds
Co
re d
imen
sio
ns
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
3
2 1
0
III.E
.1
E.1
.1: T
here
is a
hea
lth
serv
ice
base
d in
form
atio
n sy
stem
tha
t ye
s, it
cov
ers
both
In
tegr
ated
but
cov
ers
Cov
ers
few
pri
vate
N
o da
ta fr
om p
riva
te
Co
nte
nts
br
ings
tog
ethe
r da
ta fr
om a
ll pu
blic
and
pri
vate
faci
litie
s pu
blic
and
pri
vate
fe
w p
riva
te fa
cilit
ies
faci
litie
s (e
.g.,
only
fa
cilit
ies
fa
cilit
ies
(e.g
., fo
r-pr
ofit
and
not-
for-
profi
t)
not-
for-
profi
t)
41
III.
AS
SE
SS
ING
NA
TIO
NA
L H
IS D
ATA
SO
UR
CE
S
Co
re d
imen
sio
ns
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
3
2 1
0
E
.1.2
: The
re is
a s
yste
mat
ic a
ppro
ach
to e
valu
atin
g th
e qu
alit
y of
Th
ere
is b
oth
syst
em-
Ther
e ha
s be
en a
t lea
st
Ther
e is
info
rmat
ion
Rec
ords
of fi
ndin
gs
serv
ices
pro
vide
d by
hea
lth
faci
litie
s. T
his
incl
udes
bot
h:
atic
sta
ndar
dize
d 1
nati
onal
ly r
epre
sen-
on
qua
lity
of s
ervi
ces
from
str
uctu
red
(a
) sys
tem
atic
sta
ndar
dize
d su
perv
isio
n w
ith
repo
rtin
g of
find
ings
su
perv
isio
n w
ith
tati
ve h
ealt
h-fa
cilit
y bu
t on
ly fr
om a
su
perv
isio
n or
hea
lth-
to
dis
tric
t an
d na
tion
al le
vels
; and
(b) a
hea
lth-
faci
lity
surv
ey o
f all
re
port
ing
and
a na
tion
- su
rvey
in t
he p
ast
conv
enie
nce
sam
ple
faci
lity
surv
eys
are
fa
cilit
ies
or o
f a n
atio
nally
rep
rese
ntat
ive
sam
ple
at le
ast
once
al
ly r
epre
sent
ativ
e 5
year
s of
hea
lth
faci
litie
s no
t av
aila
ble
ev
ery
5 ye
ars
heal
th-f
acili
ty s
urve
y
III.E
.2
E.2
.1: T
he h
ealt
h in
form
atio
n sy
stem
has
a c
adre
of t
rain
ed h
ealt
h A
t lea
st 7
5% o
f dis
tric
ts
10–7
4% o
f dis
tric
ts
1–9%
of d
istr
icts
N
ot in
any
dis
tric
t C
apac
ity
&
info
rmat
ion
staf
f who
hav
e at
leas
t 2
year
s of
spe
cial
ized
tra
inin
gp
ract
ices
an
d ar
e in
pla
ce a
t th
e di
stri
ct le
vel
E
.2.2
: Hea
lth
wor
kers
in h
ealt
h fa
cilit
ies
(clin
ics
and
hosp
ital
s)
Mos
t he
alth
wor
kers
25
–49%
of h
ealt
h 5
–24%
of h
ealt
h Le
ss t
han
5% o
f hea
lth
re
ceiv
e re
gula
r tr
aini
ng in
hea
lth
info
rmat
ion
that
is e
ithe
r
have
rec
eive
d su
ch
wor
kers
hav
e re
ceiv
ed
wor
kers
hav
e w
orke
rs h
ave
rece
ived
in
tegr
ated
into
con
tinu
ing
educ
atio
n or
thr
ough
in-s
ervi
ce t
rain
ing
tr
aini
ng in
the
pas
t su
ch t
rain
ing
in t
he
rece
ived
suc
h tr
aini
ng
such
tra
inin
g
in t
he p
ublic
sec
tor
5 ye
ars
past
5 y
ears
in
the
pas
t 5
year
s
E
.2.3
: The
re a
re m
echa
nism
s in
pla
ce a
t na
tion
al a
nd s
ubna
tion
al
Hig
hly
adeq
uate
A
dequ
ate
Pre
sent
, but
not
N
ot a
dequ
ate
at a
ll
leve
ls fo
r su
perv
isin
g, a
nd r
ecei
ving
feed
back
on,
info
rmat
ion
ad
equa
te
prac
tice
s in
the
pub
lic s
ecto
r
E
.2.4
: The
re is
a m
echa
nism
in p
lace
from
dis
tric
t up
thr
ough
H
ighl
y ad
equa
te
Ade
quat
e P
rese
nt, b
ut n
ot
Not
ade
quat
e at
all
na
tion
al le
vel f
or v
erif
ying
the
com
plet
enes
s an
d co
nsis
tenc
y of
ad
equa
te
data
from
faci
litie
s
III.E
.3
E.3
.1: T
he t
ime
elap
sed
sinc
e an
ann
ual s
umm
ary
of h
ealt
h se
rvic
e Le
ss t
han
2 ye
ars
ago
2–3
yea
rs a
go
4–5
yea
rs a
go
6 ye
ars
ago
or m
ore
Dis
sem
inat
ion
st
atis
tics
was
pub
lishe
d w
ith
stat
isti
cs d
isag
greg
ated
by
maj
or
ge
ogra
phic
al o
r ad
min
istr
ativ
e re
gion
E
.3.2
: Deg
ree
to w
hich
dis
tric
ts o
r si
mila
r ad
min
istr
ativ
e un
its
H
ighl
y ad
equa
te
Ade
quat
e P
rese
nt, b
ut n
ot
Not
ade
quat
e at
all
co
mpi
le t
heir
ow
n m
onth
ly/q
uart
erly
and
ann
ual s
umm
ary
repo
rts,
ad
equa
te
disa
ggre
gate
d by
hea
lth
faci
lity
III.E
.4
E.4
.1: D
egre
e to
whi
ch v
erti
cal r
epor
ting
sys
tem
s (e
.g.,
for
Hig
hly
adeq
uate
A
dequ
ate
Pre
sent
, but
not
N
ot a
dequ
ate
at a
ll In
tegr
atio
n
tube
rcul
osis
or
vacc
inat
ion
) com
mun
icat
e w
ell w
ith
the
gene
ral
adeq
uate
& u
se
heal
th s
ervi
ce r
epor
ting
sys
tem
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
42
taBl
e iii
.e –
Con
tinue
dC
ore
dim
ensi
on
s It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
3
2 1
0
E
.4.2
: Deg
ree
to w
hich
man
ager
s an
d an
alys
ts a
t na
tion
al a
nd
Hig
hly
adeq
uate
A
dequ
ate
Pre
sent
, but
not
N
ot a
dequ
ate
at a
ll
subn
atio
nal l
evel
s fr
eque
ntly
use
find
ings
from
sur
veys
, civ
il
adeq
uate
re
gist
rati
on (o
r ot
her
vita
l sta
tist
ics
syst
ems)
to
asse
ss t
he v
alid
ity
of
clin
ic-b
ased
dat
a
E
.4.3
: Deg
ree
to w
hich
dat
a de
rive
d fr
om h
ealt
h se
rvic
e re
cord
s
yes,
alw
ays
yes,
som
etim
es
Occ
asio
nally
N
ever
ar
e us
ed t
o es
tim
ate
the
cove
rage
of k
ey s
ervi
ces
(e.g
., an
tena
tal
ca
re, d
eliv
ery
wit
h a
skill
ed a
tten
dant
and
imm
uniz
atio
n)
taBl
e iii
.F –
ass
essi
nG n
atio
nal H
is D
ata
soUr
ces:
res
ourc
e re
cord
sin
fras
truc
ture
and
hea
lth se
rvic
esC
ore
dim
ensi
on
s It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
3
2 1
0
III.F
.1
F.1.
1: T
here
is a
nat
iona
l dat
abas
e/ro
ster
of p
ublic
and
pri
vate
- ye
s Th
ere
is a
dat
abas
e/
N
o C
on
ten
ts
sect
or h
ealt
h fa
cilit
ies.
Eac
h he
alth
faci
lity
has
been
ass
igne
d a
rost
er o
f pub
lic h
ealt
h
uniq
ue id
enti
fier
code
tha
t pe
rmit
s da
ta o
n fa
cilit
ies
to b
e m
erge
d
faci
litie
s w
ith
a co
ding
sy
stem
tha
t pe
rmit
s
in
tegr
ated
dat
a
m
anag
emen
t
F.
1.2
: Glo
bal P
osit
ioni
ng S
yste
m (G
PS)
coo
rdin
ates
for
each
hea
lth
Tr
ue fo
r 90
% o
r m
ore
True
for
90%
or
mor
e Tr
ue fo
r le
ss t
han
90%
N
ot a
dequ
ate
at a
ll
faci
lity
are
incl
uded
in t
he d
atab
ase
of p
ublic
and
pri
vate
of
pub
lic fa
cilit
ies
of p
ublic
faci
litie
s
faci
litie
s
III.F
.2
F.2.
1: T
here
are
hum
an r
esou
rces
and
equ
ipm
ent
for
mai
ntai
ning
H
ighl
y ad
equa
te
Ade
quat
e P
rese
nt, b
ut n
ot
Not
ade
quat
e at
all
Cap
acit
y &
an
d up
dati
ng t
he d
atab
ase
and
map
s on
hea
lth
faci
litie
s an
d
ad
equa
tep
ract
ices
se
rvic
es
F.
2.2
: Per
iod
sinc
e th
e na
tion
al d
atab
ase
of fa
cilit
ies
was
up
date
d Le
ss t
han
2 ye
ars
ago
2–3
year
s ag
o M
ore
than
3 y
ears
ago
Th
ere
is n
o na
tion
al
da
taba
se
43
Co
re d
imen
sio
ns
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
3
2 1
0
III.F
.3
F.3.
1: M
aps
are
avai
labl
e in
mos
t di
stri
cts
show
ing
the
loca
tion
of
Hig
hly
adeq
uate
A
dequ
ate
Pre
sent
, but
not
N
ot a
dequ
ate
at a
ll D
isse
min
atio
n
heal
th in
fras
truc
ture
, hea
lth
staf
f and
key
hea
lth
serv
ices
ad
equa
te
III.F
.4
F.4.
1: M
anag
ers
and
anal
ysts
at
nati
onal
and
dis
tric
t le
vels
H
ighl
y ad
equa
te
Ade
quat
e P
rese
nt, b
ut n
ot
Not
ade
quat
e at
all
Inte
grat
ion
co
mm
only
eva
luat
e ph
ysic
al a
cces
s to
ser
vice
s by
link
ing
adeq
uate
& u
se
info
rmat
ion
abou
t th
e lo
cati
on o
f hea
lth
faci
litie
s an
d he
alth
serv
ices
to
the
dist
ribu
tion
of t
he p
opul
atio
n
Hum
an re
sour
ces
Co
re d
imen
sio
ns
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
3
2 1
0
III.F
.5
F.5.
1: T
here
is a
nat
iona
l hum
an r
esou
rces
(HR
) dat
abas
e th
at
yes,
the
nat
iona
l HR
The
nati
onal
HR
data
- Th
e na
tion
al H
R da
ta-
No
nati
onal
HR
data
- C
on
ten
ts
trac
ks t
he n
umbe
r of
hea
lth
prof
essi
onal
s by
maj
or p
rofe
ssio
nal
data
base
tra
cks
base
tra
cks
num
bers
ba
se d
oes
not
prov
ide
base
ca
tego
ry w
orki
ng in
eit
her
the
publ
ic o
r th
e pr
ivat
e se
ctor
nu
mbe
rs o
f hea
lth
by
pro
fess
iona
l st
atis
tics
pr
ofes
sion
als
by
cate
gory
but
onl
y th
ose
disa
ggre
gate
d by
pr
ofes
sion
al c
ateg
ory
w
orki
ng in
the
pub
lic
prof
essi
onal
cat
egor
y
in b
oth
the
publ
ic a
nd
sect
or
priv
ate
sect
ors
F.
5.2
: The
re is
a n
atio
nal d
atab
ase
that
tra
cks
the
annu
al n
umbe
rs
yes
N
umbe
rs g
radu
atin
g N
o
grad
uati
ng fr
om a
ll he
alth
-tra
inin
g in
stit
utio
ns
from
cer
tain
hea
lth
tr
aini
ng in
stit
utio
ns
(e
.g.,
nurs
ing
or p
riva
te
in
stit
utio
ns) a
re n
ot
tr
acke
d
III.F
.6
F.6.
1: T
here
are
hum
an r
esou
rces
for
mai
ntai
ning
and
up
dati
ng t
he
Hig
hly
adeq
uate
A
dequ
ate
Pre
sent
, but
not
N
ot a
dequ
ate
at a
ll C
apac
ity
&
nati
onal
HR
data
base
ad
equa
tep
ract
ices
F.
6.2
: Per
iod
sinc
e na
tion
al H
R da
taba
se s
tati
stic
s w
ere
last
0
–1 y
ear
ago
2–3
year
s ag
o 4–
5 ye
ars
ago
6 ye
ars
ago
or m
ore
up
date
d:
III.
AS
SE
SS
ING
NA
TIO
NA
L H
IS D
ATA
SO
UR
CE
S
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
44
taBl
e iii
.F –
Con
tinue
dFi
nanc
ing
and
expe
nditu
re fo
r hea
lth se
rvic
esC
ore
dim
ensi
on
s It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
3
2 1
0
III.F
.7
F.7.
