Prepared By: Asiimwe Abel

Health Management Information Systems I (HMIS I)-Degree

Definitions: ‘Health Management Information Systems (HMIS)’ is a tool which
helps in gathering, aggregating, analyzing and using information for taking
actions to improve performance of health systems. It is designed to assist
managers to undertake evidence- based decision making at all levels of the
health care service delivery system as its goal states …… to provide quality data
that supports evidence-based decision making at all levels of the health care service
delivery system in Uganda

HMIS is an integrated system used by MOH, development partners, and

stakeholders to collect relevant and functional information on a routine basis to
monitor the Health Sector Strategic and Development Plan (HSSDP) indicators to
enable planning, decision making, monitoring, and evaluation of the health care
delivery system.

The Mandate of HMIS: To ensure that there is a continuous flow of good quality
disaggregated data on health of populations and health care services to assist
in local planning, programme implementation, management, monitoring and
evaluation.

Attributes/Concepts of HMIS
HMIS was developed within the framework of the following thoughts/ideas of how the
system will work continuously:
❖ Relevancy: The information collected is relevant to the policies and goals of the
Government of Uganda, and to the responsibilities of the health professionals at the
level of collection.
❖ Functionality: The information collected is functional; it is to be used immediately for
management and should not wait for feedback from higher levels.
❖ Integration: Information collection is integrated; there is one set of forms and no
duplication of reporting.
❖ Routine Basis: The information is collected on a routine basis from every health unit
in all districts within Uganda.
❖ Routine Reporting: The frequency of routine HMIS reporting varies from
weekly, monthly, quarterly to annually depending on the health care service
offered and the urgency of the reported information.

Page 1 of 67
 Prepared By: Asiimwe Abel

Uses of HMIS data and information

• Planning
• Predicting epidemics
• Detecting epidemics
• Designing disease-specific interventions
• Allocating resources/Resource allocation
• Monitoring Work plan performance. Help health workers to organize and monitor
health development work in their communities;
• Program Monitoring and Evaluation i.e monitor and evaluate the progress of the
sector activities (Measures Performance and Results)
• Health Infrastructure Development
• Drugs Quantification
• Human Resources Deployment
• Support Decision making
• Health Care Assessment.
• Health Needs Assessment
• Comparisons of health care trends

5 Major/desired qualities of HMIS data and information

HMIS must provide accurate, timely, completeness, relevant and functional information
in order to accomplish the long-term goal of supporting evidence-based health care
delivery services and achieve health for all.

1. Accuracy - Ability to collect information which is error free and can provide the
best representation of the true prevailing situation. To ensure accuracy of HMIS
information, data must be collected using standard methods, correctly following
procedures for compiling data, continuously cross checking to eliminate errors and
make corrections where necessary, and store data in a format ready for analysis at any
time.

2. Timelines - Ability to provide the information at the earliest time possible to support
adequate decision making at any level. To ensure timeliness of HMIS information, all
levels of reporting should comply with the agreed deadlines. A DATABASE is required at
the health units, HSDs and the Districts to record and monitor aggregated information in
one central place.

Page 2 of 67
 Prepared By: Asiimwe Abel

3. Completeness: Ability to wholesomely fill the data collection tools with required
data as well as send all the reports as per the expected target. To ensure completeness
of HMIS information, data must be collected using standard data collection tools meant
for collecting data, continuously verified and validated ready for timely
submission/reporting.

4. Relevance: The information collected is applicable to the policies and goals of

the Government of Uganda, and to the responsibilities of the health professionals to
support decision making at the point of collection. To ensure relevance of HMIS
information, HMIS is regularly reviewed to ensure that it is in-line with the goals and
objectives of the major health policies and programmes, and that the collected
information is actually utilized and or consumed by the stakeholders.

5. Functional - to ensure functionality, the information collected should be

used immediately at the point of data collection for management and decision
making before reporting to the next/higher level. You should not wait for
feedback from higher levels.

Page 3 of 67
 Prepared By: Asiimwe Abel
SIX COMPONENTS OF A HEALTH MANAGEMENT INFORMATION SYSTEM
The Health Metrics Network’s
There is clear value in
“Framework and Standards for defining what constitutes a
Countries Health Information Systems” health management
information system and
describes the six components of a
how its components
health management information interact with one another
system and the standards needed for to produce better
information for better
each. There is clear value in defining decisions and better
what constitutes a health management health.
information system and how its components interact with one another to produce
better information for better decisions and better health. In addition to its six
components, a health information system can be further divided into its inputs,
processes, and outputs. Inputs refer to resources; processes touch on how indicators
and data sources are selected and data are collected and managed. Outputs
deal with the production, dissemination, and use of information. Accordingly, the six
components of a health management information system are as follows:

Inputs

1. Health information system resources. These consist of the legislative,

regulatory, and planning frameworks required to ensure a fully functioning health
management information system, and the resources that are prerequisites for such
a system to be functional. Such resources involve personnel, financing, logistics
support, information and communications technology (ICT), and coordinating
mechanisms within and among the six components.

Processes

2. Indicators. A core set of indicators and related targets for the three
domains of health information outlined in is the basis for a plan and strategy for
a health information system. Indicators need to encompass determinants of
health; health system inputs, outputs, and outcomes; and health status.

3. Data sources can be divided into two main categories: (1) population-
based approaches (censuses, civil registration, and population surveys) and (2)
institution-based data (individual records, service records, and resource records)
describes a basic set of standards for each source and strategic elements in
Page 4 of 67
 Prepared By: Asiimwe Abel
achieving these standards. A number of other data-collection approaches and
sources-occasional health surveys, research, and information produced by
community-based organizations do not fit neatly into either of the two main
categories but can provide important information that may not be available
elsewhere.

4. Data management. This covers all aspects of data handling: collection,

storage, quality-assurance, flow, processing, compilation, and analysis. Specific
requirements for periodicity and timeliness are defined where critical—as in the
case of disease surveillance.

Outputs

5. Information products. Data must be transformed into information that will

become the basis for evidence and knowledge to shape health action.

6. Dissemination and use. The value of health information (information

product) can be enhanced by making it readily accessible to decision makers
(giving due attention to behavioral and organizational constraints) and by
providing incentives for information use.

For a health information system to

For a health management
function, policy, administrative,
information system to
organizational, and financial function, system resources
prerequisites must be in place. policy(ies), administrative
(ion), organizational, and
Supportive legislative and regulatory financial prerequisites must
environments are needed to enable be in place.
confidentiality, security, ownership,
sharing, retention, and destruction of data. Investment from domestic and
international sources is required to strengthen ICT and provide human resources to
run these systems.

Page 5 of 67
 Prepared By: Asiimwe Abel
HMIS DATA MANAGEMENT

The HMIS data management helps you to understand procedures for data collection,
storage, processing, analysing, distribution and use of data. An illustrative tool that is used to
define data management is the “Information Cycle”.

Data management involves a set of procedures for collection, storage, processing,

analyzing, distribution and use of data. It enables you to sees the link between the different
phases of collecting data, processing data by checking quality, analysing data to obtain
information in form of indicators, presenting information in a user-friendly way and using the
information as evidence based in decision making at local, district and national levels.

The Information Cycle. The information cycle presents the key steps in the data
handling/management process which is applicable to both the users and data collectors of
health information. Each stage/step is briefly described below;

BASIC CONCEPTS

Data - is an aggregation of data elements - in the form of numbers, characters,

images -that gives information after being analyzed.

Data Element - is a recorded event used as numerators and denominators in the

calculation of indicators
Information - is data organized with reference to a context which gives data a
meaning.
Page 6 of 67
 Prepared By: Asiimwe Abel
Data set - is a group of data elements that are categorized under a minimum set of
essential indicators
Knowledge - when information is analyzed, communicated and acted upon, it
becomes knowledge. Forexample;-
Knowledge: Why are some
pregnant women able to
Data: No. of pregnant Information: % of pregnant receive skilled birth
women received skilled birth
women in an area who assistance? Why some
assistance & % of pregnant pregnant women who were
received skilled birth left out? Who were left out?
women who were left out
assistance in delivery What are the issues related
to access to service?
Group Work/Presentation

In groups of 5 students, answer one of the following:

1. Identify and Explain the various sources of HMIS data and Information.
2. Explain ten (10) uses of HMIS data and Information
3. Examine the three (3) major components of HMIS framework
4. Describe the flow of HMIS data in Uganda’s health system.
5. Describe the six (6) key steps involved in HMIS data management Information
cycle

SOPs for Data Collection and Aggregation of HMIS Data

DEFINITION OF SOPs. Standard operating procedures (SOPs) ‘are a set of step by step
instructions compiled by an organization to help workers carry out complex routine
operations. SOPS aim at achieving efficiency, quality output and uniformity of performance
while reducing communication and failure to comply with organizational regulations. The
HMIS SOPs are written, step-by step InStruction5 that describe how HMIS data s collected
aggregated and cleaned Health workers and records staff involved in management of HMIS
data should follow these SOPs in the exact same way every time so that health facilities can
remain consistent in the management and reporting of their HIV related data.

These HMIS SOPS have been developed using simple language, they are easy to read, brief,
easy to understand and contain actions steps that are simple follow. These SOPs clearly
outline the various steps involved in management of HIMS data and guide the target users
in case of any concerns. These SOPs should be the basis for training any new staff in
management of HMIS data. They will be updated whenever revisions are made in the HMIS

Page 7 of 67
 Prepared By: Asiimwe Abel
tools used in the collection aggregation and reporting of HMIS data to ensure that they stay
relevant to the current needs of the Ministry of Health.

The HMIS SOPS relate to general aspects of management HMIS data including data
collection and aggregation This SOP document describes specific data quality control
measures during data collection and aggregation of HMIS data monthly and quarterly for
reporting. The document lays out the Structure of the staff and parties involved in
management of HMIS data and their specific responsibilities necessary to implement the
Data Collection and Aggregation functions in management of HMIS data.

There a-e several, challenges involved in management of HMIS data and these include the
following among others:
❖ Existence of parallel information systems which have affected the efficiency of data
management in various sub-systems as it overloads the already existing government
systems and affects quality of data produced
❖ Poor and incomplete recording of HMIS data.
❖ Use of non-Standardized forms in provision of health services at service delivery points,
has been happening owing to lack of Standard Operating Procedures (SOPs)
❖ Lack of guidance on how to collect and aggregate HMIS data.

The overall purpose of the HIV related data management SOPs is to guide data collection,
analysis, Storage and utilization of HIMS data. They win also provide management strategies,
tools and devices used to manage HMIS data.

