Health Information Systems in Ethiopia

Belesti Melesse Asress

MSc student in Computer science at HiLCoE,

school of computer science & technology

Addis Ababa, Ethiopia

[email protected]

Abstract
Health Information Systems (HIS) is potentially very important for the development of the
health sector in Ethiopia. In spite of some efforts to make the health care system integrated
with information systems, it continues to be not well-developed in the nation's health sector.
This paper tries to show the present condition of HIS in Ethiopia based on a review of
information from existing sources. Different searching strategies were used to gather
information on the concept of HIS development in Ethiopia from electronic journals, thesis
papers, databases, internet, conference proceedings, Government publications, reports,
statistics and books. Then the information gathered was thoroughly reviewed to summarize
the level of development of HIS in the nation and synthesis a conclusion. The aim of this
paper is to investigate information and make analysis to determine the current status of HIS in
this country. Finally it enables readers to identify many questions that have not been answered
yet and find research agenda to be addressed in the future. This research concludes that HIS in
Ethiopia is poorly developed.

Keywords
Health informatics in Ethiopia, biomedical informatics in Ethiopia, medical informatics in
Ethiopia.
1. INTRODUCTION
Ethiopia has a poor health status in relation to other low-income countries, even within Sub-
Saharan Africa[1]. The most serious global health problems are in poorer countries, and good
health information is vital in tackling these problems. Effective HIS offer government and
health department officials a clearer understanding of the effects of their policies on the health
of their people[2].

Health information systems in most developing countries are woefully inadequate to provide
the needed information support[3]. There is a need by the health sector of developing
countries to use the limited resource effectively in order to provide an efficient and equitable
health service to the communities. This then requires sound management that is based on
information, which is crucial at each level of the health service management[4]. Correct and
up-to-date information is critical, not only for the provision of high-quality clinical care, but
also for continuing health care, maintaining health care at an optimal level, clinical and health
service research, and planning and management of health systems[5].

Health information systems refer to any system that captures, stores, manages or transmits
information related to the health of individuals or the activities of organizations that work
within the health sector. Overall, a well-functioning HIS is an integrated effort to collect,
process, report and use health information and knowledge to influence policy and decision-
making, program action, individual and public health outcomes, and research. Sound decision-
making at all levels of a health system requires reliable health statistics that are disaggregated
by sex, age and socioeconomic characteristics[6].

Health information can be the aggregate information about all patients that have attended or
been admitted to a hospital, or attended a health center, outlying clinic or a community
immunization or health screening program[5]. Whether we collect data on paper or in a
computer, the data should be organized in such a way that we can understand and retrieve
them when needed [7]. A country’s HIS is made up of all the data and records about the
population’s health. The sources of data include civil and vital registration (recording births,
deaths and causes of death), censuses and surveys, individual medical records, service records
and financial and resource tracking information[2].

The objective of this paper is to review previous researches related to HIS and identify the
level of development of the field in Ethiopia so that readers would easily see the gap for their
future researches. An extensive systematic review of literature is the first thing that a novice
researcher should begin with to acquire the knowledge and skills for conducting a meaningful
research. In addition, in writing this paper, I got the opportunity to find a research problem for
my master thesis which will be conducted in the area of HIS next year.
2. METHODS
To determine the current state of HIS I conducted an extensive review of literature. The first
phase of the review was to identify relevant resource materials. Different searching techniques
were used to obtain those materials related to HIS development in Ethiopia and sub-Saharan
Africa from electronic journals, thesis papers, databases, internet, conference proceedings,
Government publications, reports, statistics and books. The keywords used for searching were
health informatics, health information systems, public health, medical informatics and
biomedical informatics in Ethiopia, and sub-Saharan Africa. In the next phase of the review
the selected resource materials were thoroughly analyzed to summarize the present condition
of HIS in the country.

The review was done based on the Health Metrics Network (HMN ) Framework division of
the components and standards of HIS made by World Health Organization (WHO) in 2008[8].