1: F
inan
cial
rec
ords
are
ava
ilabl
e on
gen
eral
gov
ernm
ent
A
ll co
mpo
nent
s, p
ublic
O
nly
publ
ic a
nd h
ouse
- O
nly
publ
ic
No
syst
em o
r
Co
nte
nts
ex
pend
itur
e on
hea
lth
and
its
com
pone
nts
(e.g
., by
min
istr
y of
an
d pr
ivat
e ho
ld o
ut-o
f-po
cket
ex
pend
itur
e in
com
plet
e
heal
th, o
ther
min
istr
ies,
soc
ial s
ecur
ity,
reg
iona
l and
loca
l
expe
ndit
ure
go
vern
men
ts, a
nd e
xtra
bud
geta
ry e
ntit
ies)
and
on
priv
ate
ex
pend
itur
e on
hea
lth
and
its
com
pone
nts
(e.g
., ho
useh
old
out-
of-
po
cket
exp
endi
ture
, pri
vate
hea
lth
insu
ranc
e, N
GO
s, fi
rms
and
co
rpor
atio
ns)
F.
7.2
: The
re is
a s
yste
m fo
r tr
acki
ng b
udge
ts a
nd e
xpen
ditu
re b
y al
l A
ll so
urce
s of
fina
nce
Sour
ces
othe
r th
an
Gov
ernm
ent
budg
et/
No
trac
king
or
only
th
e fin
anci
al a
gent
s lis
ted
abov
e in
F.7
.1 d
isag
greg
ated
by
ar
e di
sagg
rega
ted
by
hous
ehol
d ou
t-of
- ex
pend
itur
e pl
us a
t tr
acki
ng o
f nat
iona
l
subn
atio
nal o
r di
stri
ct le
vel
subn
atio
nal o
r di
stri
ct
pock
et e
xpen
ditu
re
leas
t 1
mor
e so
urce
go
vern
men
t
leve
l (e
.g.,
gove
rnm
ent
(s
uch
as d
onor
s) b
ut
expe
ndit
ure
incl
udin
g so
cial
on
ly a
t na
tion
al le
vel
secu
rity
and
loca
l
go
vern
men
t, d
onor
s,
and
heal
th in
sura
nce)
by
sub
nati
onal
leve
l
III.F
.8
F.8.
1: A
dequ
ate
num
bers
of q
ualifi
ed, l
ong-
term
sta
ff a
re r
egul
arly
ye
s A
dequ
ate
num
bers
In
adeq
uate
num
bers
A
d ho
c st
aff c
hose
n C
apac
ity
&
depl
oyed
to
wor
k on
the
Nat
iona
l Hea
lth
Acc
ount
(NH
A) w
heth
er
an
d sk
ills
but
staf
f are
of
ski
lled
staf
f, or
w
hen
acti
vity
tak
esp
ract
ices
or
not
the
y ar
e em
ploy
ed b
y th
e m
inis
try
of h
ealt
h
not
empl
oyed
long
- ad
equa
te n
umbe
rs b
ut
plac
e
te
rm b
y an
y in
-cou
ntry
st
aff r
equi
re e
xter
nal
N
ote
: Not
app
licab
le if
no
NH
A c
ondu
cted
agen
cy o
r ar
e no
t
tech
nica
l sup
port
regu
larl
y de
ploy
ed t
o
w
ork
on t
he N
HA
F.
8.2
: Per
iodi
city
and
tim
elin
ess
of r
outi
ne N
HA
Es
tim
ates
eve
ry y
ear
Esti
mat
es e
very
yea
r Es
tim
ates
eve
ry
At
leas
t 5
year
s
wit
h 1-
year
lag
wit
h 2-
year
lag
2–5
year
s be
twee
n es
tim
ates
or
N
ote
: Not
app
licab
le if
no
NH
A c
ondu
cted
be
twee
n ye
ar r
epor
ted
be
twee
n ye
ar r
epor
ted
no
est
imat
es
and
publ
icat
ion
year
an
d pu
blic
atio
n ye
ar
45
Co
re d
imen
sio
ns
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
3
2 1
0
F.
8.3
: NH
A r
outi
nely
pro
vide
s in
form
atio
n on
the
follo
win
g 4
A
ll 4
Any
3
Any
2
Non
e or
onl
y 1
cl
assi
ficat
ions
of fi
nanc
ial fl
ow: (
1) fi
nanc
ial s
ourc
es; (
2) fi
nanc
ial
ag
ents
; (3
) pro
vide
rs; a
nd (4
) fun
ctio
ns
fu
ncti
ons
– th
e ty
pes
of g
oods
and
ser
vice
s pr
ovid
ed a
nd a
ctiv
itie
s
perf
orm
ed
N
ote
: Not
app
licab
le if
no
NH
A c
ondu
cted
F.
8.4
: NH
A p
rovi
des
info
rmat
ion
on h
ealt
h ex
pend
itur
e by
maj
or
Hea
lth
expe
ndit
ure
Hea
lth
expe
ndit
ure
Esti
mat
es a
re a
vaila
ble
Non
e
dise
ases
, hea
lth
prog
ram
me
area
s, g
eogr
aphi
cal o
r ad
min
istr
ativ
e
info
rmat
ion
is a
vaila
ble
info
rmat
ion
is a
vaila
ble
of e
xpen
ditu
re o
n so
me
re
gion
and
/or
targ
et p
opul
atio
ns (a
ccor
ding
to
maj
or p
olic
y
for
at le
ast
2 m
ajor
fo
r 1
maj
or d
isea
se
area
s of
pol
icy
conc
ern
co
ncer
ns)
dise
ase
prog
ram
mes
pr
ogra
mm
e an
d bu
t th
ey e
xclu
de s
ome
an
d an
othe
r ar
ea o
f an
othe
r ar
ea o
f pol
icy
impo
rtan
t so
urce
s of
N
ote
: Not
app
licab
le if
no
NH
A c
ondu
cted
po
licy
conc
ern
conc
ern
finan
ce (e
.g.,
out-
of-
po
cket
)
III.F
.9
F.9.
1: N
HA
find
ings
are
wid
ely
and
easi
ly a
cces
sibl
e N
HA
find
ings
hav
e N
HA
find
ings
hav
e N
HA
find
ings
are
W
ritt
en r
epor
t on
NH
A
Dis
sem
inat
ion
be
en w
idel
y be
en d
isse
min
ated
to
avai
labl
e w
ithi
n th
e fin
ding
s no
t av
aila
ble
N
ote
: Not
app
licab
le if
no
NH
A c
ondu
cted
di
ssem
inat
ed a
nd a
re
the
publ
ic
agen
cy b
ut h
ave
not
ci
ted
in a
doc
umen
t
be
en w
idel
y
acce
ssib
le o
n a
web
diss
emin
ated
si
te
III.F
.10
F.10
.1: N
HA
has
bee
n us
ed fo
r po
licy
form
ulat
ion
and
reso
urce
Th
ere
is a
t le
ast
one
At
leas
t so
me
findi
ngs
Pol
icy-
mak
ers
and
Ther
e is
no
evid
ence
In
tegr
atio
n
allo
cati
on
maj
or p
olic
y do
cum
ent
from
the
NH
A h
ave
othe
r st
akeh
olde
rs
that
pol
icy-
mak
ers
are
& u
se
that
has
bee
n be
en u
sed
in
are
awar
e of
the
NH
A
awar
e of
NH
A fi
ndin
gs
No
te: N
ot a
pplic
able
if n
o N
HA
con
duct
ed
subs
tant
ially
influ
ence
d b
udge
ting
and
plan
ning
fin
ding
s bu
t th
ere
is n
o
by (o
r pr
omin
entl
y
ev
iden
ce t
hat
thes
e
cite
s) N
HA
find
ings
findi
ngs
have
sha
ped
po
licy
and
plan
ning
III.
AS
SE
SS
ING
NA
TIO
NA
L H
IS D
ATA
SO
UR
CE
S
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
46
taBl
e iii
.F –
Con
tinue
deq
uipm
ent,
supp
lies a
nd c
omm
oditi
esC
ore
dim
ensi
on
s It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
3
2 1
0
III.F
.11
F.11
.1: E
ach
faci
lity
is r
equi
red
to r
epor
t at
leas
t an
nual
ly o
n th
e ye
s
N
o C
on
ten
ts
inve
ntor
y an
d st
atus
of e
quip
men
t an
d ph
ysic
al in
fras
truc
ture
(e.g
., co
nstr
ucti
on, m
aint
enan
ce, w
ater
sup
ply,
ele
ctri
city
and
sew
age
syst
em) i
n th
e pu
blic
sec
tor
F.
11.2
: Eac
h fa
cilit
y is
req
uire
d to
rep
ort
at le
ast
quar
terl
y on
its
ye
s
N
o
leve
l of s
uppl
ies
and
com
mod
itie
s (e
.g.,
drug
s, v
acci
nes
and
co
ntra
cept
ives
) in
the
publ
ic s
ecto
r
III.F
.12
F.12
.1: T
here
are
suf
ficie
nt a
nd a
dequ
atel
y sk
illed
hum
an r
esou
rces
H
ighl
y ad
equa
te
Ade
quat
e P
rese
nt, b
ut n
ot
Not
ade
quat
e at
all
Cap
acit
y &
to
man
age
the
phys
ical
infr
astr
uctu
re, a
nd t
he lo
gist
ics
of
adeq
uate
pra
ctic
es
equi
pmen
t, s
uppl
ies
and
com
mod
itie
s in
the
pub
lic s
ecto
r
F.
12.2
: Per
iodi
city
and
com
plet
enes
s of
rep
orti
ng o
n eq
uipm
ent
C
ompl
ete
quar
terl
y C
ompl
ete
annu
al
Inco
mpl
ete
repo
rtin
g N
one
an
d ph
ysic
al in
fras
truc
ture
in t
he p
ublic
sec
tor
repo
rtin
g re
port
ing
F.
12.3
: Per
iodi
city
and
com
plet
enes
s of
rep
orti
ng o
n su
pplie
s an
d
Com
plet
e m
onth
ly
Com
plet
e qu
arte
rly
Inco
mpl
ete
repo
rtin
g N
one
co
mm
odit
ies
in t
he p
ublic
sec
tor
repo
rtin
g re
port
ing
III.F
.13
F.13
.1: D
egre
e to
whi
ch r
epor
ting
sys
tem
s fo
r di
ffer
ent
supp
lies
Fully
P
arti
ally
So
mew
hat
All
supp
lies
and
Inte
grat
ion
an
d co
mm
odit
ies
are
inte
grat
ed in
the
pub
lic s
ecto
r
com
mod
itie
s&
use
sepa
rate
ly r
epor
ted
F.
13.2
: Man
ager
s at
nat
iona
l and
sub
nati
onal
leve
ls r
outi
nely
R
outi
ne m
onth
ly
Occ
asio
nally
R
arel
y N
ever
at
tem
pt t
o re
conc
ile d
ata
on t
he c
onsu
mpt
ion
of c
omm
odit
ies
wit
h
reco
ncili
atio
n
data
on
case
s of
dis
ease
rep
orte
d in
the
pub
lic s
ecto
r
47
IV. Assessing national HIS data management[Table IV]
Data management is a set of procedures for the collection, storage, processing and compi-lation of data. Countries should have a centralized (preferably electronic) data depository that brings together all information for the national HIS and is made available to all – ideally via the Internet. The availability of such a data depository facilitates the cross-referencing of data among programmes, promotes adherence to standard definitions and methods, and helps to reduce redundant and overlapping data collection. It also provides a forum to examine and understand data inconsistencies and to facilitate the reconciliation of data reported through different systems.
Whatever the source of a data item, it is essential to pay special attention to the activi-ties and subsystems concerned with data collection, storage, analysis and dissemination (Table IV). The aim is to carefully assemble data from a variety of disparate sources – both within the health system and beyond – and to ensure its quality by cleaning and checking prior to releasing information to a broader public.
Metadata is data about data. It covers definitions of data elements/variables, their use in indicators, data-collection method, time period of data-collection, analysis techniques used, estimation methods and possible data biases. Metadata is captured and managed within an integrated data repository to support the disparate needs of the technical, admin-istrative and health user groups of the data-management system. It is essential for provid-ing accurately described common data-element definitions and for ensuring that other vital information is understood (such as data time periods, geographical designations and other dimensions). To relate data from multiple sources, it is essential to develop common defini-tions and to understand the characteristics of each data element.
Data processing and compilation also has a number of other broad requirements, among which are ensuring that relevant and appropriate information is made easily accessible and its contents understandable. At the same time, this also means securing and protecting the information assets of the system. For example, a system may contain disaggregated patient information affected by privacy and security considerations. It is therefore essential to control access to confidential information.
The results of data processing and compilation are a variety of reporting mechanisms that may be generalized to include both online and conventional reports. Where Internet access is available, the system reporting mechanisms can be accessed directly. Conventional reports can be produced where online access is not yet practical or appropriate to provide sophisticated data analysis and presentation tools developed centrally and benefiting from data-quality procedures. The reports may contain comparative information from other areas or programmes to improve understanding of the data and promote their use.