Anticipated benefits of having SOPs for management of HMIS data:

1) Harmonization of HMIS data management procedures to ensure efficiency and
effective coordination in the use of scare resources
2) Complete and good quality HMIS data
3) To provide guidance to health workers on how to collect and aggregate HMIS data
4) To provide guidance to health workers and other staff Involved in aggregation and
cleaning of HMIS data.
5) To provide complete HMIS data to achieve efficiency, quality output and uniformity
of performance

Target Users of the SOPs for management of HMIS data;

The intended users of the HMIS data management SOPs include health workers involved in
provision of health services and management of HMIS data and their supervisors at district
and national level.

Page 8 of 67
 Prepared By: Asiimwe Abel

Staff involved in provision of health services and management of HMIS data are the primary
users of these SOPs and are expected to ensure that the recommended tools are utilized
during service delivery while the secondary users, who are the supervisors are expected to
institute mechanisms that promote compliance and adherence to national tools.

Data acquisition teams at all levels in the health sector are instrumental in follow-up of HMIS
data quality assurance issues and functionality of the EMR and DHIS2 to ensure that all
relevant HIV related data are entered into the respective electronic systems in a timely
manner.

The primary users of the HMIS SOPs include Staff Involved in provision of health services are
management of HIV data namely:
1) Frontline health workers managing HMIS data
2) Data personnel involved in management of HMIS data
3) District Health Team members involved in supervision of HMIS data management
processes
4) Data Managers and M&E related staff involved in management of HMIS data at
various levels of the Health Sector
5) Implementing Partner staff involved in supporting provision of health services
6) Central level supervisors

While the secondary users Include Regional and National level Supervisors namely,
1) Health service Supervisors at Regional Referral Hospitals
2) Health Implementing Partner Technical staff involved in supporting district and health
facility HMIS teams
3) Regional HMIS Data Supervisors at Regional Hospitals and Health Implementing
Partners
4) MoH Program and M&E related staff DHI and other MoH Programs and Departments
5) PEPFAR M&E Agents e.g. METS
6) PEPFAR SI TWG
7) MoH, USG & UN Health Committee

Page 9 of 67
 Prepared by ASIIMWE ABEL
Roles & Responsibilities of HMIS Data Managers
This section describes the responsibilities of all parties involved in implementation and use
of the SOPs for management of HMIS data:

A) NATIONAL LEVEL. These are structures charged with streamlining and steering the
operating apparatus and delivery mechanisms for health services within the health
sector. The structures include:
1) MoH, USG & UN HIV/AIDS Committee
2) MoH M&E Technical Working Group (M&E, TWG)

Data Management Expectations of MoH, USG & UN HIV/AIDS Committee

➢ Coordinate HIV related data quality management and assurance efforts.
➢ Demand and advocate for utilization of valid and real-time HIV related data,
➢ Provide technical assistance to implement and coordinate evidence-based
HIV responses,
➢ Discuss HIV related national reports to identify gaps and strategic remedies.
➢ Share experiences, lessons and best practices for replication.
➢ Use HIV related reports to propose policy reviews with a purpose to improve
resource allocation to HIV related services.

Data Management Expectations of MoH M&E Technical Working Groups

➢ Extract data from HMIS systems including DHIS2 and other relevant data sources
at national level and thus;
❖ Clean HMIS data
❖ Send feedback to regional level HMIS teams, districts and health facilities
detailing inconsistencies
❖ Follow-up and address inconsistency in HMIS data
❖ Validate HMIS data
➢ Approve, review and rollout HMIS data management tools and technical
resources including data collection registers, assessment forms, standard
operating procedures (SOPs) and indicators, among others.
➢ Support supervises Regional and other sub-national structures involved in data
quality assurance and utilization of SOPs and manuals for HMIS data quality
improvement.

Page 10 of 67
 Prepared by ASIIMWE ABEL
➢ Support supervises regional and other related sub-national levels on HMIS data
validation and quality assurance.
➢ Review HIV M&E frameworks and plans of the Health Sector, quarterly/ annual
health reports and recommend actions for improvement.
➢ Share experiences, lessons and emerging practices and recommend appropriate
actions to improve the health response.
➢ Review reports to inform strategic policy direction and inform health programming
including developing issue papers for Health Sector Health Committees to guide
on advocacy efforts.

B) REGIONAL LEVEL. These include Regional Teams involved in supervision of district and
health facility level staff involved in provision of health services and management of
HMIS data, these Include;

Regional Level Teams at the Regional Referral Hospital Including Implementing Partners
that support provision of health Services

Data Management Expectations of Regional Level Teams at the Regional Hospital

including Regional Level Implementing Partners;
➢ Extract data from HMIS systems including DHIS2 and other relevant data sources
within their respective regions:
❖ Clean HMIS data
❖ Send feedback to districts and health facilities detailing inconsistencies
❖ Follow-up and add inconsistency in HMIS data
❖ Validate HMIS data
➢ Analyze quarterly/annual HMS data, generate HIV M&E reports arid share reports
with district/health facility level health data governance and management
structures, district level implementing partners (IPs) and all other relevant
stakeholders and:
❖ Develop HMIS technical resource materials for approval by M0H MoH M&E, TWG
❖ Support provision of health-related services within the respective district in the
region

Page 11 of 67
 Prepared by ASIIMWE ABEL
C) DISTRICT LEVEL. Premised on the instrument of decentralization, a district and HSD
have the obligation to effect and regulate health service delivery within its precincts.
The MoH-UACP does not encourage formation of additional structures but calls for
support to already established and functional decision support systems to assimilate
HMIS data governance and management functions. Structures include;

1) District Health Committees

2) District Health Teams (DHTs)

HMIS Data Management Expectations of District Health Committee:

➢ Harmonize health programming and service delivery including follow-up on
implementation of HMIS data management tools and guidelines,
➢ Provide quarterly reports on performance of health interventions, provide
feedback to health facilities and submit action reports to the district council,
➢ Support holding of quarterly data reviews, planning and feedback meetings,
➢ Use HMIS data to formulate and review district health strategic plans and ensure
its integration into the district development plan and submission to District Council
for approval,
➢ Promote programme advocacy and fundraising for health actions,
➢ Conduct support supervision, monitoring and evaluation focusing on health data
demand and use,

Data Management Expectations of the District Health Teams (DHTs)

➢ Review Health reports and make recommendations to Health facilities and
other health committees,
➢ Review support supervision reports and develop action points to address HMIS
data quality,
➢ Develop HMIS data quality improvement plans and devise ways for their
implementation
➢ Plan tor the subsequent integrated support supervision to address technical
gaps.
➢ Identify issues to present to council for approval and financing of health
interventions
➢ Conduct HMIS data quality assessment to ensure generation of quality HMIS
data,

Page 12 of 67
 Prepared by ASIIMWE ABEL
➢ Coach/mentor Health Facility Staff on HMIS DQA protocols.
➢ Support HMIS collection, reporting, validation and audits,
➢ Disseminate HMIS too1s and promote use of approved MoH HMIS tools

D) HEALTH FACILITY LEVEL. Health Workers involved in provision of health services and
Management of HMIS data.

HMIS Data Management Expectations of the Health Workers involved in provision of

health services and Management of HMIS data
➢ Ensure provision of quality health services within the health facility catchment area
➢ Ensure generation of Quality, complete and real-time analyzed data to support
health decision making
➢ Ensure quality HMIS data collection, validation, cleaning analysis, reporting and
data dissemination
➢ Timely reporting, resolve inconsistencies and validate HMIS data using HMIS
source documents
➢ Increased stakeholder’s confidence and reliance on HMIS data to make health
decisions
➢ Ensure that all HMIS data reported through DHIS2 is validated, audited, cleaned
and entered in time
➢ Adherence to all HMIS data management tools, procedures. SOPs and manuals
➢ All HMIS data validated and cleaned before being reported through DHIS2
➢ Utilization of HMIS data to make management decisions at the health facility level
➢ Utilize HMS data to make health facility-based health plans and decisions aimed
at improving the quality of health services within the health facility catchment
area.

HMIS Reporting Mechanism

HMIS reporting is both internal and external. Internal within the department or the
health facility by using report forms and the summary tables found in the
database. External reporting pertains to higher administrative level on routine
basis or during an emergency to facilitate decision making.

HMIS provides data collection tools for capturing patient level data, which is
aggregated into summary reports for submission to the next level. The flow of HMIS

Page 13 of 67
 Prepared by ASIIMWE ABEL
information is from the lowest level which is the community, to the health unit,
health Sub-district, district and finally to the National Health Databank /Resource
Centre of the Ministry of Health.

Types of HMIS reports

• Emergency/Special Reports: Used for reporting urgent information like

suspected disease outbreaks and breakdown of key medical equipment.
HMIS tools used include: case-based forms, log-books, equipment
breakdown form e.t.c

• Routine reports: Used to carry out periodic reports submitted to higher levels
of health care for regular monitoring of health care delivery indicators and
routine decision making.

Periodicity of HMIS reporting Tools by Event

▪ Special event
✓ Daily reporting (Within 24 hours)
• Case-based investigation forms (HMIS 033a HU notifiable disease report) i.e
Line listing of case-based investigation forms used for reporting cases of
communicable diseases or diseases identified for eradication e.g. AFP,
Granular TB case report or any disease outbreak
• Equipment breakdown - Just in case very essential equipment broke down.
▪ Routine
✓ Weekly reports
• HU/HSD/District weekly epidemiological surveillance report (HMIS
033b)
• Partner SURGE reports

✓ Monthly reports
• HU Monthly OPD Report (HMIS 105)
• HU Monthly Inpatient Report (HMIS 108)
• District Monthly OPD Report -HMIS 123

Page 14 of 67
 Prepared by ASIIMWE ABEL
• District Monthly Inpatient Report -HMIS 124
✓ Quarterly
• HU Quarterly report (HMIS 106a)
• HU Quarterly assessment report (HMIS 106b)

✓ Bi-annual reporting tools e.g HU/District Equipment inventory, HU/District

Physical inventory HU/District Staff list

✓ Annual reports e.g. Annual report (HMIS 107)

▪ Performance Assessment
✓ Population report
✓ Quarterly reports (Quarterly assessment report (HMIS106b) and Quarterly
indicator summary (HMIS Table 15)

HMIS Reporting Tree – Flow of HMIS Data and Information

- See bellow an illustration for HMIS data reporting mechanism and get to
know the MOH deadline at each level of reporting

Page 15 of 67
 Prepared by ASIIMWE ABEL

Reporting of HMIS data in Uganda is done through a network of district health

offices, which collect and summarise health information from health sub-districts
and health facilities. Summary reports for the districts are then submitted to the
Ministry of Health where data is compiled to derive national figures on health and
health management indicators.

