Cloud Computing as a Catalyst for Integrated Health Information Systems in Developing Countries

Cloud Computing is increasingly becoming important in the generation, storage and transmission of information worldwide. In this paper, we discuss the potential of Cloud Computing in terms of how it can strengthen health information systems in developing countries. Like any new technology, Cloud Computing is no silver bullet; it solves certain challenges while bringing new ones to the table. Based on a case study of the innovative use of Cloud Computing for the national health information system in Kenya, we discuss how Cloud Computing can enable the integration and harmonization of fragmented systems and provide real-time information to health managers for evidence based decision making. The key contribution of the paper is to provide an understanding of how Cloud Computing can enhance health management by acting as a catalyst for the integration of health information systems

Assessing bed net use and non-use after long-lasting insecticidal net distribution: a simple framework to guide programmatic strategies

<p>Abstract</p> <p>Background</p> <p>Insecticide-treated nets (ITNs) are becoming increasingly available to vulnerable populations at risk for malaria. Their appropriate and consistent use is essential to preventing malaria, but ITN use often lags behind ITN ownership. In order to increase ITN use, it is necessary to devise strategies that accurately identify, differentiate, and target the reasons and types of non-use.</p> <p>Methods</p> <p>A simple method based on the end-user as the denominator was employed to classify each individual into one of four ITN use categories: 1) living in households not owning an ITN; 2) living in households owning, but not hanging an ITN; 3) living in households owning and hanging an ITN, but who are not sleeping under one; and 4) sleeping under an ITN. This framework was applied to survey data designed to evaluate long-lasting insecticidal nets (LLINs) distributions following integrated campaigns in five countries: Togo, Sierra Leone, Madagascar, Kenya and Niger.</p> <p>Results</p> <p>The percentage of children <5 years of age sleeping under an ITN ranged from 51.5% in Kenya to 81.1% in Madagascar. Among the three categories of non-use, children living in households without an ITN make up largest group (range: 9.4%-30.0%), despite the efforts of the integrated child health campaigns. The percentage of children who live in households that own but do not hang an ITN ranged from 5.1% to 16.1%. The percentage of children living in households where an ITN was suspended, but who were not sleeping under it ranged from 4.3% to 16.4%. Use by all household members in Sierra Leone (39.9%) and Madagascar (60.4%) indicate that integrated campaigns reach beyond their desired target populations.</p> <p>Conclusions</p> <p>The framework outlined in this paper provides a helpful tool to examine the deficiencies in ITN use. Monitoring and evaluation strategies designed to assess ITN ownership and use can easily incorporate this approach using existing data collection instruments that measure the standard indicators.</p

Development of novel composite data quality scores to evaluate facility-level data quality in electronic data in Kenya: A nationwide retrospective cohort study

BACKGROUND: In this evaluation, we aim to strengthen Routine Health Information Systems (RHIS) through the digitization of data quality assessment (DQA) processes. We leverage electronic data from the Kenya Health Information System (KHIS) which is based on the District Health Information System version 2 (DHIS2) to perform DQAs at scale. We provide a systematic guide to developing composite data quality scores and use these scores to assess data quality in Kenya. METHODS: We evaluated 187 HIV care facilities with electronic medical records across Kenya. Using quarterly, longitudinal KHIS data from January 2011 to June 2018 (total N = 30 quarters), we extracted indicators encompassing general HIV services including services to prevent mother-to-child transmission (PMTCT). We assessed the accuracy (the extent to which data were correct and free of error) of these data using three data-driven composite scores: 1) completeness score; 2) consistency score; and 3) discrepancy score. Completeness refers to the presence of the appropriate amount of data. Consistency refers to uniformity of data across multiple indicators. Discrepancy (measured on a Z-scale) refers to the degree of alignment (or lack thereof) of data with rules that defined the possible valid values for the data. RESULTS: A total of 5,610 unique facility-quarters were extracted from KHIS. The mean completeness score was 61.1% [standard deviation (SD) = 27%]. The mean consistency score was 80% (SD = 16.4%). The mean discrepancy score was 0.07 (SD = 0.22). A strong and positive correlation was identified between the consistency score and discrepancy score (correlation coefficient = 0.77), whereas the correlation of either score with the completeness score was low with a correlation coefficient of -0.12 (with consistency score) and -0.36 (with discrepancy score). General HIV indicators were more complete, but less consistent, and less plausible than PMTCT indicators. CONCLUSION: We observed a lack of correlation between the completeness score and the other two scores. As such, for a holistic DQA, completeness assessment should be paired with the measurement of either consistency or discrepancy to reflect distinct dimensions of data quality. Given the complexity of the discrepancy score, we recommend the simpler consistency score, since they were highly correlated. Routine use of composite scores on KHIS data could enhance efficiencies in DQA at scale as digitization of health information expands and could be applied to other health sectors beyondHIV clinics

Understanding the Role of Institutional Incentives in Shaping Data Quality and Information Use in Devolved Health Systems: A Case of Health Information System Implementation in Kenya