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
48
taBl
e iV
– a
sses
sinG
nat
iona
l His
Dat
a m
anaG
emen
t
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
3 2
1 0
IV.1
Th
ere
is a
wri
tten
set
of p
roce
dure
s fo
r da
ta m
anag
emen
t
yes,
a w
ritt
en s
et o
f pro
cedu
res
yes,
a w
ritt
en s
et o
f ye
s, a
wri
tten
set
of
No
wri
tten
pro
cedu
res
in
clud
ing
data
col
lect
ion,
sto
rage
, cle
anin
g, q
ualit
y co
ntro
l,
exis
ts in
clud
ing
all t
he s
teps
da
ta-m
anag
emen
t da
ta-m
anag
emen
t ex
ist
an
alys
is a
nd p
rese
ntat
ion
for
targ
et a
udie
nces
, and
the
se a
re
in d
ata
man
agem
ent
and
thes
e pr
oced
ures
exi
sts,
but
pr
oced
ures
exi
sts,
but
im
plem
ente
d th
roug
hout
the
cou
ntry
ar
e im
plem
ente
d th
roug
hout
th
ese
are
only
par
tial
ly
thes
e ar
e no
t
th
e co
untr
y im
plem
ente
d im
plem
ente
d
IV.2
Th
e H
IS u
nit
at n
atio
nal l
evel
is r
unni
ng a
n in
tegr
ated
dat
a
yes,
the
re is
a d
ata
war
ehou
se
yes,
the
re is
a d
ata
yes,
the
re is
a d
ata
No
nati
onal
dat
a
war
ehou
se c
onta
inin
g da
ta fr
om a
ll po
pula
tion
-bas
ed a
nd
at n
atio
nal l
evel
wit
h a
user
- w
areh
ouse
at
nati
onal
w
areh
ouse
at
nati
onal
w
areh
ouse
exi
sts
in
stit
utio
n-ba
sed
data
sou
rces
(inc
ludi
ng a
ll ke
y he
alth
fr
iend
ly r
epor
ting
utili
ty a
cces
sibl
e le
vel b
ut it
has
a li
mite
d le
vel b
ut it
has
no
pr
ogra
mm
es) a
nd h
as a
use
r-fr
iend
ly r
epor
ting
uti
lity
acce
ssib
le
to a
ll re
leva
nt g
over
nmen
t an
d re
port
ing
utili
ty
repo
rtin
g ut
ility
to
var
ious
use
r au
dien
ces
othe
r pa
rtne
rs
IV.3
A
t th
e su
bnat
iona
l lev
el, a
dat
a w
areh
ouse
equ
ival
ent
to t
he
yes,
the
re is
a d
ata
war
ehou
se
yes,
the
re is
a d
ata
yes,
the
re is
a d
ata
No
subn
atio
nal d
ata
na
tion
al o
ne e
xist
s an
d ha
s a
repo
rtin
g ut
ility
tha
t is
acc
essi
ble
at
the
sub
nati
onal
leve
l wit
h a
nati
onal
leve
l but
it h
as
war
ehou
se a
t th
e su
b-
war
ehou
se e
xist
s
to v
ario
us u
sers
us
er-f
rien
dly
repo
rtin
g ut
ility
a
limit
ed r
epor
ting
na
tion
al le
vel b
ut it
has
acce
ssib
le t
o us
ers
at a
ll le
vels
, ut
ility
no
rep
orti
ng u
tilit
y
in
clud
ing
user
s at
the
dis
tric
t lev
el
IV.4
A
met
adat
a di
ctio
nary
exi
sts
whi
ch p
rovi
des
com
preh
ensi
ve
yes,
the
re is
a m
etad
ata
yes,
the
re is
a
yes,
the
re is
a
No
met
adat
a di
ctio
nary
de
finit
ions
abo
ut t
he d
ata.
Defi
niti
ons
incl
ude
info
rmat
ion
in t
he
dict
iona
ry w
hich
pro
vide
s m
etad
ata
dict
iona
ry
met
adat
a di
ctio
nary
ex
ists
fo
llow
ing
area
s: (1
) use
of d
ata
in in
dica
tors
; (2)
spe
cific
atio
n of
de
finit
ions
in a
ll 6
area
s
but
it o
nly
prov
ides
bu
t it
onl
y pr
ovid
es
colle
ctio
n m
etho
ds u
sed
; (3
) per
iodi
city
; (4)
geo
grap
hica
l
defin
ition
s in
3–5
are
as
defin
ition
s in
1–2
are
as
desi
gnat
ions
(urb
an/r
ural
); (5
) ana
lysi
s te
chni
ques
use
d; a
nd (6
)
poss
ible
bia
ses
IV.5
U
niqu
e id
enti
fier
code
s ar
e av
aila
ble
for
adm
inis
trat
ive
U
niqu
e id
enti
fier
code
s ar
e us
ed
Iden
tifie
r co
des
are
Iden
tifie
r co
des
are
Not
ava
ilabl
e
geog
raph
ical
uni
ts (e
.g.,
regi
on/p
rovi
nce,
dis
tric
t or
mun
icip
alit
y)
in d
iffe
rent
dat
abas
es o
r a
us
ed in
dif
fere
nt d
ata-
av
aila
ble
but
do n
ot
to fa
cilit
ate
the
mer
ging
of m
ulti
ple
data
base
s fr
om d
iffe
rent
co
mpl
ete
rela
tion
al t
able
is
base
s an
d w
ork
is
mat
ch u
p be
twee
n
sour
ces
avai
labl
e to
mer
ge t
hem
re
quir
ed t
o ha
rmon
ize
di
ffer
ent
data
base
s
thes
e ac
ross
dat
abas
es
or
to
crea
te a
rel
atio
nal
ta
ble
to a
llow
mer
ging
49
V. Assessing national HIS data quality[Tables V.A–J]
The national HIS should aim to have accurate and reliable data available for a select set of core indicators within each domain shown in Fig. 3. Most indicators are estimated on the basis of empirical data sources. To ensure data quality, a wide range of policies and proc-esses are required. One overall guiding principle is to reduce the necessary amount of infor-mation to a “minimum dataset”. This will then reduce the burden of data collection and this alone should improve data quality. Other management actions to improve data are regular local quality control and data-use checks, the use of clear definitions of data elements, up-to-date training, and frequent feedback to data collectors and users. When electronic communication facilities are available, data can be entered at decentralized locations to provide immediate reporting to all levels.
Strong health information systems ensure that data meet high standards of reliability, transparency and completeness. It is important to assess source data and the statisti-cal techniques and estimation methods used to generate indicators. Building on the IMF Data Quality Assessment Framework (DQAF)1 and IMF General Data Dissemination System (GDDS),2 the following criteria can be used to assess the quality of health-related data and indicators:
n data-collection method – sometimes there is only one gold-standard data-collection method for a given indicator; more often, however, different sources can be used.
n timeliness – the period between data collection and its availability to a higher level, or its publication;
n periodicity – the frequency with which an indicator is measured;
n consistency – the internal consistency of data within a dataset as well as consistency between datasets and over time; and the extent to which revisions follow a regular, well-established and transparent schedule and process;
n representativeness – the extent to which data adequately represent the population and relevant subpopulations;
n disaggregation – the availability of statistics stratified by sex, age, socioeconomic sta-tus, major geographical or administrative region and ethnicity, as appropriate; and
n confidentiality, data security and data accessibility – the extent to which practices are in accordance with guidelines3 and other established standards for storage, backup, transport of information (especially over the Internet) and retrieval.
1 International Monetary Fund Data Quality Assessment Framework (DQAF), 2003. http://dsbb.imf.org/Applications/web/dqrs/dqrsdqaf/
3 International Monetary Fund General Data Dissemination System (GDDS), 2003. http://dsbb.imf.org/vgn/images/pdfs/gdds_oct_2003.pdf
3 For example, the OECD Guidelines for data protection at: http://www.oecd.org/document/18/0,2340,en_2649_34255_1815186_1_1_1_1,00.html
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
50
n adjustment methods – the extent to which crude data are adjusted in order to take into account bias and missing values. Specifically refers to adjustments, data transformation and analysis methods that follow sound and transparent statistical procedures.
Tables V.A–J provide an approach for assessing data quality for the following 10 selected indicators covering the three domains of health information shown in Fig. 3:
Health status domain
n Table V.A – under-5 mortality (all causes)
n Table V.B – maternal mortality
n Table V.C – HIV prevalence
Health system domain
n Table V.D – measles vaccination coverage
n Table V.E – attended deliveries
n Table V.F – tuberculosis treatment
n Table V.G – general government health expenditure (GGHE) per capita
n Table V.H – private expenditure
n Table V.I – workforce density
Determinants of health domain
n Table V.J – smoking prevalence
Although these largely reflect the MDG indicators, the assessment group may wish to add to or replace these with indicators more relevant to their situation, applying the same set of assessment criteria.
51
V.
AS
SE
SS
ING
NA
TIO
NA
L H
IS D
ATA
QU
AL
ITy
taBl
e V.
a –
asse
ssin
G na
tion
al H
is D
ata
qUal
ity:
Und
er-5
mor
talit
y (al
l cau
ses)
Ind
icat
or
Qu
alit
y as
sess
men
t It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
cr
iter
ia
3
2 1
0
A. U
nd
er-5
V
.A.1
D
ata-
colle
ctio
n m
etho
d us
ed fo
r es
tim
ate
Vit
al r
egis
trat
ion
of a
t B
irth
his
tory
from
O
ther
met
hods
(suc
h N
o da
tam
ort
alit
y
Dat
a-co
llect
ion
publ
ishe
d m
ost
rece
ntly
or
to b
e pu
blis
hed
leas
t 90
% o
f und
er-5
ho
useh
old
surv
ey o
r as
indi
rect
met
hods
) (a
ll ca
use
s)
met
hod
de
aths
Sa
mpl
e R
egis
trat
ion
ba
sed
on h
ouse
hold
Syst
em
surv
eys
or c
ensu
ses
V
.A.2
Fo
r th
e m
ost
rece
ntly
pub
lishe
d es
tim
ate,
num
ber
0–2
yea
rs
3–5
yea
rs
6–9
yea
rs
10 y
ears
or
mor
e
Tim
elin
ess
of y
ears
sin
ce t
he d
ata
wer
e co
llect
ed
V
. A.3
N
umbe
r of
tim
es m
easu
red
in t
he p
ast
10 y
ears
3
or m
ore
2 1
Non
e
Per
iodi
city
V
.A.4
D
atas
ets
from
maj
or d
ata
sour
ces
cons
iste
nt
No
maj
or
Seve
ral d
iscr
epan
cies
M
ulti
ple
disc
repa
ncie
s N
ot a
pplic
able
Con
sist
ency
du
ring
pas
t 10
yea
rs
disc
repa
ncie
s
V
.A.5
C
over
age
of d
ata
upon
whi
ch t
he m
ost
rece
ntly
A
ll de
aths
(>90
%)
Sam
ple
of d
eath
s Lo
cal s
tudi
es
Not
app
licab
le
Re
pres
enta
tive
ness
rep
orte
d es
tim
ate
is b
ased
V
.A.6
M
ost
rece
nt e
stim
ate
disa
ggre
gate
d by
: A
ll 3
2 1
Non
e
Dis
aggr
egat
ion
(1) d
emog
raph
ic c
hara
cter
isti
cs (e
.g.,
sex,
age
);
(2
) soc
ioec
onom
ic s
tatu
s (e
.g.,
inco
me,
occ
upat
ion,
ed
ucat
ion
of p
aren
t); a
nd (3
) loc
alit
y (e
.g.,
urba
n/
rura
l, m
ajor
geo
grap
hica
l or
adm
inis
trat
ive
regi
on)
V
.A.7
In
-cou
ntry
adj
ustm
ents
use
tra
nspa
rent
, wel
l- ye
s
N
o
Adj
ustm
ent
es
tabl
ishe
d m
etho
ds
met
hods
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
52
taBl
e V.