Page 16 of 67
 Prepared by ASIIMWE ABEL
Data Communication and Feedback
All health service delivery data and information must be routed through the MOH
Division of Health Information for validation, analysis, and dissemination. A
feedback mechanism exists where by the central health data bank provides
summary analyses on a monthly basis to all districts, showing their comparative
performance in terms of reporting (timeliness and completeness) and a selected
list of health sector indicators. Feedback mechanisms on reported data flow from
top to bottom (Ministry of Health to the community level).The districts with poor
indicators are encouraged to review their service delivery strategies and
reporting status. Districts are further encouraged to replicate this feedback to the
lower health facilities.

Page 17 of 67
 Prepared by ASIIMWE ABEL
Subsystems of HMIS Reporting Systems

WHO categorizes HMIS reporting under five interrelated “subsystems”?

1. Epidemiological Surveillance Reporting system- e.g. for notifiable infectious

diseases, certain environmental conditions, disease outbreaks and risk
factors;
2. Routine Service Reporting- e.g. routine disease/condition health care data
from the basic health services at community level, health centers, first
referral hospitals, and tertiary hospitals;
3. Special Program Reporting Systems- e.g. HIV/AIDS, Malaria, tuberculosis (TB)
control, maternal and child health (MCH), and school health, e.t.c.
4. Administrative Systems, including/such as health care financing systems,
health personnel Human resource systems, drugs and logistic systems,
financial management systems, health-training programs, health research
programs, and health documentation management;
5. Vital Registration Reporting Systems- e.g. for births, deaths, Marriages .and
migratory movements e.t.c

Categories of data reported under HMIS reports.

Below is the list of aggregate data reported under HMIS reports

➢ Preventive Activities e.g. Notifiable diseases, PMTCT, child health, ANC,
maternity services, FP, HCT etc.
➢ Resource Management e.g. Building and equipment, HR, Finances etc.
➢ Curative service and MCH e.g. OPD data, Inpatient data/information,
laboratory Information, operating theatre information, x-ray information
etc.
➢ Individual Client Activities e.g., drugs/treatment, referrals, diagnosis
(Provisional and final e.g. at discharge), New and re-attendances, final
status lf the patient etc.
➢ Logistics and Commodities e.g. Medical and other health supplies
➢ Finance and Accounts e.g. Private wings, cash analysis, financial summaries
for accountabilities

Page 18 of 67
 Prepared by ASIIMWE ABEL
➢ Disease surveillance data - daily or weekly special reporting of diseases of
public health concern e.g. outbreaks/rampat of Ebola, measles, maternal
death, AFP, AEFI etc
➢ Community data (VHT) e.g. General information on households, information
on children 5 years and below, pregnant women, Household effects
(water, food, sanitation and other services)

Principles of HMIS Data Reporting

✓ Service delivery Data needs to be recorded in primary recording registers.

✓ When service is delivered, the monthly data is aggregated and written

onto the reporting format.

✓ Data reported should reflect the services rendered by the providers in that
facility.

✓ Each Data to reported should be entered in one form only. (reduce

burden and errors)

✓ No reported data should be collected which does not contribute to at

least one health indicator. (a data that is not convertible as an indicator
can seldom be used at all)

Issues that affect HMIS reporting (Problems/Challenges)

• Human resource (lack of personnel or absenteeism)
• Create demand for data at the point of collection
• Build capacity to utilize the data collection tools
• Technical support supervision and follow ups
• Sufficient feedback e.g. league tables
• Lack of HMIS logistics like calculator, computers and stationery
• Lack of commitment
• Confusion about the correct reporting channels
• Lack strong conditions concerning violation of reporting deadline
• People attitude or thoughts
• Poor coordination of work as to create time for data mgt.
• Lack of fast means of reports at each level

Page 19 of 67
 Prepared by ASIIMWE ABEL

HMIS Documentations and Tools (Data Collection Tools)

Categories of HMIS Documentation

HMIS manual: The manual consists of all pre-primary and primary data collection
tools (patient cards, registers, among others).

HMIS database: This is a secondary document that contains all relevant summary
tables for summarizing data from both pre-primary and primary data collection
tools.

Indicator booklet: This contains indicator definitions, methods of data collection,

frequency, calculation, and interpretation.

Categories of HMIS Data Collection Tools

Data collection tools serve as the key entry point of data into the information
cycle. Accurate and completed at a collection therefore forms the foundation
of any data management plan. Capturing data usually involves recording data
about an individual patient or service that is rendered. Individual patient
monitoring tools are used to document information for monitoring the status of an
individual patient.

These are either Forms, Registers, Log/Record/Stock Books, Reports, Card or Notes
used to capture or report health care data and information. They capture raw
data of health indicators categorized under data sets and data elements. These
are of four types; -

1. Source Document aka Pre-Primary HMIS tools. Contain the first contact information
used to identify/locate a patient’s details. These are considered patient monitoring
tools for capturing both curative and preventive individual patient health care data
e.g. OPD Medical form/sheets, Cards (HCT, ANC, MCH, Growth, Child Health e.t.c.),
Requests (Lab request, x-ray request e.t.c) and Notes like (Referral note & Discharge
note)

Page 20 of 67
 Prepared by ASIIMWE ABEL
2. / Data Sources aka Primary HMIS tools. Also called Aggregate Data Collection Tools
that Records patient details on a daily basis for evaluating health unit performance
e.g. Registers, Tally sheets (abstract of registers), Log books, Records books cash
analysis book, Stock books and Requisition books e.t.c.

3. Secondary tools/ Aggregate Data Reporting tools. These reports summaries

of performance by programmatic area as per data sets and data elements

e.g. Decision Support Reporting tools (HMIS 105, 108, 033b e.t.c.),
Performance Assessment/ M & E Tools; - M & E tools (Quarterly reports
(Quarterly assessment report (HMIS106b) and Quarterly indicator summary
(HMIS Table 15), annual reports) and Population reports (HMIS 109)

4. Resource Management tools. Used to evaluate health unit managerial

functions e.g. (Physical inventory, Physical and Equipment inventory reports,
Staff list Supervisory checklists e.t.c.

Components of Data collection tool.

Data collection tools involves three important components; -

- Standardized definitions for data elements and indicators

- An essential dataset based on a defined minimum indicator set
- Appropriate data collection tools

Qualities of Good Data Collection Tool (HMIS Tool)

An HMIS Data collection tool should be measured against the SOURCE criteria:

➢ Simple and easy-to-use for collecting data and extracting it

➢ Overlap between tools should not exist
➢ Useful to data collectors locally, supervisors and researchers
➢ Relevant to key functions of the unit
➢ Clearly laid out and easy to understand
➢ Effective in providing the required outcomes and results

Page 21 of 67
Prepared by ASIIMWE ABEL

Page 22 of 67
 Prepared by ASIIMWE ABEL
HMIS Data Quality

What is Data Quality?

The degree to which the data or statistics measure what was intended to be
measured when the data collection system was designed. No data set is perfect;
however, we need to control the quality of data so as to aim for the highest
possible quality. Good data quality should start with reliable and appropriate
collection tools and methods. If the data collection process is made easy, the
chances of getting good quality data are increased. Building quality into the
process of data collection right from the beginning will assist data quality control.

Elements of HMIS Data Quality.

Quality of HMIS data has two components i.e.

- the characteristics that meet user needs and thereby provides user
satisfaction (e.g. timely, complete, consistent and user friendly).

- the absence of deficiencies that result in user dissatisfaction (e.g. gaps,

outliers and inaccessibility)
The above elements assume that the “user” is the key person who will determine
and be the judge of quality. This implies that we all are responsible and have a
hand in determining and defining how and what the quality of our data in the
public health sector should be.

Qualities of good quality HMIS data.

The essential characteristics of good quality data are as follows:

▪ Available at all levels and on time. Old data is of historical value only. Decisions
must be made based on current, updated information thus should be readily
available when needed.
▪ Comprehensive – collected from all possible data sources.
▪ Reliable - truthful enough to support decisions
▪ Accurate –. If data is not accurate, then wrong impressions and information
are being conveyed to the user. Recording data is subject to human error and

Page 23 of 67
 Prepared by ASIIMWE ABEL
steps must be taken to ensure that errors do not occur or, if they do occur, are
picked up and immediately rectified.
▪ Usable, if not discard the data.
▪ Comparable i.e. using the same definitions of data items. If we don't measure
by using the same tool we can't compare each other's results. Comparability
can be ensured by using the same numerators and denominators in formulas.

Importance/Significance of good quality HMIS data and Information

Why HMIS data quality Important. Accurate, timely and accessible health care
data plays a vital role in the Planning, Development, and Maintenance e.t.c of
health care services. Poor data means Poor Decisions. Therefore, good quality
HMIS data facilitate:
▪ Good decision making
▪ Appropriate planning
▪ Ongoing Monitoring and Evaluation
▪ Improved coverage quality of care
▪ Accurate picture of health programs and services
▪ E.t.c refer to purpose/uses of HMIS data and information

Factors that contribute to poor quality HMIS data:

▪ Inappropriate data collection

▪ Failure to report data
▪ Unintentional recording and reporting of inaccurate data
▪ Intentional recording and reporting of false data
▪ Errors in processing data - Editing, Coding, Data entry, Tabulating
▪ Faulty information systems
▪ Poor processes indicators
▪ Poor guidance and training of staff
▪ Poor or No feedback in terms of data completeness, timeliness and
quality
▪ Insufficient capacity and shortage of Health Information Managers
▪ Poor data collection tools
▪ Poor data elements and indicator definitions

Page 24 of 67
 Prepared by ASIIMWE ABEL
Assessment of HMIS data quality (Data quality Assessment).
When assessing data quality, one needs to keep in mind the essential
components of good quality data previously/earlier mentioned. Listed below are
some quick and common ways to check data quality:

▪ “Eyeballing” (visual scanning) the data for gaps and outliers

▪ Application of software data quality functions
▪ Regular setting of minimum and maximum ranges
▪ Missing records and outlier’s analysis
▪ Displaying records with “check it” ticket
▪ Applying validation rules
▪ Comparing data to historical trends
▪ Comparing data to other unit (facilities/districts)
▪ Searching for patterns and analysing the relationships between data
elements

How do we ensure good quality HMIS data?