Figure1. The HMN Framework[8]

3. RESULTS
A national health information system assessment was carried out in 2008 using the Health
Metrics Network framework and tools and this was updated and validated in 2011 as a step
towards developing a national health information system strategic plan. According to the
validated assessment results, among the six components of HIS, four components scored low,
and the remaining two scored adequate. Data management scored as “not functional” (13%),
and three components, HIS resources (42%), dissemination and use (48% ) and data sources
(52%) were found to be present but not adequate. Indicators (83%) and information products
(73%) were considered adequate[9].

Table1. Summary assessment scores of HIS in Ethiopia, Sept 2011[9].

3.1. Data Management

Health Management Information System (HMIS) was established to “support informed

strategic decision-making by providing quality data that help managers and health workers
plan and manage the health service system.” As of 2008, a comprehensive electronic HMIS
has been developed in conjunction with doctors associated with Tulane University and is now
being deployed to health facilities in several regions of the country[10].

During the F.Y. 2011/12, to ensure timely and reliable data, HMIS has been strengthened.
Based on that, a system has been practical in 92 percent of the hospitals and 78 percent of the
health centers. In order to initiate rural Family Folders (FF) in all Health posts, guideline on
rural FF was finalized. Family Folders adequate for 7.1 million rural families have been
distributed and it was possible to have FF for 3.6 million (33.3 percent) rural families.
Regarding urban FF, the design was finalized and piloting is underway in cities utilizing the
close service of urban Health Extension Workers[11].

With respect to data management, assessments indicated that the situation of data management
in general was considered “not functional” with very low score (13%). Central Statistical
Agency (CSA) has standard procedures for data management and data warehouse for different
demographic and socio-economic surveys that were conducted so far; but other institutions
have no complete national data standards. CSA has procedure and guideline to collect,
compile, store and exchange data & information at various levels for its own use but this had
not been applied widely in the national HIS. Also CSA has data quality assurance
mechanisms at various levels although it is not widely used covering comprehensive HIS.
FMOH and sub national units lack integrated data ware house. Although the Ministry of ICT
has prepared data management tools, there is no standard definition (Meta data dictionary) and
data warehouse at national and sub-national level in the country[9].

3.2. Dissemination and Use

Available information needs to be timely disseminated and used for strategic decision making
at all levels of the health system. Otherwise its availability becomes meaningless and useless.
Dissemination and use component was assessed in terms of analysis and use of information,
for policy and advocacy, planning and priority setting, resource allocation, implementation
and action[9]. Through widespread dissemination and use of information products, the HIS
provides direct benefit to all those who participate in it, providing an ongoing incentive for
users to continue to strengthen the system[12].

Assessments showed that all sub categories under dissemination and use are present, but not
adequate. Dissemination and use of information for resource allocation, and advocacy,
performance monitoring and feedback mechanism is weak[9].

3.3. Resources

Networks (WAN and LAN), computers, internet access, databases and transport facilities are
required to ensure data quality, to enhance feedback, information use and greatly facilitate the
ability of health information systems to produce timely, relevant and high quality information.
The HIS assessment finding showed that computer availability is adequate and availability of
basic communication infrastructure is highly adequate. Lack of integrated ICT infrastructures
for HIS, limited use of available computers for health information purpose within the health
sector, and limited access to internet at sub national level is noted. There is no strong support
system for Information Communication Technology (ICT) equipment maintenance[9].

There is shortage of skilled human resource for HIS, the professional mix is poor and the
attrition rate is very high in the health sector. In general the human resources capacity in core
health information sciences to meet health information needs is limited[9].

Health care informatics has been identified as a critical area in need of extensive
improvement. In June 2008, the FMOH began a large, nation-wide development initiative to
reform the Ethiopian HMIS. Health care informatics development is also occurring in the area
of telemedicine, including teleradiology. Ethiopia’s Black Lion Hospital in Addis Ababa was
one of the initial test sites for development of the telemedicine component of the Pan-African
e-network, a joint project between India and the African Union to provide telemedicine and
teleradiology services to over 50 African nations. The Pan-African e-network is an integrated
satellite, fiber optics, and wireless network[13].