B –
asse
ssin
G na
tion
al H
is D
ata
qUal
ity:
mat
erna
l mor
talit
yIn
dic
ato
r Q
ual
ity
asse
ssm
ent
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
cr
iter
ia
3
2 1
0
B. M
ater
nal
V
.B.1
D
ata-
colle
ctio
n m
etho
d us
ed fo
r th
e es
tim
ate
Vit
al r
egis
trat
ion
of a
t Sa
mpl
e V
ital
D
irec
t m
etho
ds fr
om
No
data
mo
rtal
ity
Dat
a-co
llect
ion
pu
blis
hed
mos
t re
cent
ly o
r to
be
publ
ishe
d le
ast
90%
of d
eath
s R
egis
trat
ion
wit
h ho
useh
old
surv
ey o
r
met
hod
an
d w
ith
good
med
ical
V
erba
l Aut
opsy
ce
nsus
es (s
uch
as
cert
ifica
tion
of c
ause
sibl
ing
hist
ory,
rec
ent
of
dea
th
de
aths
wit
h ve
rbal
auto
psy)
V
.B.2
Fo
r th
e m
ost
rece
ntly
pub
lishe
d es
tim
ate,
num
ber
0–2
yea
rs
3–5
yea
rs
6–9
yea
rs
10 o
r m
ore
year
s
Tim
elin
ess
of y
ears
sin
ce t
he d
ata
wer
e co
llect
ed
V
.B.3
N
umbe
r of
tim
es m
easu
red
in t
he p
ast
10 y
ears
3
or m
ore
2 1
No
data
Per
iodi
city
V
.B.4
D
ata
cons
iste
nt o
ver
past
10
year
s N
o m
ajor
Se
vera
l dis
crep
anci
es
Mul
tipl
e di
scre
panc
ies
Not
app
licab
le
C
onsi
sten
cy
di
scre
panc
ies
V
.B.5
C
over
age
of d
ata
upon
whi
ch t
he m
ost
rece
nt
All
deat
hs
Sam
ple
of d
eath
s Lo
cal s
tudi
es
No
data
Repr
esen
tativ
enes
s es
tim
ate
is b
ased
V
.B.6
Es
tim
ate
that
was
pub
lishe
d m
ost
rece
ntly
(or
will
D
isag
greg
atio
n D
isag
greg
atio
n D
isag
greg
atio
n D
isag
greg
atio
n no
t
Dis
aggr
egat
ion
be p
ublis
hed
) is
disa
ggre
gate
d by
: (1)
dem
ogra
phic
av
aila
ble
for
all 3
av
aila
ble
for
2 av
aila
ble
for
1 el
emen
t po
ssib
le
ch
arac
teri
stic
s (e
.g.,
age)
; (2)
soc
ioec
onom
ic
elem
ents
el
emen
ts
st
atus
(e.g
., in
com
e, o
ccup
atio
n, e
duca
tion
); an
d
(3
) loc
alit
y (e
.g.,
urba
n/r
ural
, maj
or g
eogr
aphi
cal o
r
ad
min
istr
ativ
e re
gion
)
V
.B.7
In
-cou
ntry
adj
ustm
ents
use
tra
nspa
rent
, wel
l- ye
s
N
o
Adj
ustm
ent
es
tabl
ishe
d m
etho
ds
met
hods
53
taBl
e V.
c –
asse
ssin
G na
tion
al H
is D
ata
qUal
ity:
HiV
pre
vale
nce
Ind
icat
or
Qu
alit
y as
sess
men
t It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
cr
iter
ia
3
2 1
0
C. H
IV
V.C
.1
Dat
a-co
llect
ion
met
hod
used
for
esti
mat
ep
reva
len
ce
Dat
a-co
llect
ion
pu
blis
hed
mos
t re
cent
ly o
r to
be
publ
ishe
d
met
hod
1. If
gen
eral
ized
epi
dem
ic
1. G
ener
al p
opul
atio
n 1.
AN
C s
urve
illan
ce
1. H
IV c
ase-
repo
rtin
g 1.
Any
oth
er m
etho
d
surv
ey +
AN
C
su
rvei
llanc
e
2.
If c
once
ntra
ted
or lo
w-l
evel
epi
dem
ic
2. S
urve
illan
ce a
mon
g
2. S
urve
illan
ce a
mon
g 2.
HIV
cas
e-re
port
ing
2. A
ny o
ther
met
hod
po
pula
tion
at
high
ris
k
popu
lati
on a
t hi
gh r
isk
w
ith
rand
om s
ampl
ing
wit
h pu
rpos
ive
sam
plin
g
V
.C.2
Fo
r th
e m
ost
rece
ntly
pub
lishe
d es
tim
ate,
num
ber
<2
year
s 2
year
s 3
–4 y
ears
5
year
s or
mor
e
Tim
elin
ess
of y
ears
sin
ce t
he d
ata
wer
e co
llect
ed
V
.C.3
N
umbe
r of
tim
es m
easu
red
in p
ast
5 ye
ars
5 3
–4
2 1
or n
one
P
erio
dici
ty
V
.C.4
D
ata
cons
iste
ncy
over
tim
e du
ring
pas
t 5
year
s N
o m
ajor
dis
crep
anci
es S
ever
al d
iscr
epan
cies
M
ulti
ple
disc
repa
ncie
s N
ot a
pplic
able
Con
sist
ency
V
.C.5
C
over
age
of d
ata
upon
whi
ch t
he m
ost
rece
nt
Re
pres
enta
tiven
ess
esti
mat
e is
bas
ed
1.
If g
ener
aliz
ed e
pide
mic
1.
Nat
iona
lly r
epre
sen-
1.
Bot
h ur
ban
and
rura
l 1.
Inad
equa
te s
ampl
e 1.
Any
oth
er m
etho
d
tati
ve s
urve
y +
bot
h
AN
C c
linic
s of
clin
ics
ur
ban
and
rura
l AN
C
cl
inic
s
2.
If c
once
ntra
ted
or lo
w-l
evel
epi
dem
ic
2. A
ll m
ajor
pop
ulat
ions
2.
At
leas
t on
e m
ajor
2.
One
pop
ulat
ion
at
2. A
ny o
ther
met
hod
at
hig
h ri
sk w
ith
po
pula
tion
at
high
ris
k hi
gh r
isk
in o
ne
rand
om s
ampl
ing
in m
ulti
ple
loca
tion
s lo
cati
on
V
.C.6
Es
tim
ate
that
was
pub
lishe
d m
ost
rece
ntly
(or
will
D
isag
greg
atio
n D
isag
greg
atio
n D
isag
greg
atio
n D
isag
greg
atio
n no
t
Dis
aggr
egat
ion
be p
ublis
hed
) is
disa
ggre
gate
d by
: (1)
dem
ogra
phic
av
aila
ble
for
3 el
emen
ts
avai
labl
e fo
r 2
avai
labl
e fo
r po
ssib
le
ch
arac
teri
stic
s (e
.g.,
sex,
age
); (2
) soc
ioec
onom
ic
– sp
ecifi
cally
, el
emen
ts
1 el
emen
t
st
atus
(e.g
., in
com
e, o
ccup
atio
n, e
duca
tion
); an
d
prev
alen
ce a
mon
g
(3
) loc
alit
y (e
.g.,
urba
n/r
ural
, maj
or g
eogr
aphi
cal o
r 15
–24
year
old
s is
ad
min
istr
ativ
e re
gion
) es
tim
ated
wit
h an
adeq
uate
sam
ple
size
V.
AS
SE
SS
ING
NA
TIO
NA
L H
IS D
ATA
QU
AL
ITy
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
54
taBl
e V.
D –
asse
ssin
G na
tion
al H
is D
ata
qUal
ity:
mea
sles v
acci
natio
n co
vera
geIn
dic
ato
r Q
ual
ity
asse
ssm
ent
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
cr
iter
ia
3
2 1
0
D. M
easl
es
V.D
.1
Cov
erag
e ca
n be
est
imat
ed fr
om r
outi
ne
yes.
Adm
inis
trat
ive
Adm
inis
trat
ive
Ther
e is
litt
le
Mea
sles
vac
cina
tion
vacc
inat
ion
D
ata-
colle
ctio
n ad
min
istr
ativ
e st
atis
tics
sub
mit
ted
by a
t le
ast
90%
st
atis
tics
are
com
plet
e st
atis
tics
are
eva
luat
ed
eval
uati
on o
f the
co
vera
ge c
anno
t be
cove
rage
by
m
etho
d –
of
imm
uniz
ing
heal
th fa
cilit
ies.
The
se s
tati
stic
s ar
e (>
90%
) and
qua
lity
fo
r co
mpl
eten
ess
and
com
plet
enes
s or
es
tim
ated
from
12 m
on
ths
ad
min
istr
ativ
e sy
stem
atic
ally
rev
iew
ed a
t ea
ch le
vel f
or
cont
rol i
s go
od;
cons
iste
ncy;
pop
ulat
ion
cons
iste
ncy
of a
dmin
- ad
min
istr
ativ
eo
f ag
e st
atis
tics
co
mpl
eten
ess
and
cons
iste
ncy,
and
inco
nsis
tenc
ies
popu
lati
on d
enom
i- de
nom
inat
ors
are
istr
ativ
e st
atis
tics
or
stat
isti
cs
in
vest
igat
ed a
nd c
orre
cted
. To
calc
ulat
e co
vera
ge,
nato
rs a
re b
ased
upo
n ba
sed
upon
pop
ulat
ion
they
are
sub
mit
ted
by
re
liabl
e es
tim
ates
of p
opul
atio
n ar
e av
aila
ble
full
(>90
%) b
irth
pr
ojec
tion
s le
ss t
han
90%
of
re
gist
rati
on
re
leva
nt fa
cilit
ies,
or
no
po
pula
tion
pro
ject
ions
are
avai
labl
e
V
.D.2
C
over
age
has
been
mea
sure
d by
at
leas
t 2
yes,
in t
he p
ast
5 ye
ars
In t
he p
ast
5 ye
ars
Dur
ing
the
hous
ehol
d N
o co
vera
ge e
stim
ate,
Dat
a-co
llect
ion
na
tion
ally
rep
rese
ntat
ive
hous
ehol
d su
rvey
s in
the
th
ere
have
bee
n at
th
ere
has
been
1
surv
ey, i
mm
uniz
atio
n or
est
imat
e ba
sed
on
met
hod
– ho
use-
pa
st 5
yea
rs a
nd im
mun
izat
ion
card
s w
ere
show
n le
ast
2 na
tion
ally
na
tion
ally
rep
rese
nta-
ca
rds
wer
e sh
own
for
a ho
useh
old
surv
ey
hold
sur
vey
du
ring
eac
h su
rvey
for
at le
ast
two
thir
ds o
f re
pres
enta
tive
hou
se-
tive
hou
seho
ld s
urve
y le
ss t
han
two
thir
ds
mor
e th
an 5
yea
rs o
ld
stat
isti
cs
child
ren
hold
sur
veys
mea
suri
ng
mea
suri
ng m
easl
es
of c
hild
ren
m
easl
es v
acci
nati
on
vacc
inat
ion
cove
rage
,
cove
rage
, dur
ing
whi
ch
duri
ng w
hich
car
ds
card
s w
ere
show
n fo
r
wer
e sh
own
for
at le
ast
at
leas
t tw
o th
irds
of
two
thir
ds o
f chi
ldre
n
child
ren
V
.D.3
Fo
r th
e m
ost
rece
ntly
pub
lishe
d es
tim
ate,
num
ber
0–1
1 m
onth
s 12
–17
mon
ths
18–2
9 m
onth
s 30
mon
ths
or m
ore
Ti
mel
ines
s of
mon
ths
sinc
e th
e da
ta w
ere
colle
cted
V
.D.4
N
umbe
r of
tim
es in
the
pas
t 5
year
s th
at a
n an
nual
5
tim
es
3–4
tim
es
Onc
e or
tw
ice
Non
e
Per
iodi
city
es
tim
ate
was
pub
lishe
d ba
sed
on a
dmin
istr
ativ
e
st
atis
tics
V
.D.5
D
ata
cons
iste
nt b
etw
een
rece
nt s
urve
ys a
nd
No
maj
or
Seve
ral d
iscr
epan
cies
M
ulti
ple
disc
repa
ncie
s N
ot a
pplic
able
Con
sist
ency
re
port
s di
scre
panc
ies
55
V.
AS
SE
SS
ING
NA
TIO
NA
L H
IS D
ATA
QU
AL
ITy
Ind
icat
or
Qu
alit
y as
sess
men
t It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
cr
iter
ia
3
2 1
0
V
.D.6
C
over
age
of d
ata
upon
whi
ch t
he m
ost
rece
nt
(1) D
ata
from
at
leas
t D
ata
from
at
leas
t 80
%
Dat
a fr
om le
ss t
han
Any
thin
g le
ss t
han
this
Repr
esen
tativ
enes
s es
tim
ate
is b
ased
90
% o
f hea
lth
faci
litie
s
of h
ealt
h fa
cilit
ies
and
80%
of h
ealt
h fa
cilit
ies
an
d ou
trea
ch s
ites
tha
t o
utre
ach
site
s th
at
and
outr
each
sit
es t
hat
im
mun
ize
child
ren
im
mun
ize
child
ren
imm
uniz
e ch
ildre
n
incl
udin
g al
l maj
or
ho
spit
als
and
both
publ
ic a
nd p
riva
te
se
ctor
; or
(2) n
atio
nally
repr
esen
tati
ve h
ouse
-
hold
sam
ple
V
.D.7
Es
tim
ate
that
was
pub
lishe
d m
ost
rece
ntly
(or
will
D
isag
greg
atio
n D
isag
greg
atio
n D
isag
greg
atio
n D
isag
greg
atio
n no
t
Dis
aggr
egat
ion
be p
ublis
hed
) is
disa
ggre
gate
d by
: (1)
dem
ogra
phic
av
aila
ble
for
all 3
av
aila
ble
for
2 av
aila
ble
for
1 po
ssib
le
ch
arac
teri
stic
s (e
.g.,
sex,
age
); (2
) soc
ioec
onom
ic
elem
ents
el
emen
ts
elem
ent
stat
us (e
.g.,
inco
me,
occ
upat
ion,
edu
cati
on o
f
pa
rent
s); a
nd (3
) loc
alit
y (e
.g.,
urba
n/r
ural
, maj
or
geog
raph
ical
or
adm
inis
trat
ive
regi
on)
taBl
e V.
e –
asse
ssin
G na
tion
al H
is D
ata
qUal
ity:
atte
nded
del
iver
ies
Ind
icat
or
Qu
alit
y as
sess
men
t It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
cr
iter
ia
3
2 1
0
E. D
eliv
erie
s
V.E
.1
The
perc
enta
ge o
f del
iver
ies
atte
nded
by
a sk
illed
ye
s. A
dmin
istr
ativ
e A
dmin
istr
ativ
e Th
ere
is li
ttle
eva
lu-
The
perc
enta
ge o
fat
ten
de
d b
y
Dat
a-co
llect
ion
heal
th p
rofe
ssio
nal c
an b
e es
tim
ated
from
rou
tine
st
atis
tics
are
com
plet
e st
atis
tics
are
eval
uate
d at
ion
of t
he c
ompl
ete-
de
liver
ies
atte
nded
by
skill
ed
hea
lth
m
etho
d –
ad
min
istr
ativ
e st
atis
tics
sub
mit
ted
by a
t le
ast
90%
(>
90%
) and
qua
lity
fo
r co
mpl
eten
ess
and
ness
or
cons
iste
ncy
a sk
illed
hea
lth
pro
fess
ion
als
adm
inis
trat
ive
of
rel
evan
t he
alth
faci
litie
s. T
hese
sta
tist
ics
are
cont
rol i
s go
od;
cons
iste
ncy;
of
adm
inis
trat
ive
prof
essi
onal
can
not
st
atis
tics
sy
stem
atic
ally
rev
iew
ed a
t ea
ch le
vel f
or
popu
lati
on d
enom
in-
popu
lati
on d
enom
in-
stat
isti
cs, o
r th
ey a
re
be e
stim
ated
from
com
plet
enes
s an
d co
nsis
tenc
y, a
nd in
cons
iste
ncie
s
ator
s ar
e ba
sed
upon
at
ors
are
base
d up
on
subm
itte
d by
less
tha
n ad
min
istr
ativ
e
ar
e in
vest
igat
ed a
nd c
orre
cted
. To
calc
ulat
e
full
(>90
%) b
irth
po
pula
tion
pro
ject
ions
90
% o
f rel
evan
t st
atis
tics
cove
rage
, rel
iabl
e es
tim
ates
of p
opul
atio
n ar
e
regi
stra
tion
faci
litie
s, o
r no
pop
u-
av
aila
ble
lati
on p
roje
ctio
ns a
re
av
aila
ble
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
56
taBl
e V.
e –
Cont
inue
dIn
dic
ato
r Q
ual
ity
asse
ssm
ent
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
cr
iter
ia
3
2 1
0
V
.E.2
Th
e pe
rcen
tage
of d
eliv
erie
s at
tend
ed b
y a
skill
ed
yes.