▪ The most effective way of ensuring good data quality is to check the data
yourself by visually scanning for the common sources of errors like gaps,
spellings, or duplicates.
▪ Also, another effective way to ensure data quality is to look at the data and
conduct visual scanning (eye-balling), specifically looking for the potential
data quality problems. First look across each line and then from top to
bottom; it is important to look for missing data values, obvious fluctuation,
inconsistencies between linked data elements and for mathematical errors.
▪ Another way is to set up systems to make sure that the data we collect is of
good quality right from the start. The following systems and procedures can
be applied:
➢ Training staff in data collection, data quality checks and use of information
for action

Page 25 of 67
 Prepared by ASIIMWE ABEL
➢ Ensuring that standardised data elements and indicator definitions are
made available at data collection points and are understood. Keep a list
posted in your facility
➢ Looking for possible weaknesses in the system, such as double counting or
missing of entries
➢ Making data collection as easy as possible using user friendly tools, limited
dataset, limited number of forms and registers or limited duplication of
entries
➢ Pre-testing any new data collection tools before introducing them
➢ Having clearly defined responsibilities at every step in the information cycle
➢ Having procedures in place to formally check data quality
➢ Proving feedback to staff on the quality of the data they submit
➢ Helping staff to understand why they collect data i.e. provide feedback
on how data is used by managers and how to use data themselves to take
local decisions or to lobby for specific management decisions or actions
➢ If possible, errors are identified, look for the source of the error and correct
where possible
➢ Use or Ensure standards for data collection, processing and analysis
achieved with the help of;

Note; - With detailed raw data we can pick up many mistakes that would be
invisible in aggregated indicators. Many small mistakes also impact on nationally
aggregated indicators. It is therefore recommended that data be checked after
it has been captured, before it can influence future indicators.

HMIS poor quality data problems (What are the common data problems)

Poor data quality can be attributed to errors in the way information is collected
and processed. These errors include among the following;
• Large gaps
• Data entry in wrong boxes
• Unusual month to month variations
• Typing errors (typos)

Page 26 of 67
 Prepared by ASIIMWE ABEL
• Maths problems or Poor calculations
• Duplication
• Inconsistencies or unlikely values
• Data present where it should not be (wrongly presented)
• Eligibility E.t.c.

HMIS Data quality checks

All health care service employee, including clerical staff, health professionals,
administrators and health information managers, need to gain a thorough
knowledge and understanding of the key components of the data quality in
order to always verify and validate both collated and aggregated health care
information as it is a requirement for continuous data improvement. The three ‘C’s’
of good quality data are that it must be:

▪ Correct
▪ Complete
▪ Consistent

Data Verification. Data Verification is the process of assessing data accuracy,

completeness, consistency, availability and internal control practices that serve
to determine the overall reliability of the data collected. For data verification to
be correctly applied, various standards, procedures and ground rules need to be
in place at the health centre to ensure that data collection rules are consistently
ad uniformly applied and clearly communicated to those who are responsible for
data collection

The following ground rules must be put in place at the health centre level to
support verification of data collected:

➢ Data elements are well defined, documented and definitions are

available, understood and used
➢ Collection standards are documented, available and used
➢ Data reporting schedules documented, distributed and followed

Page 27 of 67
 Prepared by ASIIMWE ABEL
➢ Staff responsible for data collection are trained and skilled in proper
procedures

Data validation ascertains the usability of the data against a set of rules to find
out if data are correct which involves assessing whether data collected are a
true reflection of the performance being measured often done automatically
through computer checks to ensure that the data entered is sensible and
reasonable. The main aim of data validation is to reduce data entry errors and
enhance the integrity of data before data is saved or submitted or reported.

Forms of Validation Rules (Applying Validation Rules).Data validation can be

done manually or electronically, but validation can also be done without a
computer applying certain validation rules on the monthly data reports before
sending the report to the next level. Validation rules are predefined rules to ensure
good quality data. There are two forms of validation rules; - Absolute and
Statistical.
▪ Absolute rules apply when one value cannot be higher than another. E.g,
if child attendances at a Health Facility for a month is 234, then the total
Health Facility headcount of children for that month cannot be 225

▪ Statistical rules are more flexible and are designed to ensure that the ratios
between data elements are not transgressed (go beyond the limits set by
standards). E.g, children with diarrhea is correlated/connected with
headcount for children under 5years. If the headcount goes up, one would
expect the number of cases of diarrhea to increase as well in the same
proportion. The statistical rule follows the pattern and will identify outliers.

Note- A number of these rules can pre-defined in the electronic information

system and the system will run these checks automatically and give warnings if
the data that was entered violated any of these rules. Data captures have to
carefully check the data and verify possible wrong entries with the facilities that
submitted the data. However, facilities with no computers have to apply these
validation rules manually.

Page 28 of 67
 Prepared by ASIIMWE ABEL
Note- Implementing the verification and validation of data is an important step in
data processing to identify incorrect data for corrective action so that only valid
data are recorded, processed and used for decision making.

Elements of HMIS Data Quality (Data Quality Dimensions in Respect to Health

Information Products)

What should be done to improve the quality of data collection?

In respect to health information data, accurate and complete data collection

is the foundation of a good data management plan at all levels. Therefore, it is
incumbent that all staff involved in provision of health services and management
of HMIS data are always oriented, support supervised, coached and mentored
with integrity and confidentiality in order to adhere to the dimensions and
achieve quality HMIS data and to ensure that HMIS data meet quality standards
framework. The following elements/dimensions are key to delivery of quality HMIS
data:

1. Accuracy. To ensure accuracy of health information, HMIS data must be

collected using standard methods, correctly following procedures of compiling,
continuously cross checking to identify and eliminate errors and making
corrections where necessary and storing data in a format ready for analysis at
any time.
2. Timeliness. HMIS data is timely when they are up-to-date (current) and
when health information is available on time ready for serviceability/use. To
ensure timeliness of health information, health service providers should comply
with agreed upon deadlines for reporting of HMIS data. In addition to the EMR
and DHIS2, all staff involved in provision of health care services are encouraged to
record and monitor aggregated health information in one central place.
3. Validity. HMIS data is considered correct for use when it measures what it
intended to measure. To achieve quality, HMIS data should be collected
consistently using approved tools. Data collection should be based on protocols

Page 29 of 67
 Prepared by ASIIMWE ABEL
and procedures that do not change according who is using them and when or
how often HMIS data are used.
4. Completeness. This quality element means that an information system from
which the results are derived is appropriately inclusive. It represents the complete
list of eligible persons or units and not just a fraction of the list. Staff involved in
management of HMIS data should report complete information of the health
service they provide to various clients.
5. Consistency. HMIS data generated should have logical coherence among
related aspects of data. For example, the number of pregnant women given
iron/folic acid for treatment of anemia should not be greater than number of
anemic pregnant women.
6. Reliability. The extent to which we can rely on the source data and this
evaluates whether HMIS Data show similar results when health indicators are
measured more than once using similar characteristics.
7. Integrity. Maintaining integrity of HMIS data means that the HMIS data
generated should be protected from deliberate bias or manipulation for any
reason whatsoever. Its assumed that data will determine quality service rendered.
This implies that we all are responsible and have a hand in determining and
defining how and what the quality of our data in the public health sector should
be.
8. Confidentiality. Facility/Personal HMIS data should not be disclosed
inappropriately and data that is kept in hard copy or electronic form should be
secured in locked cabinets and use of password protected files is highly
recommended.

Page 30 of 67
 Prepared by ASIIMWE ABEL
Knowledge, Use and Calculations of Health Indicators

Knowledge of Health Indicators

Raw data has to be made into useful information in the form of indicators, which
relate the data to standardized populations or sub-groups or items. In order to
manage health services well and for attainment of optimum health of
beneficiaries and users, Health Program Managers at various levels need to
know…

– Who gets sick?

– What illnesses are most common?

– Where do these people live?

They also need to know…

– What health services are provided?

– Who uses these services?

– What is the quality of these services?

– How much do these services cost?

Health Indicators help to answer these questions. So what is a Health

Indicator?

- An indicator is: "A measurable variable (or characteristic) that can be used to
determine the degree of adherence to a standard or the level of quality
achieved."
- Indicators are generally defined as “variables that help to measure changes,
directly or indirectly” – (WHO, 1981).
- Indicators are variables that indicate or show a given situation, and thus can be
used to measure change over time – (Green)

Page 31 of 67
 Prepared by ASIIMWE ABEL
Use of Health Indicators (why do we need indicators?). Note the following; -

- We can’t use terms like “a lot” “too many” to describe the status of
immunization or any service delivery.
- We can’t compare the raw data of service delivery of one facility with
other facilities or over time, because the population served and case loads
seen, and types of illness all vary. But an indicator places the raw data in
context.

- To make data meaningful the use of indicators is essential since it convert

raw data into information.

Indicator = Numerator X 100 = …....% (information)

Denominator

The usefulness of health indicators can be summarised as follows; -

a. Serving as observable markers to progress towards defined health

indicator targets.

b. Describing the situations and serving as a measure of changes in a health

care profile over time.

c. Providing information about a broad range of conditions/diseases and

services through a single measure

d. Indicators are used to alert Managers to potential problems, possible

causes for these problems, and additional questions that can be asked.
Indicators rarely indicate specific cause of the problem and possible
solution.

a. Serving as a yardstick for institutions or team with which they can compare
themselves to others doing worker/services

b. When calculated or measured, they convert raw data/facts into

meaningful and useful information.

c. Comparison of trends. An isolated indicator by itself does not mean much.

It needs comparison over time across facilities and Districts to show trends
in order to be useful.

Page 32 of 67
 Prepared by ASIIMWE ABEL

Qualities of a good Health indicator

It is easy to calculate indictor but difficult to construct & select. The Ideal health
indicator MUST be; -

Reliable/Reproducible - Gives the same results if reported by different people in

different places or different times or is the change shown by indicator a true
change in the situation under study.

Appropriate - Fits in with local needs and the decisions to be made.

Relevance - What is the significant importance of the subject matter to be

addressed.

Valid/Validity - Truly measures what is of interest or what is the indicator supposed

to measure based on facts.

Feasible/Measurable - Able to collect the numerator and denominator, and

compute the indicator without much difficulty or How possible or conveniently
measure the data to arrive at the numerator and denominator of the indicator.

Sensitive - Even small changes are picked up and reflected as changes in the
health profile indicator to be accomplished/achieved.

Specific - Does the indicator actually capture the changes that occur in the
situation under study and does what is reported relates only to what is being
studied.

Health Indicator Target

Goals are broken down into a number of objectives which are measured by
indicators. Accomplishing a certain number of indicators in a given time period
are called target. Targets need to state what needs to be achieved, by when
and to what degree.

Page 33 of 67
 Prepared by ASIIMWE ABEL
The targets need to be well known locally, agreed upon by all role players and
expressed. The use of SMART criteria helps in qualifying targets factors; -
▪ Specific : Measure real changes in one specific situation concerned.

▪ Measurable : Able to be easily and precisely quantified.

▪ Achievable : Consensus reached with all major role players on the target.

▪ Relevant : Fit local need, capacities and culture using available

resources.

▪ Timebound : To be achieved by a certain time.

Types of Indicators (Health Indicators)

There are four (4) main types of indicators, namely:

1. Count Indicators – Count Indicators do not involve calculation. They

measure or count the number of events without a denominator. Data
elements are used alone as information e.g. number of new cases of TB.
2. Proportion Indicators – This involve numerator divided by denominator and
the indicator is usually expressed as a percentage e.g. the numerator is part
of the denominator.
3. Ratio Indicators – Rate indicator is used to express comparisons between
two groups e.g. ratio of male to female, nurses to doctor’s ratio e.t.c. The
numerator is not included in the denominator.
4. Rate Indicators – Rate indicators measure the frequency of an event
(incidence) during a specified time period (incidence) in a specified
population. They are often expressed per 1000 population, but also as
percentage. The numerator is part of the denominator.