In 2011 the Health Ministry organized an eHealth workshop in order to begin developing
appropriate health informatics standards and an architectural framework for interoperability
and scalability of the various eHealth initiatives in the country. The “WoredaNet”, the e-
government communication backbone developed by the Ethiopian Telecommunication
Corporation, promises to be a major enabler for rapid ICT development in the country[10].

3.4. Data Sources

The country has had a national e-Government policy since 2009[10]. The Federal Ministry of
Health (FMOH) has implemented the Ethiopian HMIS while the CSA, a division of the
Ethiopian government, manages population–based health information sources, i.e. censuses,
ad hoc surveys, and registering vital events[10].

Concerning electronic health record, lack of coordination and standardization among various
efforts, and lack of clear long term plan to move the whole system is a major concern[9].
More recently, Ethiopia has seen a significant deployment of the SmartCare system used in
Zambia. Over 100 clinics and hospitals in the Dire Dawa region, covering the entire area, have
successfully deployed this system for building and maintaining electronic medical records,
which will improve both the quality of health information as well as patient care[14].

Computerized applications for healthcare include: SMARTCARE Ethiopia – an electronic

health record system that supports longitudinal recordkeeping for a clinical care, especially for
HIV/AIDS treatment, TB care, VCT, and antenatal care. The system is being rolled out
nationally and provides clinical decision support and data portability via the use of smart cards
[10]. SmartCare’s most attractive features include the ability of SmartCare to personalize
Patient’s medical record by using SmartCards. SmartCards are pocket/credit card sized plastic
cards embedded with an electronic memory chip capable of storing Patient’s information.
Furthermore, SmartCards are used as an ID for a patient so that it will easier to filter and
retrieve his/her record and history during the follow-up sessions or visiting different point of
services like reception, laboratory, pharmacy and so on[15].

Ethiopia had a health information system in which morbidity and mortality statistics could be
captured and used at national level. As the previous system was tedious and required so many
variables to be collected, with the new reform of Business Process Re-engineering (BPR) the
health management information system has been reformed with a big reduction in data
collection tools and limited variables at regional and national levels. One of the strategic
changes made is standardization with one data source, one channel and one reporting system,
as opposed to the previous fragmented vertical system for different health programs. The new
design is currently in its pilot implementation phase. At various administrative levels –
including national, regional, woreda and health facility levels – there are clerks who compile
morbidity and mortality statistics. Each year a health indicator is produced at national level,
and regions also produce their own annual performance monitoring reports. At FMoH level
the system is computerized for data clerks and managers, but this is not the case in all
regions[16].

The leading data collection methods are: Health and Disease Records (including disease
surveillance systems) Census, Vital Statistics, Population-based Surveys, Health Service
Records, and Administrative Records. In general data sources were assessed to present but not
adequate with a score of 52%[9]. Since the latest international statistical classification of
diseases and related health problems (ICD) is not in use, it is difficult to standardize recording
and reporting [9].

3.5. Indicators

Indicators are a set of measures that show changes in the country’s health profile. Indicators
measure determinants of health, health system, and health status[12]. As part of the HMIS
reform a total of 108 core indicators have been identified for use in monitoring and evaluation
of the HSDP. These were identified through discussions and consultations with stakeholders
and cover determinants of health, health system and health status. However; early reviews
indicate that some essential indicators for tracking key health programs were not covered in
the reformed HMIS, but it is agreed to implement the system nationwide and address these
limitation after a comprehensive evaluation [9]. The national core indicators reflective of
health-related UN Millennium Development Goals indicators are: risk factors, mortality,
health systems, health status and morbidity[17].

In this regard it was found from assessments that this component of HIS is adequate with a
total score of 83%[9]. With the exception of indicators related to risk factors, all were
adequate or highly adequate[17].

3.6. Information Products

Lack of timeliness and completeness of HIS reporting remains a weakness, and such delays
contribute to the failure (at all levels) to use data as the basis for informed decision-making in
health care planning and management. Recognizing the weaknesses of existing routine paper-
based system, there have been repeated efforts to reform HMIS in the country[18].