In t
he p
ast
5 In
the
pas
t 5
year
s
No
cove
rage
est
imat
e,
D
ata
colle
ctio
n
heal
th p
rofe
ssio
nal h
as b
een
mea
sure
d by
at
leas
t ye
ars
at le
ast
2 th
ere
has
been
1
or
est
imat
e ba
sed
on
met
hod
– ho
use-
2
nati
onal
ly r
epre
sent
ativ
e ho
useh
old
surv
eys
in
nati
onal
ly r
epre
sen-
na
tion
ally
rep
rese
nta-
a ho
useh
old
surv
ey
hold
sur
vey
th
e pa
st 5
yea
rs
tati
ve h
ouse
hold
ti
ve h
ouse
hold
sur
vey
m
ore
than
5 y
ears
old
st
atis
tics
surv
eys
have
m
easu
ring
cov
erag
e
mea
sure
d co
vera
ge
V
.E.3
Fo
r th
e m
ost
rece
ntly
pub
lishe
d es
tim
ate,
num
ber
0–1
1 m
onth
s 12
–17
mon
ths
18–5
9 m
onth
s 60
mon
ths
or m
ore
Ti
mel
ines
s of
mon
ths
sinc
e th
e da
ta w
ere
colle
cted
V
.E.4
N
umbe
r of
tim
es m
easu
red
in t
he p
ast
10 y
ears
3
or m
ore
2 1
Non
e
Per
iodi
city
V
.E.5
D
atas
ets
cons
iste
nt b
etw
een
rece
nt s
urve
ys a
nd
No
maj
or
Seve
ral d
iscr
epan
cies
M
ulti
ple
disc
repa
ncie
s N
ot a
pplic
able
Con
sist
ency
re
port
s di
scre
panc
ies
V
.E.6
C
over
age
of d
ata
upon
whi
ch t
he m
ost
rece
nt
Dat
a fr
om a
t le
ast
90%
N
atio
nally
rep
rese
nta-
Lo
cal s
tudi
es;
Non
e
Repr
esen
tativ
enes
s es
tim
ate
is b
ased
of
pro
fess
iona
lly s
uper
- ti
ve h
ouse
hold
sam
ple
inco
mpl
ete
repo
rtin
g
vise
d de
liver
ies
and
on p
rofe
ssio
nally
fr
om c
ompl
ete
(>90
%)
su
perv
ised
del
iver
ies
re
gist
rati
on o
f bir
ths
w
ith
limit
ed o
r no
eva
lu-
at
ion
of c
ompl
eten
ess
V
.E.7
M
ost
rece
nt e
stim
ate
disa
ggre
gate
d by
: D
isag
greg
atio
n D
isag
greg
atio
n D
isag
greg
atio
n D
isag
greg
atio
n no
t
Dis
aggr
egat
ion
(1) d
emog
raph
ic c
hara
cter
isti
cs (e
.g.,
age)
; av
aila
ble
for
all 3
av
aila
ble
for
2 av
aila
ble
for
1 el
emen
t po
ssib
le
(2
) soc
ioec
onom
ic s
tatu
s (e
.g.,
inco
me,
occ
upat
ion,
el
emen
ts
elem
ents
educ
atio
n);
and
(3) l
ocal
ity
(e.g
., ur
ban
/rur
al, m
ajor
ge
ogra
phic
al o
r ad
min
istr
ativ
e re
gion
)
57
V.
AS
SE
SS
ING
NA
TIO
NA
L H
IS D
ATA
QU
AL
ITy
taBl
e V.
F –
asse
ssin
G na
tion
al H
is D
ata
qUal
ity:
tube
rcul
osis
trea
tmen
tIn
dic
ato
r Q
ual
ity
asse
ssm
ent
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
cr
iter
ia
3
2 1
0
F. T
uber
culo
sis
V.F
.1
Sour
ce o
f dat
a an
d m
etho
d us
ed fo
r m
ost
rece
nt
Clin
ic r
epor
ts w
ith
Dis
tric
t re
port
s w
ith
Nat
iona
l rep
orts
wit
h N
one
(TB
) tre
atm
ent
Dat
a-co
llect
ion
data
ev
alua
tion
of r
epor
ting
ev
alua
tion
of r
epor
ting
lim
ited
eva
luat
ion
ofsu
cces
s ra
te
met
hod
ra
te
rate
re
port
ing
bias
un
der
DO
TS
V
.F.2
Fo
r th
e m
ost
rece
ntly
pub
lishe
d es
tim
ate,
num
ber
1 ye
ar
2 ye
ars
3-4
year
s 5
or m
ore
year
s
Tim
elin
ess
of y
ears
sin
ce t
he d
ata
wer
e co
llect
ed
V
.F.3
N
umbe
r of
tim
es m
easu
red
in t
he p
ast
year
4
<
4 N
one
P
erio
dici
ty
(sho
uld
be q
uart
erly
)
V
.F.4
C
onsi
sten
cy o
f tre
atm
ent
succ
ess
rate
s du
ring
N
o m
ajor
Se
vera
l dis
crep
anci
es
Mul
tipl
e di
scre
panc
ies
Not
app
licab
le
C
onsi
sten
cy
past
10
year
s (fl
uctu
atio
n du
e to
non
-sta
ndar
dize
d
disc
repa
ncie
s
da
ta-c
olle
ctio
n pr
oced
ure,
defi
niti
ons,
etc
.)
V
.F.5
C
over
age
of d
ata
upon
whi
ch t
he m
ost
rece
nt
Ove
r 90
%
75%
–89%
5
0%
–75%
Le
ss t
han
50%
Repr
esen
tativ
enes
s es
tim
ate
is b
ased
-- %
of s
ubna
tion
al D
OTS
qu
arte
rly
repo
rts
rece
ived
by
nati
onal
TB
pr
ogra
mm
e in
mos
t re
cent
yea
r
V
.F.6
Es
tim
ate
that
was
pub
lishe
d m
ost
rece
ntly
or
will
D
isag
greg
atio
n D
isag
greg
atio
n D
isag
greg
atio
n D
isag
greg
atio
n no
t
Dis
aggr
egat
ion
– 1
be p
ublis
hed
is d
isag
greg
ated
by
dem
ogra
phic
av
aila
ble
for
3 av
aila
ble
for
2 av
aila
ble
for
1 po
ssib
le
ch
arac
teri
stic
s (e
.g. a
ge),
soci
oeco
nom
ic s
tatu
s
elem
ents
el
emen
ts
elem
ent
(e.g
. inc
ome,
occ
upat
ion,
edu
cati
on) a
nd lo
calit
y
(e
.g. u
rban
/rur
al, m
ajor
geo
grap
hica
l or
adm
inis
trat
ive
regi
on)
V
.F.7
M
ost
rece
nt e
stim
ate
disa
ggre
gate
d by
HIV
sta
tus
Dis
aggr
egat
ed b
y bo
th
Dis
aggr
egat
ed b
y 1
N
eith
er
D
isag
greg
atio
n –
2 an
d by
dru
g re
sist
ance
of t
hese
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
58
taBl
e V.
G –
asse
ssin
G Da
ta q
Uali
ty: G
GHe
Ind
icat
or
Qu
alit
y as
sess
men
t It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
cr
iter
ia
3
2 1
0
G. G
ener
al
V.G
.1
Dat
a-co
llect
ion
met
hod
used
for
mos
t re
cent
dat
a D
ata
com
pile
d us
ing
Dat
a co
mpi
led
from
D
ata
impu
ted
from
N
o da
tago
vern
men
t
Dat
a-co
llect
ion
N
atio
nal H
ealt
h ad
min
istr
ativ
e so
urce
s se
cond
ary
sour
ces
hea
lth
m
etho
d
Acc
ount
s (N
HA
) (i.
e. p
rim
ary
sour
ces
of
(e.g
. rep
ort
from
thi
rdex
pen
dit
ure
m
etho
dolo
gy
each
com
pone
nt)
part
y)(G
GH
E)
per
capi
ta
(min
istr
y of
he
alth
, oth
er
min
istr
ies
and
soci
al s
ecur
ity,
re
gion
al a
nd
loca
l gov
ern-
men
ts, e
xtra
bu
dget
ary
enti
ties
)
V
.G.2
Fo
r th
e m
ost
rece
ntly
pub
lishe
d es
tim
ate,
num
ber
0–1
yea
rs
2 ye
ars
3 or
mor
e ye
ars
Non
e
Tim
elin
ess
of y
ears
sin
ce t
he d
ata
wer
e co
llect
ed
V
.G.3
P
erio
dici
ty
year
ly
Ever
y 1–
2 ye
ars
Mor
e th
an e
very
N
o da
ta
P
erio
dici
ty
2
year
s
V
.G.4
C
onsi
sten
cy o
f defi
niti
ons
of e
xpen
ditu
re o
n he
alth
Si
ngle
sou
rce
wit
h no
V
ario
us s
ourc
es t
hat
Var
ious
sou
rces
tha
t N
one
C
onsi
sten
cy
acro
ss c
ompo
nent
s (m
inis
try
of h
ealt
h, o
ther
br
eak
in s
erie
s ar
e ha
rmon
ized
ar
e no
t ha
rmon
ized
min
istr
ies
and
soci
al s
ecur
ity,
reg
iona
l and
loca
l
go
vern
men
ts, e
xtra
bud
geta
ry e
ntit
ies)
and
ove
r
ti
me
V
.G.5
C
ompo
nent
s re
pres
ente
d A
ll co
mpo
nent
s:
Min
istr
y of
hea
lth,
M
inis
try
of h
ealt
h as
O
nly
min
istr
y of
hea
lth
Re
pres
enta
tiven
ess
m
inis
try
of h
ealt
h,
regi
onal
and
loca
l w
ell a
s so
cial
sec
urit
y (o
r no
ne)
ot
her
min
istr
ies
and
go
vern
men
ts a
nd
soci
al s
ecur
ity,
reg
iona
l so
cial
sec
urit
y
and
loca
l gov
ernm
ents
,
extr
a bu
dget
ary
enti
ties
59
V.