Page 34 of 67
 Prepared by ASIIMWE ABEL

Classification of Indicators (Health Indicators)

a) Input indicators: indicate resources invested in the system, e.g., number of

doctors per 100,000 people.

b) Process indicators: indicate activities of the health system, e.g.,

percentage of doctors trained in safe delivery skills.

c) Output indicators: indicate achievements made specific health strategies

e.g. percentage of women who received 3 ANCs.

d) Outcome indicators: indicates achievements of a health programme or

health system. e.g institutional delivery rate, breastfeeding in one hour rate
etc.

e) Impact indicators: indicates achievement health status of particular group

of people e.g. Maternal Mortality Ratio, Infant Mortality Rate, Total fertility
Rate etc.

Health Indicators Dictionary

- ANTENATAL CARE COVERAGE

- IMMUNISATION COVERAGE INDICATORS
- DELIVERY SERVICES INDICATORS
- POST NATAL CARE INDICATORS
- CHILD & NEONATAL HEALTH INDICATORS
- FAMILY PLANNING COVERAGE INDICATORS
- MORTALITY INDICATORS
- SERVICE DELIVERY INDICATORS
- LABORATORY SERVICES INDICATORS
- ART CARE INDICATORS
- E.t.c

Page 35 of 67
 Prepared by ASIIMWE ABEL

Calculating Health Indicators

An indicator is determined by a calculation involving a numerator (top number)
and the denominator (bottom number). Numerators are the data elements that
we count: e.g. number of clients, morbidity, mortality, resources, and activities.
Denominators are the group with which the data elements we count are
compared: e.g. total population, gender population, age group population, all
births in a year, number of beds in the hospital etc. Example;-

Rate Indicator Calculation: At Kokoola H/C IV, 285 newborns were weighed after
birth during last month. Of these weighed, 26 were found to have weight less than
2.5 Kg. What percentage of newborns had low birth weight?

Percentage calculation ( per 100)

Newborns weighing less than 2.5 kg X 100

Newborns weighed 1

26 X 100 = 2,600 = 9.1%

285 1 285

The Low Birth Weight Rate 9.1%

Percentage calculation ( per 1000)

District X Has a population of 3750 children under 5 years. In last month, 56 children
under 5 years come to clinic with diarrhea. Calculate the; -

a) Incidence of diarrhea in District X.

b) Incidence rate of diarrhea in children under 5 years

= New cases of diarrhoea x 1000
Popn <5 years

= 56 X 1,000 = 56,000 = 14.9 per 1000 population

3750 1 3750

The Incidence Rate of Diarrhea in District X is 14.9 per 1,000 population under 5
years

Page 36 of 67
 Prepared by ASIIMWE ABEL
Ratio Indicator Calculation: Consider District-X where 4 doctors serve a population
of 15,000. How many people per doctor? =15,000 / 4 = 3750 people per doctor.
50 nurses serve this population. How many people per nurse? =15,000 / 50 = 300
people per nurse. How many nurses per doctor?. 50 / 4 = 12.5 nurses per doctor.

Example involving calculating indicator rates and ratios……see, HMIS Module 7 notes

The District Health Information Software Version 2 (DHIS2)

By the end of this session, participants should be able to:

✓ Describe the evolution of eHMIS

✓ Discuss the implementation of DHIS2 in Uganda
✓ Explain the key dimensions of DHIS2
✓ Navigate the DHIS2 software
Evolution of eHMIS

- HMIS was introduced in 1985.

- With the introduction of the Health Sector Strategic and Development Plan (HSSDP), the
HMIS was revised to provide data to monitor the performance of the HSSDP.
- In 2005, age and gender disaggregation and Epi-Info-based system was introduced.
- In 2007, the District-HIS (DHIS version 1) was introduced.
- It was upgraded to web-based HMIS (w-HMIS) in 2008.
- In 2011/2012, a National electronic system, DHIS version 2 (DHIS2) was approved in
Uganda.

DHIS2 Overview

• A web-based application used for collection, validation, analysis, and presentation of

aggregate statistical data tailored to integrated health information management activities.
• Generic in nature, the contents can be customized without programming.
• Developed by the Health Information Systems Programme (HISP) project as an open
source and globally distributed program.

Page 37 of 67
 Prepared by ASIIMWE ABEL
DHIS2 Implementation in Uganda

With support from implementing partners, MOH-Division of Health Information (DHI) rolled out
this system to all districts, Regional Referral Hospitals, and a few Health Sub-districts and Health
Units starting in 2011.

Accessing DHIS2

DHIS2 is accessible on a standard web browser.

URL: http://hmis2.health.go.ug/

MOH website: health.go.ug

– To access the system, type the URL in a web browser and a Login Page will appear.
– Username and Password are required to gain entry to the main features of the
system.
– A Standard Operating Procedure (SOP) on getting access to the system is in place
at the MOH/DHI or MOH Web Portal.

Navigating DHIS2

• DHIS2 has two main menu items:

– The Apps Menu (Most features in DHIS2 appear as independent application)
– The Profile Menu (Account settings, Help sub-menu and Log out of the system)
• For ease of use, a search box is provided to quickly search for and display a feature of
choice.

Page 38 of 67
 Prepared by ASIIMWE ABEL
Features of DHIS2—Demonstration

Benefits of DHIS2

1. Designed to facilitate smooth harmonized national reporting.

2. Facilitates data use and sharing with stakeholders at various levels.
3. Can be customized to include additional requirements.
4. Enables data entry and reporting at various levels and for different reporting cycles.
5. Provides different applications for data validation for improvement of data quality.
6. Is a simple, flexible, and open-source information system with easy to use visualization
features such as GIS, charts and pivot tables.

DHIS2 Terminology

• Data elements. Units of data entry that are part of datasets.

• Data sets. A set of related data elements that are collected together

- An equivalent of a data entry form

- Not linked directly to the data
- Can be modified at any time
- Focus is on the data output, not where it came from
• Indicators. ‘Variables that help to measure changes, directly or indirectly’ (WHO 1981).
A combination of one or more data elements used to convert raw data into information’.

Page 39 of 67
 Prepared by ASIIMWE ABEL
• Organisation units (org units). The location of the data, the geographical context which
is represented as organisation units. Organisation units can be either a health facility or
department/sub-unit that provides services or an administrative unit that represents a
geographical area (e.g., a district) .
• Reporting periods. The frequency of reporting a set of defined indicators/variables
through a dataset.

- Daily
- Weekly
- Monthly
- Quarterly
- Bi-annual
- Annual (can either be calendar or financial)

DHIS2 Core Dimensions

DHIS2 dimensions can be summarized as:

• What – data element

• Where – organization unit
• When – time period
For example

WHAT WHERE WHEN

Data element Organisation Unit Time Period Value

No. of clients with moderate acute malnutrition Mukono HCIV Dec-09 22

Page 40 of 67
 Prepared by ASIIMWE ABEL
DHIS2 Data Model: Data input = Data output

In summary, with HMIS/DHIS2 we can know…

Page 41 of 67
 Prepared by ASIIMWE ABEL

HMIS II (Health Management Information Systems) - Degree

Concepts of Epidemiology

✓ Concepts of Epidemiology

Epidemiology is the study/analysis of the distribution, frequency and determinants of health in

a given population. It is of the use of health information to promote health and reduce disease. It
uses indicators to answer the basic epidemiological questions and looks at the distribution,
frequency and determinants of health problems and diseases.

Epidemiology is the study of factors affecting the health and illness of populations, and serves as
the foundation and logic of interventions made in the interest of public health and preventive
medicine. It is considered a cornerstone methodology of public health research, and is highly
regarded in evidence-based medicine for identifying risk factors for disease and determining
optimal treatment approaches to clinical practice.

• Health : is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity.
• Illness : (sometimes referred to as ill-health or ail) can be defined as a state of poor
health.
• Population : The main focus of epidemiology is on the effect of disease on the
population rather than individuals.
• Distribution : Refers to the geographical distribution of diseases, the distribution in time,
and distribution by type of persons affected.
• Determinants : Are factors which determine whether or not a person will get a disease.
• Frequency : Number of times or observations or instances that occurs in a dataset
within a given interval
To determine any health problem, we need to know (Epidemiolocal thinking):
• Who are the people?
• Where is it happening?
• What are the condition?
• When time it happened?
• Why do people get sick?
• How do we overcome the problem?

Page 42 of 67
 Prepared by ASIIMWE ABEL

✓ Epidemiological measures of frequency

There are two (2) basic epidemiological measures of frequency that are essential to understanding
health issues. Frequency is measured as a rate and this is expressed as proportions and ratios.

▪ Incidence – New cases over a time period

▪ Prevalence – Existing cases at one point in time

Incidence - New cases

over a time period

Prevalence - Existing cases

at one point in time

Cases recover or die –

reducing prevalence

In the picture below, indicating the measures of frequency, a newly diagnosed case of a disease
can be described as the water drops from the tap (incidence - new cases) and the water already
in the basin is the (existing cases - prevalence).

✓ Levels of disease occurrence

The amount of a particular disease that is usually present in a community is referred to as the
baseline level of the disease. This level is not necessarily the desired level, which may in fact be
zero, but rather is the observed level. In the absence of intervention and assuming that the level is
not high enough to deplete the pool of susceptible persons, the disease may continue to occur at
this level indefinitely. Thus, the baseline level is often regarded as the expected level of the disease.

While some diseases are so rare in a given population that a single case warrants an epidemiologic
investigation (e.g., rabies, plague, polio), other diseases occur more commonly so that only
deviations from the norm warrant investigation. Several terms are used to tell level of disease
occurrence:
▪ Sporadic refers to a disease that occurs infrequently and irregularly.
▪ Endemic refers to the constant presence and/or usual prevalence of a disease or infectious
agent in a population within a geographic area.

Page 43 of 67
 Prepared by ASIIMWE ABEL
▪ Hyper-endemic refers to persistent, high levels of disease occurrence in the community
which occasionally rises above the expected level.
▪ Epidemic refers to an increase, often sudden, in the number of cases of a disease above
what is normally expected in that population in that area. Outbreak carries the same
definition of epidemic, but is often used for a more limited geographic area.
▪ Cluster refers to an aggregation of cases grouped in place and time that are suspected to
be greater than the number expected, even though the expected number may not be known.
▪ Pandemic refers to an epidemic that has spread over several countries or continents,
usually affecting a large number of people.