Devolution, which is becoming common in developing countries, refers to the creation of subnational governments that are substantially independent of the national level. Devolved entities have a clear legal status, recognized geographical boundaries, elect their leaders and raise their revenue. Potentially, the process of devolution generates or modifies existing institutions. Arguably, the new institutions, the incentives they create, and the behaviour of agents in the face of these incentives affords or constrains the implementation of Health Information Systems (HISs). Identifying these incentives and proposing remedies to improve the HISs is the theoretical motivation of this study. The empirical foundation for this thesis comes from studying the implementation of the District Health Information Software (DHIS2) in Kenya. During its implementation, the country adopted a new constitution, which introduced the devolution of decision making to the lowest levels of the government systems. The study attempts to answer two research questions. RQl: What institutional arrangements arise from the interactions between devolved health systems and the health information systems implementation in the context of advanced information technology? RQ2: How do the institutional arrangements generated by the devolution of health systems create institutional incentives that shape the effectiveness of health information systems in terms of data quality and information use? Using a longitudinal case study design, I collected data for this thesis from extensive desk reviews, participant observation notes from the implementation of the DHIS2 and key informant interviews. To understand the implications of devolution of health systems to the implementation of HIS, I drew upon concepts from institutional theory, particularly those relating to institutional incentives. Taking an interpretivist epistemological position, I used both qualitative and quantitative analytic approaches to understand the role of institutional incentives in shaping the effectiveness of the health information system in terms of data quality and information use in devolved health systems of developing countries. The key findings from this study show that the use of advanced Information Technology (IT), specifically central server and cloud computing enhances data access, information sharing across all levels of government and facilitates the integration of fragmented HISs. By enabling data sharing between national and devolved governments, technology becomes a centralizing factor in a decentralized environment. Concerning the role of institutional incentives, I argue that simple and practical incentives improve accuracy, timeliness and completeness of data in information systems. For instance, in the free maternity project in Kenya, the national government reimburses hospitals for deliveries using HIS data. The number of hospital deliveries are therefore important to all stakeholders, explaining the observed high accuracy of data transfer from maternity registers to DHIS2. The quest for re-election of the local leaders is a major institutional incentive driving data demand and use for planning. This thesis contributes to the institutional theory, specifically the concept of institutional incentives by claiming that successful devolution of power and authority from national level to sub-national levels creates institutional arrangements, which generate institutional incentives that facilitate multiple individuals to utilize their time, skills and knowledge to jointly, create valued HIS outcomes such as high data quality for informed decisions. However, while there are many incentives at play in a devolved health system, it is also important to step back and examine how some of these incentives might impede rather than enhance HIS outcomes. For instance, elected local leaders receive more recognition from the electorate when they implement visible projects like constructing roads, buying ambulances and building new hospitals than by printing reporting tools for HIS

The Consistency and Concurrency Between the Kenya HIV/AIDS Program Monitoring System (KePMs) and the National Reporting System (DHIS2), 2012

Background and Purpose: Kenya implemented the use of District Health Information Software (DHIS2) countrywide in 2011. The successful roll out of DHIS as the national reporting system provided a strong foundation for the development of &quot;One unified and integrated, country owned, country led, National Health Information System (NHIS).&quot; In order to achieve this, there was need to transition all existing parallel reporting systems into the DHIS. The Kenya HIV/AIDS Program Monitoring System (KePMs) was one of the major parallel reporting systems that were targeted for integration. KePMs is a computerized database for the management and analysis of the President&apos;s Emergency Plan for AIDS Relief Care (PEPFAR), treatment and prevention indicators required by United States of America Government program managers. This paper examines the current status of the implementation of the DHIS2 for use as the national health information system in order to inform transition from KePMs to DHIS2. It examines the consistency and concurrency between the DHIS2 data and KePMs data using selected indicators. Methods: In order to assess the concurrency of data between KePMs and DHIS2, data from sampled facilities and sampled indicators (in HIV Testing and Counselling (HTC), Prevention of Mother to Child Transmission (PMTCT) and Care and Treatment (CT)) were analysed by comparing datasets from the two databases (i.e. DHIS2 and KePMs). Indicator selection was purposive as determined from an indicator matrix developed in previous meetings. The PEPFAR 2012 data set on KePMs was considered as the sampling frame for facilities in both the KePMs and DHIS2. The data for September 2012 were used. Data were received from one reporting tool (dataset); the MOH711. A convenient sample size of 141 facilities (comprising three facilities per county) was determined. Descriptive data analysis was done using Microsoft Excel package. The analysis involved computing the concurrency and consistency between the data reported in DHIS2 and KePMs for the period of September 2012. During the analysis of these data, concurrency was only looking at the sites that had reported data while consistency checked through all the 134 health facilities sampled. Results: On average, data in the selected indicators showed a consistency rate of 79.5% in both systems. The consistency rate was above 75% in all indicators except in the indicator;; &quot;Number of individual tested and received results through Provider Initiated Testing and Counselling (DTC/PITC)&quot; which had 63%. The average concurency rate was 69%. Concurrency rates varied amongst the various indicators with DTC/PITC achieving the highest concurrency rate of 97%. The lowest concurency rate was for &quot;couples testing for HIV&quot; at 34%. In general 74% of data in both systems had no variance. Conclusions: The main reason for developing parallel system was the absence of a reliable national system. The results show a very high consistency rate between the two systems. Minor differences in data were attributed to data entry and poor data validation rules. It is recommended that with minor improvements, the DHIS is in a position to provide the necessary data to cater for all stakeholders and hence become the National reporting system