AS
SE
SS
ING
NA
TIO
NA
L H
IS D
ATA
QU
AL
ITy
Ind
icat
or
Qu
alit
y as
sess
men
t It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
cr
iter
ia
3
2 1
0
V
.G.6
A
vaila
bilit
y of
dis
aggr
egat
ed e
stim
ates
of g
ener
al
All
com
pone
nts:
M
inis
try
of h
ealt
h,
Min
istr
y of
hea
lth
as
Onl
y m
inis
try
of h
ealt
h
Dis
aggr
egat
ion
– 1
gove
rnm
ent
expe
ndit
ure
(all
com
pone
nts:
min
istr
y
min
istr
y of
hea
lth,
re
gion
al a
nd lo
cal
wel
l as
soci
al s
ecur
ity
(or
none
)
of
hea
lth,
oth
er m
inis
trie
s an
d so
cial
sec
urit
y,
othe
r m
inis
trie
s an
d go
vern
men
ts a
nd
re
gion
al a
nd lo
cal g
over
nmen
ts, e
xtra
bud
geta
ry
soci
al s
ecur
ity,
reg
iona
l so
cial
sec
urit
y
en
titi
es) b
y su
bnat
iona
l or
dist
rict
leve
l an
d lo
cal g
over
nmen
ts,
ex
tra
budg
etar
y en
titie
s
V
.G.7
A
vaila
bilit
y of
dis
aggr
egat
ed e
stim
ates
of
Dis
burs
ed e
xter
nal
Dis
burs
ed e
xter
nal
Com
mit
ted
exte
rnal
N
one
D
isag
greg
atio
n –
2 ex
tern
ally
fund
ed g
over
nmen
t ex
pend
itur
e by
re
sour
ces
from
mul
ti-
reso
urce
s fr
om m
ulti
- re
sour
ces
from
mul
ti-
sour
ce o
f fun
ding
(i.e
. mul
tila
tera
l, bi
late
ral,
priv
ate
la
tera
l, bi
late
ral,
priv
ate
late
ral a
nd b
ilate
ral
late
ral a
nd b
ilate
ral
foun
dati
ons,
NG
Os,
oth
ers)
fo
unda
tion
s, N
GO
s,
ot
hers
V
.G.8
A
vaila
bilit
y of
det
aile
d in
form
atio
n on
sou
rces
and
R
esul
ting
est
imat
es
Bas
ed o
n th
e av
aila
ble
Bas
ed o
n th
e av
aila
ble
Res
ulti
ng e
stim
ates
Adj
ustm
ent
st
atis
tica
l met
hodo
logi
es, a
nd r
ecor
ding
of a
ny
are
com
plet
ely
info
rmat
ion,
res
ulti
ng
info
rmat
ion,
res
ulti
ng
are
not
repl
icab
le
met
hods
de
part
ures
from
inte
rnat
iona
l gui
delin
es, f
or a
ll
repl
icab
le t
hrou
gh
esti
mat
es a
re
esti
mat
es a
re
ad
just
men
ts c
arri
ed o
ut a
nd t
heir
res
ulti
ng
data
aud
it t
rail
repl
icab
le a
t 75
%
repl
icab
le a
t 50
%
es
tim
ates
taBl
e V.
H –
asse
ssin
G Da
ta q
Uali
ty: P
rivat
e ex
pend
iture
Ind
icat
or
Qu
alit
y as
sess
men
t It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
cr
iter
ia
3
2 1
0
H. P
riva
te
V.H
.1
Dat
a-co
llect
ion
met
hod
used
for
mos
t re
cent
dat
a D
ata
com
pile
d us
ing
Dat
a co
mpi
led
usin
g D
ata
com
pile
d us
ing
No
data
exp
end
itu
re
Dat
a-co
llect
ion
N
atio
nal H
ealt
h 1
hous
ehol
d su
rvey
for
1 ho
useh
old
surv
ey fo
ro
n h
ealt
h
met
hod
A
ccou
nts
(NH
A)
out-
of-p
ocke
t, a
sur
vey
out-
of-p
ocke
t an
dp
er c
apit
a
met
hodo
logy
fo
r at
leas
t 1
othe
r im
puta
tion
s fo
r th
e(h
ouse
hold
s’
co
mpo
nent
, and
ot
her
com
pone
nts
out-
of-p
ocke
t,
im
puta
tion
s fo
rpr
ivat
e he
alth
rem
aini
ng c
ompo
nent
sin
sura
nce,
N
GO
s, fi
rms
and
corp
orat
ions
)
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
60
taBl
e V.
H –
Cont
inue
dIn
dic
ato
r Q
ual
ity
asse
ssm
ent
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
cr
iter
ia
3
2 1
0
V
.H.2
Fo
r th
e m
ost
rece
ntly
pub
lishe
d es
tim
ate,
num
ber
0–1
yea
rs
2 ye
ars
3–4
yea
rs
Non
e
Tim
elin
ess
of y
ears
sin
ce t
he d
ata
wer
e co
llect
ed
V
.H.3
P
erio
dici
ty
Dat
a fo
r al
l A
ll co
mpo
nent
s H
ouse
hold
s ex
pend
i- N
o da
ta
P
erio
dici
ty
co
mpo
nent
s av
aila
ble
su
rvey
ed a
t le
ast
once
tu
re s
urve
yed
at le
ast
ye
arly
in
pas
t 5
year
s on
ce in
pas
t 5
year
s
V
.H.4
C
onsi
sten
cy o
f defi
niti
ons
of e
xpen
ditu
re o
n he
alth
Si
ngle
sou
rce
wit
h no
V
ario
us s
ourc
es t
hat
Var
ious
sou
rces
tha
t N
o da
ta
C
onsi
sten
cy
acro
ss c
ompo
nent
s (h
ouse
hold
s’ o
ut-o
f-po
cket
, br
eak
in s
erie
s ar
e ha
rmon
ized
ar
e no
t ha
rmon
ized
priv
ate
heal
th in
sura
nce,
NG
Os,
firm
s an
d
co
rpor
atio
ns) a
nd o
ver
tim
e
V
.H.5
C
over
age
of p
opul
atio
n N
atio
nally
-rep
rese
nta-
N
atio
nally
-rep
rese
nta-
N
atio
nally
-rep
rese
nta-
Lo
cal s
tudi
es o
r
Repr
esen
tati
vene
ss
tive
incl
udin
g al
l com
- ti
ve o
nly
for
hous
e-
tive
onl
y fo
r th
e ho
use-
ot
herw
ise
po
nent
s: h
ouse
hold
s’
hold
s’ o
ut-o
f-po
cket
ho
lds’
out
-of-
pock
et
out-
of-p
ocke
t, p
riva
te
plus
1 o
ther
in
sura
nce,
NG
Os,
co
mpo
nent
fir
ms
and
corp
orat
ions
V
.H.6
A
vaila
bilit
y of
dis
aggr
egat
ed e
stim
ates
of p
riva
te
All
com
pone
nts:
H
ouse
hold
s’ o
ut-o
f-
Hou
seho
lds’
out
-of-
N
o di
sagg
rega
ted
data
Dis
aggr
egat
ion
– 1
expe
ndit
ure
(all
com
pone
nts:
hou
seho
lds’
out
-of-
ho
useh
olds
’ out
-of-
po
cket
and
1 o
ther
po
cket
onl
y
po
cket
, pri
vate
hea
lth
insu
ranc
e, N
GO
s, fi
rms
and
po
cket
, pri
vate
co
mpo
nent
corp
orat
ions
) by
subn
atio
nal o
r di
stri
ct le
vel
insu
ranc
e, N
GO
s, fi
rms
an
d co
rpor
atio
ns
V
.H.7
A
vaila
bilit
y of
dis
aggr
egat
ed e
stim
ates
of p
riva
te
Dis
burs
ed e
xter
nal
Dis
burs
ed e
xter
nal
Com
mit
ted
exte
rnal
N
o da
ta
D
isag
greg
atio
n –
2 ex
pend
itur
e by
sou
rce
of fu
ndin
g (i.
e. m
ulti
late
ral,
re
sour
ces
from
mul
ti-
reso
urce
s fr
om m
ulti
- re
sour
ces
from
mul
ti-
bila
tera
l, pr
ivat
e fo
unda
tion
s, N
GO
s, o
ther
s)
late
ral,
bila
tera
l,
late
ral a
nd b
ilate
ral
late
ral a
nd b
ilate
ral
pr
ivat
e fo
unda
tion
s,
N
GO
s, o
ther
s
V
.H.8
A
vaila
bilit
y of
det
aile
d in
form
atio
n on
sou
rces
and
R
esul
ting
est
imat
es
Bas
ed o
n th
e av
aila
ble
Bas
ed o
n th
e av
aila
ble
Res
ulti
ng e
stim
ates
Adj
ustm
ent
st
atis
tica
l met
hodo
logi
es, a
nd r
ecor
ding
of a
ny
are
com
plet
ely
info
rmat
ion,
res
ulti
ng
info
rmat
ion,
res
ulti
ng
are
not
repl
icab
le
met
hods
de
part
ures
from
inte
rnat
iona
l gui
delin
es, f
or a
ll
repl
icab
le t
hrou
gh
esti
mat
es a
re
esti
mat
es a
re
ad
just
men
ts c
arri
ed o
ut a
nd t
heir
res
ulti
ng
data
aud
it t
rail
repl
icab
le a
t 75
%
repl
icab
le a
t 50
%
es
tim
ates
61
taBl
e V.
i – a
sses
sinG
Dat
a qU
alit
y: w
orkf
orce
den
sity
Ind
icat
or
Qu
alit
y as
sess
men
t It
ems
Hig
hly
ad
equ
ate
Ad
equ
ate
Pre
sen
t b
ut
no
t ad
equ
ate
No
t ad
equ
ate
at a
ll S
core
cr
iter
ia
3
2 1
0
I. D
ensi
ty o
f
V.I.
1 R
outi
ne a
dmin
istr
ativ
e re
cord
s ar
e va
lidat
ed w
ith
Rou
tine
adm
inis
trat
ive
Adm
inis
trat
ive
reco
rds
Onl
y ad
min
istr
ativ
e N
o da
tah
ealt
h w
ork
- D
ata-
colle
ctio
n fin
ding
s fr
om a
reg
ular
ly c
ondu
cted
hea
lth
faci
lity
reco
rds
valid
ated
wit
h va
lidat
ed w
ith
eith
er
reco
rds
wit
hout
forc
e
met
hod
surv
ey/c
ensu
s, la
bour
-for
ce s
urve
y an
d th
e po
pula
tion
cen
sus,
he
alth
faci
lity
cens
us/
valid
atio
n by
any
(tot
al a
nd b
y
po
pula
tion
cen
sus
labo
ur-f
orce
sur
veys
, su
rvey
s or
labo
ur-f
orce
ce
nsus
or
surv
eypr
ofes
sion
al
heal
th fa
cilit
y ce
nsus
/ su
rvey
sca
tego
ry)
surv
eys
and
adm
inis
-vby
100
0
trat
ive
reco
rds
popu
lati
on
V
.I.2
For
the
mos
t re
cent
ly p
ublis
hed
esti
mat
e, n
umbe
r 0
–5 m
onth
s 6
–11
mon
ths
12 m
onth
s or
mor
e N
o da
ta
Ti
mel
ines
s of
mon
ths
sinc
e th
e da
ta w
ere
colle
cted
V
.I.3
Num
ber
of t
imes
mea
sure
d in
pas
t 5
year
s 5
or m
ore
3–4
1–
2 N
o da
ta
P
erio
dici
ty
V
.I.4
Var
iabl
es a
nd d
ata
defin
itio
ns a
nd c
lass
ifica
tion
s A
ll so
urce
s ar
e M
ost
of t
he s
ourc
es
Onl
y so
me
of t
he m
ain
The
mai
n so
urce
s ar
e
Con
sist
ency
co
nsis
tent
ove
r ti
me
and
acro
ss d
iffe
rent
sou
rces
co
nsis
tent
. The
ar
e co
nsis
tent
. The
so
urce
s ar
e co
nsis
tent
no
t co
nsis
tent
;
vari
able
s ha
ve t
he
vari
able
s ha
ve t
he
de
finit
ions
/
sam
e de
finit
ions
/
sam
e de
finit
ions
/
cl
assi
ficat
ion
of
clas
sific
atio
n in
all
cl
assi
ficat
ion
in m
ost
va
riab
les
vary
acr
oss
so
urce
s of
the
sou
rces
sour
ces
V
.I.5
Cat
egor
ies
of h
ealt
h w
orke
rs
15 o
r m
ore
occu
pati
ons
4–14
occ
upat
ions
or
Less
tha
n 4
or IS
CO
O
ther
wis
e
Dis
aggr
egat
ion
– 1
ISC
O: I
nter
nati
onal
Sta
ndar
d C
lass
ifica
tion
of
or IS
CO
4 d
igit
s or
IS
CO
3 d
igit
s or
2
digi
ts o
r na
tion
al
O
ccup
atio
ns
nati
onal
equ
ival
ent
nati
onal
equ
ival
ent
equi
vale
nt
V
.I.6
Esti
mat
e th
at w
as p
ublis
hed
mos
t re
cent
ly o
r w
ill
The
data
allo
w
The
data
allo
w
The
data
allo
w
The
data
allo
w
D
isag
greg
atio
n –
2 be
pub
lishe
d is
dis
aggr
egat
ed b
y (1
) gen
der,
di
sagg
rega
tion
by
all
disa
ggre
gati
on b
y 3
disa
ggre
gati
on b
y 2
disa
ggre
gati
on o
nly
by
(2
) urb
an/r
ural
, (3
) maj
or g
eogr
aphi
cal o
r
4 va
riab
les
vari
able
s (e
xclu
ding
va
riab
les
(exc
ludi
ng
gend
er o
r no
adm
inis
trat
ive
regi
on a
nd (4
) pub
lic/p
riva
te s
ecto
r
publ
ic/p
riva
te s
ecto
r)
publ
ic/p
riva
te a
nd
disa
ggre
gati
on p
ossi
ble
ur
ban
/rur
al)
V.
AS
SE
SS
ING
NA
TIO
NA
L H
IS D
ATA
QU
AL
ITy
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
62
taBl
e V.