✓ Facility self-epidemiological assessment

Every month, every facility must assess itself by asking themselves these four cornerstone
questions about every program that is functioning at the facility:
➢ Coverage -Did everyone who should have received services receive them? e.g. Of all the
children under one year, how many were immunized?

➢ Quality -How good is the service provided? This will often need reference to protocols
and guidelines. e.g. Did children under one get the correct vaccines at the right intervals?

➢ Continuity -Did you follow-up clients who needed it? e.g. How many of the children who
started vaccination completed all the vaccinations and became fully immunized?

➢ Risk -Did you identify all clients with potential problems and then intervened to minimize
these potential problems? e.g. What proportion of ANC clients had specific risk factors
identified?

Note; - The planning tool that helps answer these questions is the indicator, which allows
measurement of whether one is achieving what one has planned to do. The monthly report are the
key elements in the process of self-assessment at each facility. The steps to follow in processing
your routine reports are:
✓ Identify data collection tools based on case definitions and minimum essential dataset
✓ Identify facility data entry points or units or departments
✓ Proper collection of information
✓ Data quality to be ensured by staff gathering the data
✓ Facility manager to check the data for quality
✓ Data to be discussed with supervisor, obtain comments and signature on report
✓ Do Data cleaning i.e. Access, Analyze and Act on data before reporting it. This AAA cycle
needs to be repeated monthly
✓ Proceed report or deliver or submit the information to the next level

Page 44 of 67
 Prepared by ASIIMWE ABEL
✓ Graph key data on a monthly basis to assess progress made and to show visible
comparisons or trends in data
✓ Insist on feedback from the District Health Information Officer

Performance Assessment (How is performance measured?)

Performance is measured by evaluating the achievements against a defined set of objectives
• Performance is measured using indicators
• Performance is measured by comparing achievements with set targets
• Performance is assessed using the health center quarterly data
• While monitoring HSSP indicators at national and lower operational levels

An indicator is a measurement that helps you understand;

• where you are - baseline
• which way you are going - interventions -
- targets
• how far you are from where you want to be – Monitoring & Evaluation

Setting of performance targets

• Set at beginning of each financial year based on previous performance
• Should be reviewed on quarterly basis
• Set for each level
• Should be set to address local needs
• Should have factors (SMART Criteria)

Page 45 of 67
 Prepared by ASIIMWE ABEL

RESTRUCTURING and DEVELOPING A HMIS

Steps involved in restructuring a HMIS
• Step 1: Identifying information needs and feasible indicators. This involves;
✓ Identifying information needs for follow-up of a health concern/indicator e.g. maternity
services, HTS in a primary level.
✓ Identifying indicators to ensure efficient drug management in a referral hospital, to
ensure efficient Information, Education and Communication in the community and to
monitor the quality of supervision by the district management team
• Step 2: Defining data sources and developing data collection instruments for each of the
indicators selected. This includes;
✓ Develop an appropriate record form for follow-up of any care delivery e.g. ANC,
ART… in a tertiary care hospital
✓ Develop a monthly reporting form for activities performed in a primary level clinic
✓ Define data sources for a situational analysis at the district level and,
✓ Develop data sources for monitoring the quality of teaching in a medical college

• Step 3: Developing a data transmission and processing system. This involves;

✓ Developing a structured information flow on health concern/indicator e.g. appropriate
coordination of pregnant women between the traditional birth attendant and midwife in
the health centre
✓ Ensure that monthly report forms from health centers are entered in the district
computer in a timely and accurate manner
✓ Develop a mechanism for reporting of Research done in a research centre

• Step 4: Ensuring use of the information generated. That’s to say;

✓ Developing user-friendly feedback formats for regional mangers on the utilization of
health care services in the region
✓ Training health auxiliaries in follow-up procedures for specialist outpatient using a
standard record forms
✓ Developing a curriculum for the undergraduate and post-graduate medical students
depending upon the health need in the country
✓ Ensure research on the priority health issues for the country

Page 46 of 67
 Prepared by ASIIMWE ABEL
• Step 5: Planning for health MIS resources
✓ Create positions of computer operators in cases where district level data processing is
computerized
✓ Submit revised recurrent cost budgets based on proposed new data collection
procedures

• Step 6: Developing a set of organizational rules for HMIS

✓ Develop standard case definitions
✓ Change the job description of doctors in cases where health information system
restructuring involves their active participation in data collection
✓ Develop an instruction manual for computer operators

Steps involved in Developing a HMIS

▪ Step 1: Review the existing system
▪ Step 2: Define the data needs of relevant units within the health system
▪ Step 3: Determine the most appropriate and effective data flow
▪ Step 5: Design the data collection and reporting tools
▪ Step 6: Develop the procedures and mechanisms for data processing
▪ Step 7: Develop and implement a training program for data providers and data users
▪ Step 8: Pre-test, and if necessary, redesign the system for data collection, data flow, data
processing and data utilization.
▪ Step 9: Monitor and evaluate the system.
▪ Step 10: Develop effective data dissemination and feedback mechanisms.
▪ Step 11: Enhance the HMIS.

Challenges to HMIS
They are grouped into structural, procedural, content, human resource and technical knowhow
Structural
➢ Multiplicity of institutions and departments
➢ Fragmentation of data.
➢ Lack of infrastructural facilities for storage and
➢ maintenance of records.
➢ Use of many registers and data forms
➢ No guidelines on HMIS in health units.

Page 47 of 67
 Prepared by ASIIMWE ABEL
Procedural
➢ Excessive information
➢ Encryption/hidden issues
➢ Overburden of collection and recording of data along with General health care.
➢ Incomplete, unreliable and intentionally managed information.
➢ Repetition of general information
➢ Time consuming procedure
➢ Confusing coding, long list of indices
➢ Absence of feedback to information suppliers

Related to content
➢ Mostly service utilization statistics.
➢ Only summarized information reaches at higher level.
➢ Less emphasis on socioeconomic information.
➢ No user friendly
➢ Inappropriate forms/cards/reports

Related to human resource

➢ Absence or lack of skilled medical record professionals
➢ Lack of opportunity for in service training for the staff.
➢ Health care providers/nurses/biomedical trained
➢ persons are collecting and preparing data.
➢ Lack of motivation/extra incentives
➢ Health staff’s Inadequate knowledge of HMIS.
➢ Inadequate resources for HMIS.
➢ Negligence of health staffs
➢ No feedback of information to the lower level health units.
➢ Less interest of users in information

Technological
➢ Much manual paper-based system.
➢ Absence or lack of computerized data base
➢ System
➢ Low levels of public will, about vital registration system.
➢ Inadequate government’s capacity and lack of firm political
➢ decision
➢ Gender issues in vital events registration
➢ Fragmentation of health information
➢ Establishing a unified information system with in country.

Page 48 of 67
 Prepared by ASIIMWE ABEL

Some WAYS OF OVERCOMING THE CHALLENGES

✓ Training of health staffs on HMIS.
✓ Provision of adequate resources for HMIS.
✓ Support supervision.
✓ Use of an integrated data form and registers.
✓ Provision of guidelines for HMIS in health units.
✓ Immediate feedback of information to the lower level health units.
✓ e.t.c

Benefits of HMIS
➢ Helping decision makers to detect and control emerging and endemic health problems.
➢ Help in monitoring progress towards health goals and promote equity.
➢ Empowering individuals and communities with timely and understandable health related
information.
➢ Improving quality of services.
➢ Strengthening the evidence base for effective health policies.
➢ Permitting evaluation of scale up efforts and enabling innovation through research.
➢ Mobilizing new resources and ensuring accountability in the way they are used.
➢ Improving governance.
➢ e.t.c

Page 49 of 67
 Prepared by ASIIMWE ABEL

Monitoring and Evaluation (M&E) in Health Care

When you read that the prevalence of low birth weight in a country is 20%, have you ever
wondered how this calculation was derived? Or when you hear that the percentage of married
women of reproductive age in a rural area using a modern contraceptive method rose from 52% to
73%, do you wonder how they know this? These types of statistics and other similar information
result from "monitoring and evaluation" or "M&E" efforts.

What is M & E?
M&E is the process by which data are collected and analyzed in order to provide information to
policy makers and others for use in program planning and project management.

What is Monitoring?
Monitoring is a continuous process of assessing whether an activity or project is proceeding as
planned. Monitoring is not an activity by itself. It focuses on collecting information on a regular,
ongoing basis for a core set of indicators which provide you with enough information to track
progress in implementation of the plan and achieving of expected objectives. There are various
aspects or components of a project that have to be monitored. These are
✓ Inputs: Inputs are the resources necessary in order to implement the project. These include
personnel, finances, drugs, buildings and equipments.
✓ Processes: Processes involve setting in motion a sequence of tasks, in which resources are
used, to achieve the desired outputs. These tasks should be monitored to ensure they are of the
expected quality, are happening smoothly and in a logical manner. Example can be the number of
training sessions.
✓ Outputs: Outputs are products of achievements as a result of the successful completion of
activities. Ask yourself, what are the results, and why are they different from what was expected
or promised? Examples include number of staffs trained, number of people served.

Page 50 of 67
 Prepared by ASIIMWE ABEL

Designing a monitoring system

At whatever level you work, you need to develop a monitoring system to keep track of the events
happening. When designing such a system you should consider the following:
➢ Select only the key indicators that will be used
➢ Selective. Do not try to monitor everything as this can be very expensive and time
consuming
➢ Specific. Only collect data for assisting to monitor the key indicators you selected
➢ Provide Feedback to the interested parties in good time
➢ Report the Findings in a way that is easy to understand and facilitates data interpretation
and action
Monitoring reports must highlight both the success and weakness of the implementation process.
You need not feel shy to say that you have failed in implementing a particular project as long as
the reasons are well documented. However, learn from factors that resulted in failure previously,
so that when you undertake the implementation of another project in future you do not repeat the
same mistakes. Always document the successes and lessons learnt.

Page 51 of 67
 Prepared by ASIIMWE ABEL
Steps to Monitoring an Activity or a Project (How to carry out
Monitoring)
There are ten steps to monitoring an activity or a project. The first 4 cover the planning stage of
monitoring and seek to ensure that the information collected is relevant, specific, feasible to collect
and can be analyzed. The next 5 steps cover the implementation of monitoring using the results
for management action and the tenth is to decide whether to continue monitoring.

Step 1: Specify the monitoring objectives. Indicate what is going to be monitored; for what
purpose and who will use the monitoring results.

Step 2: Decide on the scope of the monitoring. Before introducing routine monitoring
procedures, you may wish to pilot test them in a few places before implementing them in all areas.

Step 3: Select indicators and set performance standards. Targets (performance standards), are
set for each indicator in order to assist your team determine whether the activity has been
implemented as planned or has been effective. The targets are usually quantified and this is what
enables you to judge actual performance with planned target performance.