Assessment of information products showed that data quality in general is adequate (72%).
Specifically quality of risk factor indicators was 67%, health status 74%, health systems
indicators 72% all of them adequate, while among health status indicators mortality indicators
(67%), is adequate and morbidtity indicators (86%) is highly adequate[9]. However,
information quality and use remain weak at the peripheral levels of woreda[19].

4. Conclusion
In this research I reviewed a large amount of existing studies related to HIS in Ethiopia and
summarized as it was shown in the previous section. The paper explained the current status of
HIS in the country with respect to the six components suggested by HMN. Readers can easily
find out that researchers should give more focus to HIS in Ethiopia.

Results confirmed that indicators and information products are considered adequate but data
management is very poor. Health information system resources, dissemination and use, as
well as data sources coverage, are also inadequate. The capacity of institutions to generate,
analyze, disseminate and use health information differs[20]. Hence this literature review
revealed that the overall HIS in Ethiopia is poorly developed. This is primarily because of lack
of extensive researches in the field. In conclusion I suggest more researches to be done on HIS
in this country by prioritizing the components which are highly affected. In this way it is
possible for individuals, organizations and other stakeholders to contribute to the development
of HIS in this country.

Acknowledgements
I am very grateful to Dr. Amare Desta for his advice. I would like to thank Dr. Ahmed
Hussein, Mr. Ashagre Getnet and Mr. Tamirat Fikre for their encouragement.

References
1. Health, E.M.o. Overview of the Sector. 2013; Available from:
http://www.moh.gov.et/English/Information/Pages/Overview%20of%20the%20Sector.aspx.

2. Organization, W.H., The Need for Strong Health Information Systems.

3. Edwards, M., Routine Health Information Systems: Concepts and Methods. 2006.

4. Damtew, Z.A., Analyzing The Role of Health Information Systems for

Enhancement of Child Health Services: A Case Study

From Ethiopia. 10th International Conference on Social Implications of Computers in
Developing Countries, Dubai, United Arab Emirates, May 2009, 2009.

5. Organization, W.H., Improving Data Quality, A Guide for Developing Countries. 2003.

6. Network, P.H.I. Health Information Systems (HIS). Available from:

http://www.phinnetwork.org/Resources/HIS.aspx.

7. Davis N, L.M., Introduction to Information Technology. 2002, Philadelphia: WB

Saunders Company.

8. Organization, W.H., Framework and standards for country health information systems /
Health Metrics Network. 2008. Second edition.

9. Ministry of Health, F.D.R.o.E., Ministry of Finance and Economic Development,

National Health Information System Road Map. 2012.

10. Foster, D.R., Review of Developing Country Health Information Systems. 2012.

11. Federal Democratic Republic of Ethiopia, M.o.F.a.E.D., Annual Progress Report for F.Y.
2011/12 Growth and Transformation Plan. 2013: Addis Ababa.

12. Organization, W.H., Components of a Strong Health Information System.

13. Radiology Serving The World, R.-A.o., Ethiopia Country Report.

14. Consulting, V.W., Health Information Systems in Developing Countries. 2009.

15. Mengesha, T., Electronic Solutions For Ethiopian Health Sector

Electronic medical record (EMR) system, in Business Information Technology. 2011, Oulu
University of Applied Sciences.

16. Observatory, A.H.W., Human Resources for Health, Country Profile of Ethiopia. 2010.

17. Ethiopian CSA, E.M.o.H., HMN, World Health Organization, Assessment of the
Ethiopian National Health Information System. 2007.

18. Mengiste, S.A., Analysing the Challenges of IS implementation in public health

institutions of a developing country: the need for flexible strategies. Journal of Health
Informatics in Developing Countries, 4(1), 1-17, 2010. Vol.4 • No.1 • 2010(Vol.4 • No.1 •
2010).

19. Ethiopian Federal Ministry of Health, H.R.T.J., Strategic Plan for Ethiopian Health
Sector. 2008.
20. Observatory, A.H. Analytical summary for Ethiopian HIS. Available from:
http://www.aho.afro.who.int.