Developing decentralised health information systems in developing countries –cases from Sierra Leone and Kenya

Health service provision is a public concern that mostly takes place at community level, through primary health care. Using cases from Sierra Leone and Kenya, this study shows how country health information systems, producing simple information products such as quarterly bulletins and league tables being distributed widely, have enabled the communities to be engaged in improving the health status of the population. The community based information systems were part of a national system and the usefulness of comparing local data with data from other communities and from across the country in pursuing equity in health services provision is demonstrated. A community based information system is thus benefiting from being part of and integrated with the larger national system. The article presents and discusses community based participatory approaches to developing information systems which are enabling the community to take ownership and ‘cultivate’ culturally appropriate systems. Illustrated by the cases, the article argues that modern ICT and Internet based technologies, and even ‘cloud’ based infrastructures, are indeed appropriate technologies even at community level in rural Africa.

The indirect impact of COVID-19 pandemic on inpatient admissions in 204 Kenyan hospitals: An interrupted time series analysis.

The first case of severe acute respiratory coronavirus 2 (SARS-CoV-2) was identified in March 2020 in Kenya resulting in the implementation of public health measures (PHM) to prevent large-scale epidemics. We aimed to quantify the impact of COVID-19 confinement measures on access to inpatient services using data from 204 Kenyan hospitals. Data on monthly admissions and deliveries from the District Health Information Software version 2 (DHIS 2) were extracted for the period January 2018 to March 2021 stratified by hospital ownership (public or private) and adjusting for missing data using multiple imputation (MI). We used the COVID-19 event as a natural experiment to examine the impact of COVID-19 and associated PHM on use of health services by hospital ownership. We estimated the impact of COVID-19 using two approaches; Statistical process control (SPC) charts to visualize and detect changes and Interrupted time series (ITS) analysis using negative-binomial segmented regression models to quantify the changes after March 2020. Sensitivity analysis was undertaken to test robustness of estimates using Generalised Estimating Equations (GEE) and impact of national health workers strike on observed trends. SPC charts showed reductions in most inpatient services starting April 2020. ITS modelling showed significant drops in April 2020 in monthly volumes of live-births (11%), over-fives admissions for medical (29%) and surgical care (25%) with the greatest declines in the under-five's admissions (59%) in public hospitals. Similar declines were apparent in private hospitals. Health worker strikes had a significant impact on post-COVID-19 trends for total deliveries, live-births and caesarean section rate in private hospitals. COVID-19 has disrupted utilization of inpatient services in Kenyan hospitals. This might have increased avoidable morbidity and mortality due to non-COVID-19-related illnesses. The declines have been sustained. Recent data suggests a reversal in trends with services appearing to be going back to pre- COVID levels

Bed net ownership in Kenya: the impact of 3.4 million free bed nets

Abstract Background In July and September 2006, 3.4 million long-lasting insecticide-treated bed nets (LLINs) were distributed free in a campaign targeting children 0-59 months old (CU5s) in the 46 districts with malaria in Kenya. A survey was conducted one month after the distribution to evaluate who received campaign LLINs, who owned insecticide-treated bed nets and other bed nets received through other channels, and how these nets were being used. The feasibility of a distribution strategy aimed at a high-risk target group to meet bed net ownership and usage targets is evaluated. Methods A stratified, two-stage cluster survey sampled districts and enumeration areas with probability proportional to size. Handheld computers (PDAs) with attached global positioning systems (GPS) were used to develop the sampling frame, guide interviewers back to chosen households, and collect survey data. Results In targeted areas, 67.5% (95% CI: 64.6, 70.3%) of all households with CU5s received campaign LLINs. Including previously owned nets, 74.4% (95% CI: 71.8, 77.0%) of all households with CU5s had an ITN. Over half of CU5s (51.7%, 95% CI: 48.8, 54.7%) slept under an ITN during the previous evening. Nearly forty percent (39.1%) of all households received a campaign net, elevating overall household ownership of ITNs to 50.7% (95% CI: 48.4, 52.9%). Conclusions The campaign was successful in reaching the target population, families with CU5s, the risk group most vulnerable to malaria. Targeted distribution strategies will help Kenya approach indicator targets, but will need to be combined with other strategies to achieve desired population coverage levels.</p