Step 4: Choose information sources and develop data collection procedures. You can use
Quantitative or Qualitative methods to collect data. Quantitative methods are those that generally
rely on structured approaches to collect and analyze numerical data. Some common quantitative
methods include the population census, population-based surveys, patient charts, logs and tally
sheets, checklists and questionnaires.

Step 5: Collect the data. If data is not available from existing sources, some training of those
involved will be necessary.

Step 6: Tabulate and analyze data. Data can be displayed using list, tables and graphs.
Step 7: Interpret the data. What does the findings from the analysis mean?
Step 8: Present the findings. Decide who should receive information regularly and establish a
mechanism for disseminating information.

Step 9: Take appropriate action. A very important reason for monitoring is to enable you to
identify shortfalls and take corrective action in time. This enables you to be in control and to ensure
quality services.

Page 52 of 67
 Prepared by ASIIMWE ABEL
Step 10: Decide whether to continue monitoring. As the needs change, your team must adjust
the frequency of monitoring, especially if there is improvement in project implementation. There
is less need for frequent detailed information on some inputs and outputs, as projects improve over
time. Therefore, the focus shifts to effect indicators. As the implementation of recommendation
takes place for some projects, the monitoring cycle starts for others.

What is Evaluation?
Evaluation is the process by which project achievements are examined. It compares outputs and
outcomes to the set objectives and the use of resources to determine the effectiveness and
efficiency of the project. Evaluation is carried out after completion of the activity or project.

Evaluators use a whole range of research methods and tools to collect information such as
interviews, questionnaires, test of knowledge skills and attitude, observations, content analysis of
documents and examination of physical evidence. There are three key parameters that are of
interest in the process of evaluation: These are; -

✓ Inputs: The evaluator has to find out whether the resources were transformed into service
or misused.
✓ Outputs: The evaluator needs to look at whether the services provided were appropriate,
relevant and adequate.
✓ Outcome: The evaluator needs to ask whether any health improvements were the direct
result of the project. Otherwise, you may end up glorifying a project that did not impact
any change at all.

How to carry out an Evaluation. Designing an evaluation process may be done in six
steps:
Step 1: Setting out clearly the questions to be answered. To answer each of the questions raised
under the section on what you need to evaluate, you must identify indicators which will allow you
to compare what actually took place with what was expected. Four types of information are likely
to be required.
➢ Baseline information. Baseline information will assist you to describe the situation prior
to the implementation of the project. For example, in an oral rehydration program, you would want
to know the number of mothers who were using oral rehydration salts (ORS) or knew how to
prepare ORS solutions prior to the start of the program.

Page 53 of 67
 Prepared by ASIIMWE ABEL
➢ Input information. Input information will describe the resources used in the project. For
example, in an immunization program, you may want to know how many fridges or staff was
utilized to provide the service.
➢ Process information. Process information will help you to describe the implementation
process of the project. For example, in an immunization program, you will want to know how the
immunization was organized and conducted.
➢ Output information. Output information will help you describe the situation after
implementation of the project. For example, in an immunization program, you would like to know
the number of children fully immunized against your set objective.

Step 2: Identify the sources of information for evaluation. Existing records may be good
sources of some information. Other information may not be available and surveys or other methods
may have to be conducted to obtain it. You could design a questionnaire that will capture all the
information required. Pre-test your questionnaire before embarking on actual evaluation.

Step 3. Collecting the information. When questionnaires have been developed, pre-tested and
the people to administer the questionnaire trained, organise how the information is to be collected
from the field.

Step 4. Analyzing the information. Before the information is collected, you should start making
arrangements on how the data is to be analyzed and tabulated. Prepare possible tables that you will
expect to generate from the data.

Step 5. Preparing the evaluation report and presenting findings. The evaluator has to write an
evaluation report and present it to other interested parties. The report should be simple and point
out major recommendations.

Step 6. Taking appropriate actions. When evaluation results have been presented and discussed
among the various project implementers, then you should make arrangements to use these results
to decide whether action needs to be taken, and if so which action. This means that you first explore
the causes and then develop the solutions.

Page 54 of 67
 Prepared by ASIIMWE ABEL
✓ Purposes of M & E
M&E is carried out for many different purposes. Thus, the key reasons for M&E can be
summarised under four headings.
(1) For accountability: demonstrating to donors, beneficiaries and implementing partners that
expenditure, actions and results are as agreed or can reasonably be expected in the situation.

(2) For operational management: provision of the information needed to co-ordinate the human,
financial and physical health resources committed to the project or programme, and to improve
performance

(3) For strategic management: provision of information to inform health care setting and
adjustment of objectives and strategies.

(4) For capacity building: building the capacity, self-reliance and confidence of beneficiaries and
implementing staff and partners to effectively initiate and implement development initiatives.

(5) For project or activity implementation: to improve, inform and implement project or activity
and programme design through the feedback provided from mid-term, terminal and long-term
goals
✓ Who needs M&E Who conducts M&E
• Managers - to improve program implementation - Program implementer
• Donors - to inform and improve future programs - Stakeholders -Donors
• Governments - Communities - Beneficiary
• Technocrats - Beneficiaries -Program Managers

✓ Differences between M&E

Monitoring Evaluation

1. Continuous process 1. Periodic process

2. Keeps track, oversight; analyses and 2. Mid-term assessment of programme

documents progress implementation and at the end or a substantial
period after programme conclusion (In-depth
analysis; compares planned with actual
achievements)

Page 55 of 67
 Prepared by ASIIMWE ABEL
3. Focuses on inputs, activities, outputs, 3. Focuses on outputs, inputs and results in relation
implementation processes, continued to cost; processes used to achieve results; overall
relevance and likely results at outcome level relevance; impact; and sustainability

4. Answers what activities were implemented

4. Answers why and how results were achieved
and results achieved
and contributes to building theories and models
for change

5. Alerts managers to problems and provides

options for corrective actions 5. Provides mangers with strategy and policy
promotions.
6. Self-assessment by programme managers,
supervisors, community stakeholders, and 6. Internal and/ or external analysis by programme
donors managers, supervisors, community stakeholders,
donors and/or external evaluators.
7. ensure that the project inputs, deliveries,
targeted outputs are carried out according to
7. determines the value of the project or activity in
plan.
terms relevance, efficiency effectiveness and
8. E.t.c impact

Concepts of Disease Surveillance System Reporting

Disease Surveillance: Ongoing, systematic collection, analysis, and interpretation of health-
related data essential to the planning, implementation, and evaluation of public health practice,
closely integrated with the timely dissemination of these data to those responsible for prevention
and control with concepts that: -
✓ There should be regular analysis and dissemination of surveillance data depending on the need
can be weekly, monthly or annually.
✓ Surveillance should begin when a public health problem exists or is likely to occur and a
programme for prevention and control exists
✓ Epidemiological surveillance is information on the occurrence and distribution of prevalence
of risk factors both personal and environmental and on the use of preventive health practices
and medical services.

Page 56 of 67
 Prepared by ASIIMWE ABEL
Terminologies in Surveillance
Surveillance: Disease surveillance is the ongoing, systematic collection, collation, analysis, and
interpretation of data related to disease. It includes the timely dissemination of analyzed data to
those who need it for action. Surveillance data are used for planning, implementing, and evaluating
public health practices at all levels of the health system.

Integrated Disease Surveillance and Response (IDSR): IDSR is a comprehensive strategy for
capturing health information of communicable disease for prevention and control by linking
community, health facility, district, provincial and national levels. This strategy provides rational
use of resources for disease prevention and control.

Control: the reduction of disease incidence, prevalence, morbidity or mortality to an acceptable

level through deliberate efforts.

Elimination: Reduction to zero incidence of a specified disease in a defined geographical area

through deliberate efforts. However, continued intervention measures are required.

Eradication: The complete interruption of transmission and the extinction of the causative agent
so that it no longer exists in the environment. Intervention measures no longer needed
Population: The main focus of epidemiology is on the effect of disease on the population rather
than individuals.
Distribution: Refers to the geographical distribution of diseases, the distribution in time, and
distribution by type of persons affected.

Determinants: Determinants are factors which determine whether or not a person will get a
disease.
Natural History of a disease. Natural history of disease refers to the progression of a disease or
condition process in an individual over time, in the absence of treatment or intervention. For
example, untreated infection with HIV causes a spectrum of clinical problems beginning at the
time of seroconversion (primary HIV) and terminating with AIDS and usually death.

Objectives of Disease Surveillance System Reporting

✓ conduct effective surveillance activities
✓ Integrate multiple surveillance systems to use resources more efficiently
✓ Improve the use of information for detecting, investigating and responding to public health
threats
✓ Improve the flow of surveillance information throughout the health system

Page 57 of 67
 Prepared by ASIIMWE ABEL
Functions of Disease Surveillance System Reporting
✓ Monitor trends, patterns and estimate magnitude of health problem
✓ Detect sudden changes in disease occurrence and distribution (Epidemics/outbreaks)
✓ Portray the natural history of a disease
✓ Monitor changes in infectious agents
✓ Detect changes in health practices
✓ Evaluate control measures
✓ Generate hypotheses, stimulate research
✓ Facilitate planning

Components of Disease Surveillance System Reporting

Surveillance systems consists of tools, procedures, people and structures required to generate
information for planning, monitoring and evaluating malaria programmes.
• Tools - report forms, tally sheets, registers, patient records
• Procedures - case definitions, reporting frequency, information flow, data analysis,
dissemination
• People - health workers, community, decision makers
• Structures - health systems

Critical characteristics of Disease Surveillance System Reporting. Critical

characteristics of surveillance are usually include:
▪ Timeliness: To implement effective control measures.
▪ Representation: To provide an accurate picture of the temporal trend of the disease.
▪ Sensitivity: To allow identification of individual persons with disease to facilitate
treatment, quarantine, or other appropriate control measures.
▪ Specificity: To exclude persons not having disease.

Page 58 of 67
 Prepared by ASIIMWE ABEL
Types of Disease Surveillance System. There are several types of surveillance used in
disease programs:
1. Healthcare facility based or community-based surveillance: A term to describe when a
particular location (such as healthcare facility or community) is the focus of surveillance
activities.
2. Sentinel surveillance: A health facility or reporting site designated for early warning of
pandemic or epidemic events. The site is usually designated because it is representative of an
area or is in an area of likely risk for a disease or condition of concern.
3. Laboratory-based surveillance: Surveillance conducted at laboratories for detecting events
or trends that may not be seen as a problem at other locations.
4. Disease-specific surveillance: Surveillance that involves activities aimed at targeted health
data for a specific disease.
5. Event-based surveillance: Surveillance that involves activities aimed at collecting health
data on specific events.
6. Passive or routine Surveillance. Collection and reporting of surveillance data on voluntary
basis from health care provider. The process of detecting and reporting information on
diseases that bring patients to the health facility is known as passive surveillance e.g. MOH -
H/U HMIS FORM 105, & 108 reports.
7. Active Surveillance. Regular collection of surveillance data on specific diseases through the
review of medical records and registers during regular visits to reporting sites.
8. Syndromic disease surveillance: Surveillance using less/fewer specific criteria. Conditions
or facts for Syndromic disease Survaillance is that; -
- Timeliness is key either for naturally occurring infectious diseases (e.g., severe acute
respiratory syndrome [SARS]), or a terrorism event.
- Making a diagnosis is difficult or time-consuming (e.g., a new, emerging, or rare
pathogen).
- Trying to detect outbreaks (e.g., when syndromic surveillance identified an increase in
gastroenteritis after a widespread electrical blackout, probably from consuming spoiled
food).
- Defining the scope of an outbreak (e.g., investigators quickly having information on the
age breakdown of patients or being able to determine geographic clustering).