J – a
sses
sinG
Dat
a qU
alit
y: s
mok
ing
prev
alen
ceIn
dic
ato
r Q
ual
ity
asse
ssm
ent
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
cr
iter
ia
3
2 1
0
J. S
mo
kin
g
V.J
.1
Dat
a-co
llect
ion
met
hod
used
for
mos
t re
cent
dat
a P
opul
atio
n-ba
sed
No
data
pre
vale
nce
D
ata-
colle
ctio
n
surv
ey w
ith
self-
repo
rt,
(15
year
s an
d
met
hod
da
ily s
mok
ers
over
olde
r)
prev
ious
mon
th
V
.J.2
Fo
r th
e m
ost
rece
ntly
pub
lishe
d es
tim
ate,
num
ber
0–2
yea
rs
3–5
yea
rs
6 or
mor
e ye
ars
Non
e
Tim
elin
ess
of y
ears
sin
ce t
he d
ata
wer
e co
llect
ed
V
.J.3
N
umbe
r of
tim
es m
easu
red
in p
ast
10 y
ears
3
or m
ore
2 1
Non
e
Per
iodi
city
V
.J.4
D
ata
cons
iste
nt o
ver
tim
e N
o m
ajor
A
few
dis
crep
anci
es
Mul
tipl
e di
scre
panc
ies
Not
app
licab
le
C
onsi
sten
cy
di
scre
panc
ies
V
.J.5
Ty
pe o
f sam
ple
upon
whi
ch m
ost
rece
nt e
stim
ate
Nat
iona
lly
Pur
posi
ve o
r ot
her
Loca
l stu
dies
A
ny o
ther
met
hod
Re
pres
enta
tiven
ess
is b
ased
re
pres
enta
tive
sam
ple
non-
rand
om n
atio
nal
ap
art
from
tho
se
sa
mpl
ing
al
read
y m
enti
oned
V
.J.6
Es
tim
ate
that
was
pub
lishe
d m
ost
rece
ntly
or
will
D
isag
greg
atio
n D
isag
greg
atio
n D
isag
greg
atio
n D
isag
greg
atio
n no
t
Dis
aggr
egat
ion
be p
ublis
hed
is d
isag
greg
ated
by
dem
ogra
phic
av
aila
ble
for
all 3
av
aila
ble
for
2 av
aila
ble
for
1 po
ssib
le
ch
arac
teri
stic
s (e
.g.,
sex,
age
), so
cioe
cono
mic
el
emen
ts
elem
ents
el
emen
t
st
atus
(e.g
., in
com
e, o
ccup
atio
n, e
duca
tion
) and
lo
calit
y (e
.g.,
urba
n/r
ural
, maj
or g
eogr
aphi
cal o
r
ad
min
istr
ativ
e re
gion
)
63
VI. Assessing national HIS information dissemination and use[Tables VI.A–E]
Although data are the raw materials of the national HIS, they have little intrinsic value in themselves. Only after data have been compiled, managed and analysed do they produce information (Fig. 13).1 Information is of far greater value, especially when it is integrated with other information and evaluated in terms of the issues confronting the health system. At this stage, information becomes evidence that can be used by decision-makers. This synthesis of evidence becomes even more powerful when it is formatted for presentation, communication or dissemination to decision-makers in a form that changes their under-standing of health issues and needs. This is the process of transforming evidence into knowledge, and once applied can result in decisions which will directly impact upon health and health equity. The actual impact on health can then be monitored by the national HIS by measuring changes in health indicators. This is how HMN visualizes the enabling of a culture of iterative and evidence-based decision-making built on a comprehensive national HIS.
1 Adapted from de Savigny D, Binka F. Monitoring future impact on malaria burden in sub-Saharan Africa. Am J Trop Med Hyg, 2004. 71:224–231.
Fig. 13 transforming data into information and evidence
Better information
Better
decisions
Better health
Monitor indicators for change
(HIS)
Implement decisions (System)
Integrate interpret and
evaluate (HIS)
Compile manage and
analyse (HIS)
Influence plans and decisions (Planners and
policy-makers)
Format for presentation to planners and stakeholders
(HIS)
Data
Knowledge
Evidence
Impact
Decisions
Information
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
64
As we move up the health-system pyramid, the link between data and decision-making seems more tenuous, and many factors come into play when strategic decisions on resource allocation are made. In a large and complex society, policy-making is fragmented and decisions are sometimes difficult to make because of the competing interests of dif-ferent players and agencies. Behavioural, organizational and environmental factors thus greatly influence the extent to which information is used. The Routine Health Information Network has even postulated that the scarcity of evidence-based decision-making is not the result of technical issues related to data generation but of institutional and behavioural barriers that impede the effective use of information. The PRISM framework and tools1
allow countries to assess such factors prior to intervention(s) to improve use of informa-tion, and to later evaluate the change brought about by the intervention(s). Examples of organizational and behavioural interventions for improving the use of information in deci-sion-making and planning are:
n mechanisms linking data/information to actual resource allocation (budgets and expend-iture);
n indicator-driven, short- (1 year) and medium-term (3–5 years) planning;
n organizational routines where managers are held accountable for performance through the use of results-based indicators at all levels of the health system;
n a programme addressing behavioural constraints to data use, for example through applying incentives for data use, such as awards for best service delivery performance, best/most-improved district or best health information system products/use;
n a supportive organizational environment that places a premium on the availability and use of well-packaged and well-communicated information and evidence for decision-mak-ing;
n ensuring that data are relevant to strategic decision-making and to planning;
n engaging all key constituencies in determining which information to collect in order to ensure broad ownership and involvement;
n making maximum efforts to ensure confidence in the reliability and validity of informa-tion;
n avoiding offering too much information with excessive detail, and making sure that important aggregations are provided;
n providing essential disaggregations, such as health status by major measures of equity;
n customizing data presentation to the needs of specific target audiences; and
n ensuring the timeliness of data.
One important function of the national HIS is to connect data production with its use. Those responsible for collecting data should also benefit from its use. Users comprise those deliv-ering care and managing and planning health programmes. More broadly, users include those financing health-care programmes both within countries (health and finance minis-tries) and externally (donors, development banks and technical support agencies). Users of health data are not confined to health-care professionals, managers or statisticians. Deci-sion-making around country health priorities necessarily involves the wider community (including civil society) as well as policy-makers at senior levels of government. Among the many advantages of developing a culture of evidence-based decision-making is that many diverse types of users can all benefit from the national HIS in line with their own needs and requirements. Health-care planners and managers responsible for tracking epidemiologi-cal trends and the response of the health-care system generally require more detailed data
1 https://www.cpc.unc.edu/measure/publications/DDIU/DDIU_PRISM_Tools.pdf
65
than policy-makers who need data for broader strategic decision-making and investment. Thus, the national HIS should present and disseminate data in appropriate formats for all its different audiences.
Tables VI.A–VI.E provide an approach for assessing the information dissemination and use in the following areas:
n Table VI.A – demand and analysis
n Table VI.B – policy and advocacy
n Table VI.C – planning and priority-setting
n Table VI.D – resource allocation
n Table VI.E – implementation and action
VI.
AS
SE
SS
ING
NA
TIO
NA
L H
IS I
NF
OR
MA
TIO
N D
ISS
EM
INA
TIO
N A
ND
US
E
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
66
taBl
e Vi
.a –
inFo
rmat
ion
Diss
emin
atio
n an
D Us
e: D
eman
d an
d an
alys
is
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
3 2
1 0
VI.A
.1
Seni
or m
anag
ers
and
polic
y-m
aker
s de
man
d co
mpl
ete,
tim
ely,
acc
urat
e,
yes
yes,
but
the
y do
not
D
eman
d fr
om
Neg
ligib
le d
eman
d
rele
vant
and
val
idat
ed H
IS in
form
atio
n
have
the
ski
lls t
o ju
dge
man
ager
s is
ad-
hoc,
fr
om m
anag
ers
usua
lly a
s a
resu
lt o
f
ex
tern
al p
ress
ure
(e.g
., qu
esti
ons
from
po
litic
ians
or
the
med
ia)
VI.A
.2
Gra
phs
are
wid
ely
used
to
disp
lay
info
rmat
ion
at s
ubna
tion
al h
ealt
h
True
at
all l
evel
s Tr
ue a
t he
alth
offi
ces
True
at
regi
onal
/ N
o gr
aphs
use
d
adm
inis
trat
ive
offic
es (e
.g.,
regi
onal
/pro
vinc
ial,
dist
rict
) and
hea
lth
faci
litie
s.
(reg
iona
l/pr
ovin
cial
, (r
egio
nal/
prov
inci
al,
prov
inci
al h
ealt
h
They
are
up
to d
ate
and
clea
rly
unde
rsto
od
dist
rict
hea
lth
offic
es,
dist
rict
), bu
t no
t at
of
fices
onl
y
he
alth
faci
litie
s)
heal
th fa
cilit
ies
VI.A
.3
Map
s ar
e w
idel
y us
ed t
o di
spla
y in
form
atio
n at
sub
nati
onal
hea
lth
Tr
ue a
t al
l lev
els
True
at
heal
th o
ffice
s Tr
ue a
t re
gion
al/
No
map
s us
ed
adm
inis
trat
ive
offic
es (e
.g.,
regi
onal
/pro
vinc
ial,
dist
rict
) and
hea
lth
faci
litie
s.
(reg
iona
l/pr
ovin
cial
, (r
egio
nal/
prov
inci
al,
prov
inci
al h
ealt
h
They
are
up
to d
ate
and
clea
rly
unde
rsto
od
dist
rict
hea
lth
offic
es,
dist
rict
), bu
t no
t at
of
fices
onl
y
he
alth
faci
litie
s)
heal
th fa
cilit
ies
taBl
e Vi
.B –
inFo
rmat
ion
Diss
emin
atio
n an
D Us
e: P
olic
y and
adv
ocac
y
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
3 2
1 0
VI.B
.1
Inte
grat
ed H
IS s
umm
ary
repo
rts
incl
udin
g in
form
atio
n on
a m
inim
um s
et o
f R
egul
ar in
tegr
ated
R
egul
ar in
tegr
ated
O
ccas
iona
l rep
orts
, N
o in
tegr
ated
rep
orts
co
re in
dica
tors
(inc
ludi
ng t
hose
use
d to
mea
sure
pro
gres
s to
war
ds
repo
rts
at le
ast
repo
rts
at le
ast
but
not
annu
ally
ac
hiev
ing
the
MD
Gs
and
thos
e us
ed b
y G
loba
l Hea
lth
Par
tner
ship
s, if
an
nual
ly t
o na
tion
al
annu
ally
, but
ap
plic
able
) are
dis
trib
uted
reg
ular
ly t
o al
l rel
evan
t pa
rtie
s an
d lo
cal r
elev
ant
di
stri
bute
d on
ly t
o th
e
pa
rtne
rs
min
istr
y of
hea
lth
67
VI.
