Guiding Principles for Implementing CHIS¶

When creating new CHIS in DHIS2, the system builders face many fundamental system design considerations, and the choices they make profoundly influence the trajectory of the CHIS. We describe these principles below and list a set of action points under each to enable operationalization of the design principles in practice.

1. Design the CHIS to strengthen government ownership and sustainability.
2. Enable and strengthen community engagement.
3. Build a balance between reporting burden and provision of care.
4. Strengthening capacity of CHWs and other stakeholders as a team.
5. Follow incremental and evolutionary principles of system design and development.

Principle 1: Strengthen Government Ownership and Sustainability of the CHIS¶

In the same way as community health fits within the larger arena of public health, the CHIS must fit within the larger ecosystem of public health information systems. A government-led CHIS strategy and implementation process ensures that essential community-level data are collected sustainably and promptly delivered to the right people in the health system, to enable effective decisions to strengthen health services delivery can be taken. Integrated design approaches which inherently strengthen government ownership will help reduce the unsustainable fragmentation of information systems, arising when non-standard systems are introduced by third-party agencies such as donors, NGOs, and faith-based organizations.

Action points to operationalize the design principle

1. Meet and engage government stakeholders at all levels - particularly district and local government - to discuss stimulating local demand for and availability of community-level health data.
2. Commit public, donor and NGO resources and infrastructure such as money, materials, and manpower to sustain locally developed plans to sustain the community system, right from the start.
3. Design CHIS to integrate with the existing government health management information system from the start.
4. Focus data collection on locally useful data on PHC, (preventive, promotive, curative, rehabilitative) and continuity of patient care. Also include data on SDGs/ MDGs, equity in care provision and universal health coverage.
5. Review CHIS-related health policies, M&E plans, and legislation regarding issues such as confidentiality, privacy, and data disaggregation.

Principle 2: Enable and Strengthen Community Engagement¶

Data collected through CHIS will only be accurate and consistent when the community and its leaders find value in the data generated and use it for local action. The CHIS, thus, must be designed to support community-based action, meaning that relevant local stakeholders should participate early in system design and implementation, and be able to see added value to their everyday work from the CHIS.

Action points to operationalize the design principle

1. Identify legitimate community stakeholders (e.g. traditional healers, chiefs, religious leaders, health committees, teachers, etc.), who can hold local actors accountable through participatory processes. They may have multiple roles such as data auditing, triage of data, and identifying gaps in service coverage.
2. Draw on existing institutional structures rather than creating new ones for CHIS. Strike a balance between ensuring continuity and promoting innovative change.
3. Strengthen use of CHIS data in local supervision, mentorship, and support to stakeholders, depending on how they will use or interact with the CHIS.
4. Ensure timely and appropriate feedback that makes the analyzed CHIS data interesting and immediately useful for targeted local stakeholders.
5. Promote community-led CHIS innovations that improve data use, using an approach that encourages critical thinking and problem solving. Identify good ideas generated in the community and nurture them to scale.

Principle 3: Build a Balance between Reporting Burden and Provision of Care¶

CHWs bear the brunt of data collection processes introduced by health programs and donors. Data collection often cuts into the time and energy that CHWs could be using to provide health care services. CHWs should prioritize care-giving tasks over data-reporting ones, which require CHIS designers to promote local action over upward reporting to national systems. While detailed household and individual data is essential for local use, it is not needed for action at higher levels which requires more aggregated data. As a general principle, data should not be transmitted upwards unless it can be used at higher levels.

Action points to operationalize the design principle

1. Keep information systems simple, sustainable, minimal, and frugal.
2. Standardize all CHW reporting forms across the country.
3. Simplify forms to make CHW data entry more efficient, user-friendly, and accurate.
4. Report only critical, "must know" information to next level. CHIS Data is for strengthening local monitoring and evaluation of programs, not for 'research purposes'.
5. Follow the hierarchy of reporting standards. Retain detailed data locally, and only report data necessary to inform policy and generate indicators to higher levels.
6. Integrate job aids such as data quality assessments or CHW diagnosis guides into the CHIS.

Principle 4: Strengthening Capacity Development Processes of All CHIS Stakeholders¶

CHIS should be both an object of capacity strengthening and a means to support teams of CHWs and stakeholders to conduct community-based health provision tasks. For example, CHWs need to build skills and capacity to use a mobile device based CHIS, but using this application they are able to strengthen their interactions with other CHWs and clinicians which can contribute to building their capacity to provide better health care services. Because of this potential, capacity strengthening around CHIS needs to span the entire information cycle. Some areas of capacity building that require attention in this context include:

• Target teams of CHWs, stakeholders and supervisors rather than individuals

• Understanding of basic concepts related to data elements and indicators, coverage, and general population data.

• Understanding why certain data elements and indicators are reported and why they are important in the larger health program picture.

• Knowing how to keep records and using appropriate technologies.

• Awareness and understanding of issues of data quality and health status assessment.

• Providing remote and supportive supervision

Action points to operationalize the design principle

1. Capacity strengthening must target teams of CHWs, supervisors and other relevant stakeholders.
2. Use locally appropriate user-focused training methods in the local language.
   • Use stories and images and perform training.
3. Combine on-the-job technical support with classroom training.
4. Develop a system of continuous coaching, supervisor mentorship and peer-to-peer support, which empowers trainees through the CHIS.
5. Focus on data use and understanding, rather than only on data collection.
6. Develop locally appropriate standard operating procedures (SOPs), which will provide the basis of capacity strengthening exercises, mentorship, and job aids.
7. Identify and train IT counterparts in local government who will be responsible for maintaining the CHIS in the long-term, as part of the overall HIS strengthening.

Principle 5: Follow Incremental and Evolutionary Principles of System Design and Development¶

This design principle focuses on adopting participatory and prototype processes that are incremental and evolutionary in nature, rather than attempting perfection at the first attempt. This requires building a prototype, exposing it to users and adapting and improving the prototype based on the feedback received. This process reflects an iterative process of evolving system improvements, and strengthening user ownership.

Action points to operationalize the design principle

1. Build upon systems that exist, ensuring that CHIS design is sensitive to history and existing work practices. Remember that no system can be designed from scratch, from a "clean slate".
2. Balance the system's user requirements between continuity and change. Focusing only on continuity may lead to automating existing processes without considering process improvements, and seeking radical change may create resistance.
3. Use [participatory design principles]{.ul} to promote local ownership and buy-in for the system.
4. When mapping the flow of data in a CHIS, implementers must balance the required complexity of data needs with the simplicity necessary for system reliability in resource-constrained communities.
5. Build simple, frugal, and user-friendly systems based on appropriate technology such as simple functional phones and dynamic dashboards.
6. Design iteratively; customize the CHIS through a prototyping framework that builds on principles of agile and incremental design.