Page 59 of 67
 Prepared by ASIIMWE ABEL
Purpose of Disease Surveillance System Reporting
✓ To characterize disease patterns by time, place and person
✓ To detect epidemics
✓ To suggest hypothesis
✓ To identify cases for epidemiological research
✓ To evaluate prevention and control programmes
✓ To project future health needs

Uses of Disease Surveillance System Reporting

✓ Estimate magnitude of the problem
✓ Portray the natural history of a disease
✓ Determine distribution and spread of illness
✓ Detect outbreaks
✓ Generate hypotheses, stimulate research
✓ Evaluate control and prevention measures
✓ Monitor changes in infectious agents
✓ Detect changes in health practices
✓ Facilitate planning

Approaches in Disease Surveillance System Reporting (Disease Surveillance

Activities)
➢ Individual case investigation- A single case of an infectious disease e.g. paralytic
poliomyelitis or Ebola can be considered an epidemic
➢ Epidemic reporting- This is done in cases such as influenza, cholera etc.
➢ Sentinel systems- It is a simple, relatively sensitive way of early detection and monitoring
of health problems and diseases in human population.
➢ Vector control systems- Infections such as yellow fever from mosquito bites
➢ Health surveys- Such as baseline surveys for prevalence and incidence data.
Steps of Disease Surveillance System Reporting
✓ Case Detection: Identify cases of priority diseases and conditions
✓ Investigation/Confirmation of suspected cases and outbreaks
✓ Reporting of priority diseases and conditions
✓ Analysis and interpretation: present findings to appropriate parties
✓ Response to outbreaks and other public health problems
✓ Feedback
✓ Monitoring and Evaluation and improve surveillance and response

Page 60 of 67
 Prepared by ASIIMWE ABEL
Case Detection
- Surveillance begins with case detection.
- Health workers need case definitions that are appropriate for the local context, and they
need practice in applying them
- Clinical diagnoses can be a problem.
- Many illnesses have similar symptoms, such as fever and rash, and can be differentiated
only by laboratory tests that may not be accessible.
- Each health facility should have a disease surveillance focal person who should co-ordinate
all activities

Investigation and Reporting

- Investigation will be determined by condition under review (targeted for control
elimination, or eradication)
- Filling a case investigation form
- Collection of specimens (where applicable)
- Contact Tracing
- Laboratory Confirmation

Reporting-Uganda system
- Each case to be reported individually using Case based investigation form
- Epidemiological weekly reporting-MOH-H/U HMIS Form 033b
- Line lists form/report- e.g. MOH-H/U HMIS Form 033a
- Monthly Reporting using MOH-H/U HMIS Form 105 & 108

Sources of Disease Survaillance data. Data collected for health-related purposes typically
come from these sources:
1. Individual persons
2. Administrative actions
3. Financial transactions
i. Sales of goods and services
ii. Taxation
4. Legal actions
5. Laws and regulations
6. The environment
i. Air

Page 61 of 67
 Prepared by ASIIMWE ABEL
ii. Water
iii. Animal vectors
7. Health-care providers and Health facilities. These are:
i. Physician offices
ii. Hospitals
iii. Outpatient departments
iv. Emergency departments
v. Inpatient settings
vi. Laboratories
8. Mortality data. Available at local and state levels and because of burial laws e.g. burial
permits. The medical personnel who detail cause and nature of death as a notification generate
the mortality data.
9. Morbidity data. Commonly used as a reporting of notifiable diseases or reportable health
events. Generated by physicians and other health care providers, and also from health
facilities.
10. Laboratory data. From routine laboratory records and in case of field investigations in case of
epidemics

Routine, epidemic or case based (Categories of data collected in Disease Survaillance

System)
• Identifying information
• Demographic information
• Clinical information
• Exposure / risk factor information
• Reporter information (name of laboratory/clinic)
• (Information on contacts)

Case definition:
A set of uniformly applied criteria for determining whether a person should be identified as having
a particular disease, injury, or other health related condition.

Page 62 of 67
 Prepared by ASIIMWE ABEL
Importance of case definition
✓ For reportable diseases
✓ For outbreak investigations
✓ For epidemiological studies
✓ For disease eradication programs
✓ For reportable diseases
✓ For outbreak investigations
✓ For epidemiological studies
✓ For disease eradication programs
✓ To create uniform classification in order to allows comparison between different
geographic regions and comparisons over time
✓ To standardize classification of persons who have similar signs and symptoms of a disease

Components of case definition

1. Clinical criteria. The characteristic symptoms of the disease which are intended for use for
individual clinical diagnosis
2. Epidemiologic criteria. Defined epidemiological links
3. Laboratory criteria. Specific test must be named (e.g., PCR, culture). Positive and
negative results must be defined
4. Case classification criteria. Suspect, probable, confirmed

Case classification. Definitions of what is needed to meet each classification. Classification

categories are called tiers (levels). Classification should be done systematically by experienced
epidemiologists – Three tiers are used by many countries; sometimes only two are used, these are;
Suspect, Probable and Confirmed.

Levels of case definition

➢ Case Definitions: Suspect
✓ Suspected-a person who meets clinical criteria of case definition
✓ Includes clinical features of the disease, Signs and symptoms frequently found. These
signs and symptoms help distinguish from other diseases that indicates that Specimen
should be collected investigated and Case should be reported

Page 63 of 67
 Prepared by ASIIMWE ABEL
➢ Case Definitions: Probable
✓ Probable-A suspected case epidemiologically linked to a laboratory confirmed case
✓ Suspect definition includes additional epidemiological data (linked with confirmed
case) OR Pathognomonic signs and symptoms
➢ Case Definitions: Confirmed
✓ Confirmed-A suspected or probable case with a positive laboratory result
✓ Positive results of preliminary laboratory tests that indicates higher level of certainty that
the case is a true case. This means having final laboratory confirmation results of ongoing
or recent infection. The case is then considered a confirmed case.
Sensitivity and Specificity in case definition
- Sensitivity: The proportion of individuals with correctly diagnosed disease among all
patients who really have the given disease. It represents Proportion of true cases reported.
- Specificity: The proportion of individuals correctly diagnosed as not having disease among
all patients who do not really have the given disease. It represents Proportion of true non-
cases reported

Consequences of Not Using a Standard Case Definition

1. Cases reported by one health provider may differ from those reported by others. Therefore,
allows clinicians to determine if the case has enough of the signs and symptoms to report the
disease
2. Without standards some cases will be misclassified. i.e. – False positives –an individual is
wrongly counted as a case. – False negatives –an individual has the disease, but is classified
as not having the disease
When Do Surveillance Case Definitions Need to Change?
- Case definition is too sensitive or specific. – Example: measles case definition cannot rule
out other febrile rash illnesses
- Advances in laboratory tests. – Example: national reference lab determines sensitivity and
specificity of PCR equal to culture
- Case confirmation requires information that is not always available. – Hepatitis A case
definition requires elevated liver function enzymes, but clinic/hospital does not perform
this test
- New disease knowledge. – Example: human cryptosporidiosis found to be caused by
multiple species; Cryptosporidium parvum and C. hominis

Page 64 of 67
 Prepared by ASIIMWE ABEL
Rationale for Case definition
✓ To accurately classify persons who are ill
✓ Surveillance: to standardize reporting for a given disease across
– different clinicians / public health staff
– different geographic regions
– different time periods
✓ The system does not need to be exact
✓ The system just needs to be consistent every day

Selection of priority diseases for surveillance. Priority diseases are selected based on:
1. Diseases with high epidemic potential for serious public health impact due to their ability
to spread rapidly locally and internationally
2. Conditions that require routine or special notification under IHR act 2005
3. Diseases or conditions which are principle causes of morbidity and mortality in the region
4. Non-communicable disease priorities in a given country
5. Diseases for which effective control and prevention interventions are available for
addressing the public health problems they pose
6. Diseases for which intervention programs exist (supported by MOH and WHO) for
prevention and control, eradication or elimination

Epidemic prone diseases

• Acute Bloody Diarrhea (Shigella)
• Acute Flaccid Paralysis (AFP)
• Cholera (Severe AWD)
• Human Rabies
• Lassa Fever
• Maternal Deaths
• Measles
• Meningitis1
• Neonatal Deaths
• Neonatal Tetanus
• Malaria
• Viral Hemorrhagic Fevers (including Ebola Virus Disease)
• Yellow Fever
• Unexplained cluster of health events
• Unexplained cluster of deaths

Page 65 of 67
 Prepared by ASIIMWE ABEL
Diseases or events of international concern that are notifiable under IHR act 2005
• Guinea Worm (Dracunculiasis)
• Human Influenza (due to a new subtype)
• Severe Acute Respiratory Syndrome (SARS)
• Smallpox
• Corona Virus
• Other Public Health Event of International Concern (PHEIC), Including: infectious,
zoonotic, food borne, chemical, radio nuclear, or due to unknown condition.

Monthly reportable diseases/conditions of public health importance

• Acute Watery Diarrhea
• Acute Viral Hepatitis
• Adverse Events Following Immunization (AEFI)
• Cataract
• Diabetes
• Diarrhea w/dehydration (in <5 years)
• Encephalitis
• Epilepsy
• HIV/AIDS (new cases)
• Hypertension
• Hookworm
• Injuries (RTAs, domestic violence)
• Malaria
• Malnutrition (< 5 years)
• Mental Health
• Onchocerciasis
• Pertussis (Whooping Cough)
• Severe Pneumonia (<5 years)
• Schistosomiasis
• Sexual Assault
• STIs
• Trachoma
• Trypanosomiasis
• Tuberculosis
• Typhoid
• E.t.c.

Page 66 of 67
 Prepared by ASIIMWE ABEL
Diseases targeted for eradication
• Buruli ulcer
• Dracunculiasis
• Leprosy
• Lymphatic filariasis
• Neonatal tetanus
• Noma
• Onchocerciasis
• Poliomyelitis
• HIV/AIDS
• E.t.c.

Page 67 of 67