Tanzanie: Integrovaná architektura zdravotnických informací¶

O tomto případu použití¶

V tomto případě použití se podíváme na různé fáze spolupráce několika týmů s University of Dar es Salaam (UDSM), ministerstvem zdravotnictví a sociálních věcí (MoHSW) a univerzitou v Oslu (UiO) jak zavést integrované zdravotnické informační systémy (HIS) v Tanzanské pevnině. Klíčovými ponaučeními byla důležitost postupného zavádění HIS pro zajištění udržitelného rámce; zefektivnění zdrojů a podpora spolupráce; zajištění pružnosti systémů; podpora vlastnictví a sdílení dat; budování kapacit na všech úrovních; velmi důležité zapojení hlavních programů; a věnování času a zdrojů budování komunity zúčastněných stran.

Profil země Tanzanie¶

Sjednocená republika Tanzanie je největší zemí ve východoafrickém regionu s 45 miliony obyvatel. Skládá se ze dvou zemí: poloautonomního ostrova Zanzibar a Tanganika nebo Tanzanské pevniny. Tanzanská pevnina je rozdělena do 25 správních oblastí, které jsou dále rozděleny do 167 okresních rad. Každá okresní rada je rozdělena na divize, oddělení, vesnice / ulice. Podle SARA (2012) existuje přibližně jedno zdravotnické zařízení na 8.000 lidí.

Vzhledem k obrovským rozdílům mezi regiony a okresy, pokud jde o geografii, historii, počet obyvatel a infrastrukturu, nemají některé oblasti Tanzanie spolehlivé silnice, elektřinu ani přístup k internetu.

Přechod od více nástrojů k jednotnému systému¶

Před DHIS2¶

První HIS na Tanzanské pevnině začal v 90. letech jako papírový systém používaný ve zdravotnických zařízeních a okresních úřadech. Informace byly shromážděny a zpracovány pomocí databáze Microsoft Access. Bez zásahu externích konzultantů najatých finančními agenturami neexistovaly žádné strategie pro udržení systému pomocí upgradů nebo opakovacích školení.

With a surge in demand for a HIS, the MoHSW was being put under strain. Lack of coordination led to fragmented vertical projects running side by side. This caused an unsustainable situation in which efforts were being duplicated as results weren’t being converged.

Around 2007, a plan called the Monitoring and Evaluation Strengthening Initiative was made by the MoSWH, UDSM, UiO and other partners. Its goal was to build a new, integrated HIS to provide reliable data for the ministry and other stakeholders. A new paper-based system combined with DHIS2 was introduced. http://www.dhis2.org

Představujeme integrovaný NIS v Tanzanii¶

In 2010, the adaptation and implementation of a totally revised HIS began. This process was enabled by a flexible, standard solution and participatory approaches operating across all levels of the national health system. It was important to find a solution that would meet the demands of health managers, implementers, designers and decision-makers.

Postupné národní zavádění HIS¶

In 2011, the coastal region of Pwani was used as a testbed for paper-based data collection tools and DHIS2. Over the next two years, revised systems were rolled out to the remaining 24 regions and associated districts and health facilities of Tanzania Mainland. On completion of this rollout, efforts were directed towards the integration of all major vertical programs such as malaria, TB/leprosy, RCH, HIV/AIDS into DHIS2. Along with the implementation process, training programs were held for implementing partners, district and regional hospital staff, and the MoHSW staff.

Fáze zavádění DHIS2 ve vnitrozemí Tanzanie pro rok 2014

Budování robustního HIS¶

Zde jsou některé z klíčových oblastí, kterým jsme věnovali čas a zdroje:

Filozofie Open-source¶

The choice to apply open-source tools rather than going through a closed, commercial product ensured that the software remained collaborative with a more diverse and flexible scope of design. Furthermore, the involvement of the many health sector stakeholders and an open source community of developers implied that the system would be geared towards long-term sustainability rather than a short-term lifecycle, dependent on a company’s paid maintenance services.

Inkrementální, flexibilní a škálovatelný design¶

DHIS2 was implemented in an incremental way, rather than in one go. Like that, issues could be tackled directly during the rollout process, and implemented in direct response to user feedback. The most glaring flaws were thus easily spotted and a more stable and efficient system was built.

Standardy pro sběr dat¶

We used a set of common data collection standards that covered data collection, reporting, analysis, and quality procedures and tools. All informal tools were removed and the recording of duplicate entries of data declined.

Participativní design¶

A community of users such as managers from the HIS, supporting partners and implementers exchanged emails, spoke on forums, and at workshops about how to make the software more user-friendly. This helped implementers fine-tuned their programs and ensure that DHIS2 was being used optimally.

Akční výzkum¶

Students enrolled on PhD and MSc degree programs at UiO and UDSM conducted “action-led research” that enabled them to participate in the roll-out of DHIS2 while doing research. By doing so, they learned and documented best practices about system customization, user support, training, and data analysis.

Budování místních kapacit¶

People learned to troubleshoot DHIS2 software, and users were encouraged to assist each other across many different organization levels and roles. By instilling a sense of ownership and self-sufficiency, the gap between implementers and users was thus reduced. Training focused on software usage, data analysis and basic and advanced features of DHIS2 for health and data managers.