AS
SE
SS
ING
NA
TIO
NA
L H
IS I
NF
OR
MA
TIO
N D
ISS
EM
INA
TIO
N A
ND
US
E
taBl
e Vi
.c –
inFo
rmat
ion
Diss
emin
atio
n an
D Us
e: P
lann
ing
and
prio
rity-
setti
ng
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
3 2
1 0
VI.C
.1
Hea
lth
info
rmat
ion
(pop
ulat
ion
heal
th s
tatu
s, h
ealt
h sy
stem
, ris
k fa
ctor
s) is
ye
s, s
yste
mat
ical
ly
Com
mon
ly u
sed
for
Hea
lth
info
rmat
ion
is
Nev
er u
sed
de
mon
stra
bly
used
in t
he p
lann
ing
and
in t
he r
esou
rce-
allo
cati
on p
roce
sses
us
ed w
ith
met
hods
di
agno
stic
pur
pose
s oc
casi
onal
ly u
sed
(e
.g.,
for
annu
al in
tegr
ated
dev
elop
men
t pl
ans,
med
ium
-ter
m e
xpen
ditu
re
and
targ
ets
alig
ned
to d
escr
ibe
heal
th
fram
ewor
ks, l
ong-
term
str
ateg
ic p
lans
, and
ann
ual h
ealt
h se
ctor
rev
iew
s)
betw
een
diff
eren
t
prob
lem
s/ c
halle
nges
,
pl
anni
ng fr
amew
orks
bu
t no
syn
chro
nise
d
use
of h
ealt
h in
form
a-
tion
bet
wee
n di
ffer
ent
pl
anni
ng fr
amew
orks
taBl
e Vi
.D –
inFo
rmat
ion
Diss
emin
atio
n an
D Us
e: r
esou
rce
allo
catio
n
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
3 2
1 0
VI.D
.1
HIS
info
rmat
ion
is w
idel
y us
ed b
y di
stri
ct a
nd s
ubna
tion
al m
anag
emen
t
The
maj
orit
y of
tar
gets
/ So
me
targ
ets/
budg
et
Few
tar
gets
/bud
get
Non
e of
the
tar
gets
/
team
s to
set
res
ourc
e al
loca
tion
s in
the
ann
ual b
udge
t pr
oces
ses
budg
et p
ropo
sals
are
pr
opos
als
are
back
ed
prop
osal
s ar
e ba
cked
bu
dget
pro
posa
ls a
re
ba
cked
up
by H
IS
up b
y H
IS in
form
atio
n up
by
HIS
info
rmat
ion
back
ed u
p by
HIS
info
rmat
ion
info
rmat
ion
VI.D
.2
HIS
info
rmat
ion
is u
sed
to a
dvoc
ate
for
equi
ty a
nd in
crea
sed
reso
urce
s to
H
IS in
form
atio
n is
H
IS in
form
atio
n is
H
IS in
form
atio
n is
N
ot u
sed
for
equi
ty
disa
dvan
tage
d gr
oups
and
com
mun
itie
s (e
.g.,
by d
ocum
enti
ng t
heir
dis
ease
sy
stem
atic
ally
use
d to
re
gula
rly
used
to
used
for
equi
ty
purp
oses
bu
rden
and
poo
r ac
cess
to
serv
ices
) pr
omot
e eq
uity
pr
omot
e eq
uity
pu
rpos
es o
nly
on a
n
ad
hoc
bas
is
AS
SE
SS
ING
TH
E N
AT
ION
AL
HE
ALT
H I
NF
OR
MA
TIO
N S
yS
TE
M
68
taBl
e Vi
.e –
inFo
rmat
ion
Diss
emin
atio
n an
D Us
e: im
plem
enta
tion
and
actio
n
Item
s H
igh
ly a
deq
uat
e A
deq
uat
e P
rese
nt
bu
t n
ot
adeq
uat
e N
ot
adeq
uat
e at
all
Sco
re
3 2
1 0
VI.E
.1
Man
ager
s at
hea
lth
adm
inis
trat
ive
offic
es a
t al
l lev
els
(nat
iona
l, re
gion
al/
Hea
lth
info
rmat
ion
is
Hea
lth
info
rmat
ion
is
All
key
deci
sion
s ar
e H
IS in
form
atio
n is
pr
ovin
cial
, dis
tric
t) u
se h
ealt
h in
form
atio
n fo
r he
alth
ser
vice
del
iver
y
used
by
man
ager
s at
all
used
by
man
ager
s at
ce
ntra
lized
to
the
occa
sion
ally
use
d
man
agem
ent,
con
tinu
ous
mon
itor
ing
and
peri
odic
eva
luat
ion
leve
ls fo
r he
alth
ser
vice
na
tion
al a
nd r
egio
nal/
na
tion
al le
vel
deliv
ery
man
agem
ent,
pr
ovin
cial
leve
ls b
ut
co
ntin
uous
mon
itor
ing
no
t at
dis
tric
t le
vel
and
peri
odic
eva
luat
ion
VI.E
.2
Car
e pr
ovid
ers
at a
ll le
vels
(nat
iona
l, re
gion
al/p
rovi
ncia
l, di
stri
ct h
ospi
tals
H
ealt
h in
form
atio
n is
H
ealt
h in
form
atio
n is
H
ealt
h in
form
atio
n is
C
are
prov
ider
s ot
her
an
d he
alth
cen
tres
) use
hea
lth
info
rmat
ion
for
heal
th s
ervi
ce d
eliv
ery
us
ed b
y ca
re p
rovi
ders
us
ed b
y ca
re p
rovi
ders
us
ed b
y ca
re p
rovi
ders
th
an t
hose
at
nati
onal
m
anag
emen
t, c
onti
nuou
s m
onit
orin
g an
d pe
riod
ic e
valu
atio
n at
all
leve
ls fo
r he
alth
at
nat
iona
l, re
gion
al/
at n
atio
nal a
nd
leve
l do
not
use
heal
th
se
rvic
e de
liver
y
prov
inci
al a
nd d
istr
ict
regi
onal
/pro
vinc
ial
info
rmat
ion
for
serv
ice
man
agem
ent,
ho
spit
als
but
not
at
hosp
ital
s bu
t no
t at
de
liver
y m
anag
emen
t,
cont
inuo
us m
onit
orin
g
heal
th c
entr
es
dist
rict
hos
pita
ls o
r co
ntin
uous
mon
itor
ing
and
peri
odic
eva
luat
ion
he
alth
cen
tres
or
per
iodi
c ev
alua
tion
VI.E
.3
Info
rmat
ion
on h
ealt
h ri
sk fa
ctor
s is
sys
tem
atic
ally
use
d to
adv
ocat
e fo
r
Such
indi
cato
rs a
re
Such
indi
cato
rs a
re
Onl
y us
ed o
n an
N
ot u
sed
th
e ad
opti
on o
f low
er-r
isk
beha
viou
rs b
y th
e ge
nera
l pub
lic a
nd b
y ta
rget
ed
syst
emat
ical
ly u
sed
regu
larl
y us
ed, b
ut
ad h
oc b
asis
vu
lner
able
gro
ups
and
tailo
red
to fi
t th
e
gene
rally
not
tai
lore
d
ri
sk p
rofil
e an
d
to e
ach
vuln
erab
le
si
tuat
ion
faci
ng e
ach
gr
oup
vuln
erab
le g
roup
69
ANNEx I
Glossary of terms
Causes of death – the causes of death to be entered on the medical certificate are defined as “all those diseases, morbid conditions or injuries which either resulted in or contributed to death and the circumstances of the accident or violence which produced any such inju-ries”.
Civil registration – defined by the United Nations as: “the continuous, permanent, com-pulsory and universal recording of the occurrence and characteristics of vital events (live births, deaths, foetal deaths, marriages and divorces) and other civil status events pertain-ing to the population as provided by decree or regulation, in accordance with the legal requirements in each country. Civil registration establishes and provides legal documenta-tion of such events. These records are also the best source of vital statistics.”1
Data management – a set of procedures to collect, store, analyse and distribute data. Once data are collected, a sound management approach is essential. Firstly, a metadata dictionary is necessary to accurately describe the data elements. Next, effective data-storage procedures require a well-designed logical structure to permit data retrieval and analysis. Data analysis and presentation include calculating indicators and preparing tables and graphs. Finally, the data should be made available to all those who can use and act upon them.
Data warehouse – an integrated information-storage area that consists of a data reposi-tory bringing together multiple databases from various data sources, and a report-gener-ating facility.
Demographic surveillance system (DSS) – the continuous demographic monitoring of a geographically defined population with timely production of data on all births, deaths and migration. DSS sites cannot provide nationally representative indicators because of their circumscribed geographical representation. Efforts are being made to provide estimates that can be generalized using several existing DSS sites as resources for training, quality control and supervision.
Enumeration – distinct from registration; the means by which the presence of individuals in a household or other group is recorded; normally used in reference to a census or survey. Enumeration is anonymous and does not provide any direct benefit to the individual.
Information and Communications Technology (ICT) – includes the computers, soft-ware, data-capture devices, wireless communication devices, and local and wide area net-works that move information, and the people that are required to design, implement and support these systems.
1 United Nations Statistics Division. Principles and Recommendations for a Vital Statistics System. Revision 2, Series: M, No.19/Rev.2. New york, United Nations, 2001. Sales No. 01.XVI.10.
http://unstats.un.org/unsd/publication/SeriesM/SeriesM_19rev2E.pdf
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International Standard Classification of Occupations (ISCO)1 – one of the main interna-tional classifications, for which ILO is responsible. ISCO is a tool for organizing jobs into a clearly defined set of groups according to the tasks and duties undertaken.
International Statistical Classification of Diseases and Related Health Problems (ICD)2 – a classification maintained by WHO for coding diseases, signs, symptoms and other factors causing morbidity and mortality; used worldwide for morbidity and mortality sta-tistics, and designed to promote international comparability, collection, processing, clas-sification, and presentation of statistics.
Medical certification of cause of death – medical practitioners or other qualified certi-fiers use their clinical judgement to diagnose the cause(s) of death to be entered on the medical certificate.
Metadata (dictionary) – metadata is “data about data”. To relate data from multiple sources, it is essential to develop common definitions and understand the characteris-tics of each data element. The tool for achieving this is the metadata dictionary. It covers definitions of data elements/variables, their use in indicators, data-collection method, time period of data-collection, analysis techniques used, estimation methods and possible data biases.
Microdata – non-aggregated data about the units sampled. In the case of population and household censuses and surveys, microdata consists of records of the individuals and households interviewed.
Mortality rate – the ratio of the number of people dying in a year to the total mid-year population in which the deaths occurred. This rate is also called the crude death rate. The mortality rate may be standardized when comparing mortality rates over time (or between countries) to take account of differences in the population. This rate is then called the age-standardized death rate.
National Health Account (NHA) – a tool for the systematic, comprehensive and consistent monitoring of resource flows in a national health system. It provides a framework with stan-dard definitions, boundaries, classifications and a set of interrelated tables for standard reporting of expenditures on health and its financing. NHAs are designed to capture the resource flows for the main functions of health-care financing, namely: resource mobiliza-tion and allocation; pooling and insurance; purchasing and providing of care; and the distri-bution of expenditures by disease, socioeconomic characteristics and geopolitical areas.3
Sample registration system – longitudinal enumeration of demographic events, including cause of death via verbal autopsy, in a nationally representative sample of clusters such as exists in China and India.
Sample Vital Registration with Verbal Autopsy (SAVVY) – proposed by MEASURE Evalu-ation and the International Programs Center, United States Census Bureau to generate data needed to estimate mortality. Builds on experience from both sentinel demographic surveillance and sample vital registration systems. SAVVy uses a validated verbal autopsy tool to ascertain major causes of death, including those from HIV/AIDS.4
Sentinel demographic surveillance system – the longitudinal enumeration of all demo-graphic events, including cause of death via verbal autopsy, in a geographically defined population.
1 http://www.ilo.org/public/english/bureau/stat/isco/index.htm2 World Health Organization. International Statistical Classification of Diseases and Related Health Problems (ICD). 10th Revision, Second Edition. Geneva, World Health Organization, 2005. http://www.who.int/classifications/icd/en/3 http://www.who.int/nha/docs/English_PG.pdf and
http://webitpreview.who.int/entity/nha/Glossary%20English.pdf4 MEASURE Evaluation, Carolina Population Center, University of North Carolina at Chapel Hill, USA.
http://www.cpc.unc.edu/measure/leadership/savvy.html accessed 08 August 2007.
71
Statistical Data and Metadata Exchange (SDMX)1 – an organization of interest promoted by the IMF, WB, UNSD, EUROSTAT, FAO, OECD, BIS and ECB, and the Global Administrative Unit Layers (GAUL).
Underlying cause of death – (a) the disease or injury which initiated the train of morbid events leading directly to death; or (b) the circumstances of the accident or violence which produced the fatal injury.
Verbal autopsy – a structured interview with caregivers or family members of households after a death occurs; used to determine probable cause(s) of death where most deaths occur outside of health facilities, and where direct medical certification is rare.
Vital event – defined by the United Nations as: “the occurrence of a live birth, death, foetal death, marriage, divorce, adoption, legitimation, recognition of parenthood, annulment of marriage, or legal separation.”2
Vital registration – all sanctioned modes of registering individuals and reporting on vital events.
Vital statistics – data on vital events drawn from all of sources of vital events data. Par-ticularly in developing country settings, where civil registration functions poorly or not at all, the United Nations acknowledges that a variety of data sources and systems are used to derive estimates of vital statistics.
Vital statistics system – as defined by the United Nations: “the total process of (1) col-lecting information by civil registration or enumeration on the frequency of occurrence of specified and defined vital events as well as relevant characteristics of the events them-selves… and (2) of compiling, processing, analysing, evaluating, presenting and disseminat-ing these data in statistical form”.2
1 http://www.sdmx.org/2 United Nations Statistics Division. Principles and Recommendations for a Vital Statistics System. Revision 2, Series: M, No.19/Rev.2. New york, United Nations, 2001. Sales No. 01.XVI.10.
http://unstats.un.org/unsd/publication/SeriesM/SeriesM_19rev2E.pdf
AN
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ANNEx II
Abbreviations and acronyms
AHPSR The Alliance for Health Policy and Systems Research
AIDS Acquired immunodeficiency syndrome
ANC Antenatal care
APHRC Africa Population and Health Research Center
CBO Community based organization
CDC Centers for Disease Control and Prevention
DANIDA Danish International Development Agency
DFID UK Department for International Development
DHS Demographic Health Survey
DOTS Directly observed treatment – the internationally recommended strategy for tuberculosis control
DPT3 Diphtheria, pertussis (whooping cough) and tetanus vaccine
DSS Demographic Surveillance System
EC European Commission
GAVI Global Alliance for Vaccines and Immunization
GDDS General Data Dissemination System
GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria
GHP Global health partners
GIS Geographic Information System
GPS Global Positioning System
HIGH Harvard Initiative for Global Health
HIS Health information system
HIV Human immunodeficiency virus
HMN The Health Metrics Network
HR Human resources
ICD International Statistical Classification of Diseases and Related Health Problems
ICT Information and communications technology
IDR Integrated data repository
IDSR Integrated disease surveillance and response
72
73
IHME The Institute for Health Metrics and Evaluation
IHR International Health Regulations
IMF International Monetary Fund
IMMPACT Initiative for Maternal Mortality Programme Assessment
ISCO International Standard Classification of Occupations
LAN Local area network
LDCs Least-developed countries
LSMS Living Standard Measurement Study
MDGs Millennium Development Goals of the United Nations
MICS Multiple Indicator Cluster Survey
MoH Ministry of Health
NGO Nongovernmental organization
NHA National Health Account
NSDS National strategies for the development of statistics
NSO National Statistics Office
OECD Organisation for Economic Co-operation and Development
PARIS21 Partnership in Statistics for Development in the 21st Century
PC Personal computer
PDA Personal digital assistant
PEPFAR President’s Emergency Plan for AIDS Relief
PES Post enumeration survey
PRSP Poverty-reduction strategy paper
SARS Severe acute respiratory syndrome
SAVVY Sample vital registration with verbal autopsy
SIDA Swedish International Development Cooperation Agency
SPA Service provision assessment
SRS Sample registration system
TB Tuberculosis
USAID United States Agency for International Development
UNDESA United Nations Department of Economic and Statistical Affairs
UNDP United Nations Development Programme
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
UNSD United Nations Statistics Division
VA Verbal autopsy
WB World Bank
WHO World Health Organization
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HealtH Metrics NetworkWorld Health Organization
Avenue Appia 20, CH-1211 Geneva 27, SwitzerlandTel.: + 41 22 791 1614Fax: + 41 22 791 1584
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