Používání informačních pokynů a standardů¶

To drive decision-making and to reach national health goals, annual planned targets, and Millennium Development Goals (MDGs), teams created processes on how to generate and use data efficiently.

Interoperabilita DHIS2 s jinými systémy¶

Since 2014, DHIS2 has been integrated with other software systems, enabling health workers to cross-cut, analyze and share data across organizations. Here are some examples of systems integrated or made interoperable with DHIS2:

eIDSR (elektronický integrovaný dohled nad nemocemi a reakcemi)¶

eIDSR was developed from scratch using USSD technology and linked with DHIS2 for the immediate reporting of data on infectious diseases. The tool is designed to improve detection and response time to diseases and is used within all health facilities in Tanzania.

HRHIS (Lidské zdroje pro zdravotnické informační systémy)¶

HRHIS was developed to report health data information from within all Tanzanian health facilities. It has helped to assess HR problems, manage the distribution of HR, and plan and evaluate HR interventions.

MFL (Master Facility List)¶

MFL is a health facility register to keep records about health facility profiles.

eLMIS (Logistics Management Information Systems)¶

eLMIS is a supply chain system for distributing and stocking of drugs and other commodities.

Řešení pro využití a povědomí o datech¶

Solutions to raise awareness about best practices for data use, data analysis and data dissemination have been embedded within DHIS2. These solutions are:

Výsledkové listy¶

Scorecards are used to communicate the status of progress toward key global, regional and national commitments for specific indicators. The representation of visual indicators has the role of stimulating actors to respond to situations rapidly through effective policies and investments.

HMIS webový portál¶

The HMIS web portal is hosted by the MoHSW and used by health stakeholders. It’s also accessible to the general public. https://hmisportal.moh.go.tz/

P4P (platba za výkon) / RBF (finance založené na výsledcích)¶

Rewards the delivery of one or more outputs or outcomes by one or more incentives that can be financial or otherwise. The P4P/RBFprogram is integrated within DHIS 2 to enable health service providers to monitor their performance and payments.

DHP / RHP (zdravotní profil okresu a regionu)¶

Provides planning and progress guidance to the district health management team. For example, it offers a summary of district health conditions through priority health indicators that reflect the district health status of the population, status of the health systems and the status of the health services delivery.

Výzvy¶

As with any big project being implemented on such large scale and with a complex health care setting, a number of challenges arose.

Nepředvídané změny správní struktury¶

District and regional administrative boundaries are frequently updated. The foundation of a new region generates a new representation of local population data. This disruption has an impact on the comparative analysis of HIS data such as the performance of health indicators.

Omezení samostatných programů¶

Reducing the amount of existing standalone programs was often achieved through demonstrating the limitations of individual programs, and highlighting the potential of DHIS2. Due to some reservations however, some vertical programs are still running in parallel with DHIS2.

Nedostatek vyškoleného personálu a geografické pokrytí¶

The lack of people with adequate HIS skills has at times weighed heavily on implementing and scaling up DHIS2 from a pilot region to the entire country. Tanzania has over 7000 health facilities across 168 district councils.

Výsledek¶

Now an endorsed and standard system of choice throughout Tanzania, DHIS2 is recognized as follows:

• An integrated e-health architecture that has strengthened health data collection, improved the analysis, use and harmonization of data and stakeholders.

• Over 1.5 million data entries are being collected and added to the national data warehouse on a monthly basis, using modems, broadband LAN and VSAT.

• Multiple, reliable, integrated tools to assist in improved evidence-based decision making (such as scorecards, dashboards, P4P).

• Open access initiative (HMIS web portal) initiated by the community of stakeholders.

• Improved data validation and quality checks for better monitoring and evaluation of health programs.

Jaké jsou ponaučení?¶

Here are some key lessons to take away from the experience of rolling out DHIS2 in a sustainable way.

Aplikování postupného přírůstkového procesu¶

The systems must be flexible and adaptable to meet emerging needs. By learning from previous iterations it has been possible to extend the system to other regions.

Vypracování a schválení komplexního národního plánu¶

To save on resources and prevent running the risk of duplicating efforts, before deploying DHIS2, streamline all resources and HIS activities of all stakeholders and use the MoHSW as a lead organization.

Navázání důvěryhodného vztahu¶

Promote system and data ownership within the MoHSW. Encourage data sharing amongst the health programs and stakeholders to help develop a sense of trust in the routine HIS and the resources and capacity that can support it.

Budování kapacit na národní, regionální a místní úrovni¶

A reliable system is maintained by well trained and knowledgeable people. Capacity building needs to be a continuous strategy. Capacity is needed for system development, maintenance, and information use to make sure the system is up and running every day, and information generated is used for health management, planning and decision making.

Zapojení dalších zdravotních programů¶

The major health programs are HIV/AIDS, Maternal Child Health (MCH), malaria and TB. Getting such big programs as these involved in a HMIS at an early stage is a means to spark the interest of other programs and associated stakeholders.

Vyhrazení svému programu správné množství času a zdrojů¶

Lots of time and effort was spent integrating the vertical programs into the HIS/DHIS2 platform and gradually rolling out the HIS. Today we’ve established a large community of stakeholders who share a common interest in building a sustainable HIS/DHIS2 platform for future generations to use and build upon.