Chapter 7: Health Systems: principled integrated care
Health information: better but not good enough
The evolution of health information
Shortages of adequate health information, as well as shortages of personnel, contribute to the potential collapse of some health care systems and threaten the long-term viability of others. Health care systems oriented to primary health care principles need robust health information components in order that the health needs of populations, especially those that are poor and marginalized, can be understood; to ensure that programmes are reaching those most in need; to measure the effects of interventions; and to assess and improve performance. As noted above, tools and structures for obtaining, organizing and sharing information are vital for improving the work of individual health care providers and raising the quality of care throughout the system.
The amount of information available to health policy-makers and planners at the time of the Declaration of Alma-Ata on primary health care was limited. The main sources of population-based health information were vital registration, censuses, national surveys, and research studies. Information was generated through routine reporting at facility level. However, data were rarely collated and used at national level, and feedback mechanisms from central to local levels were missing.
Substantial progress has been made since then in the field of health information. An increasing volume of data has become available on health status, health services utilization, and determinants of health through population-based health interview surveys. Many countries now have good data, disaggregated by sex, on levels and trends in child mortality, coverage of selected health interventions, and incidence and prevalence of certain diseases. They often have some limited information on equity in health. However, many critical gaps remain. Levels of adult mortality are poorly measured in most populations and accurate cause-of-death data are not generally available. Morbidity is inadequately measured for most conditions. Coverage and costs of many interventions are not monitored properly and insufficient information is available to monitor equity satisfactorily. The quality of health information is often highly variable and poorly documented. There is little standardization across definitions and methodologies.
Critically, the use of health information for the management of health services at the local level and for health policy-making and planning at the national level remains limited. Very few countries have developed effective and efficient health information systems that take into account the needs of different levels of users, from local to national and global levels. Much of the information collection and analysis is driven by vertical health programmes, often in the context of international initiatives, and integration is lacking.
An information system driven by primary health care
In the context of health systems driven by primary health care, a health information system can be defined as an integrated effort to collect, process, report and use health information and knowledge to influence policy-making, programme action, and research.
Health information systems use a range of data collection and analysis tools and methods. Accurate and continuous statistics on basic demographic events are a foundation of rational health and public policy. National vital registration systems (considered the "gold standard") currently cover less than one-third of the world's estimated mortality. Significant regional disparity exists, ranging from over 90% of all mortality coverage in the European Region to less than 10% coverage in the South-East Asia and African Regions (42,43) (see Table 7.1). Trends in coverage are slowly improving. Considerable effort has been devoted to developing less expensive and more accurate alternatives to national routine death certification, such as sample registration systems and survey-based or census-based questions on sibling deaths or deaths in the household. When used alone or with accompanying vital registration systems, sampling can improve coverage of events where resources are limited. These systems have been introduced in China and India, to take two examples, and are applicable to other resource-poor settings (see Box 1.1 in Chapter 1).
Population-based household surveys have become the major source of health information. Much of the information generated by surveys is based on self-reporting, raising issues of reliability, validity and cross-population comparability. In the field of morbidity and evaluation of interventions, there is an urgent need to consider a much larger and broader investment in biological and clinical data collection in surveys (44). In most countries, equity considerations are still not fully integrated into health information systems.
Health information can be used for at least four distinct but related purposes: strategic decision-making, programme implementation or management, monitoring of outcomes or achievements, and evaluation of what works and what does not. Strategic decision-making by health policy-makers should be based on the best available evidence. Data from vital registration systems, epidemiological studies, household surveys, censuses, and health service providers often give highly uncertain information about the true population value of a health indicator. Assessments of any health indicator should be based on the integration of all relevant information and the use of criteria such as internal consistency and prior knowledge of disease history to improve estimates from uncertain or inconsistent data.
In addition to the routine use of models to estimate life tables in areas where vital registration systems do not attain high rates of coverage, estimates of the incidence, prevalence and mortality of diseases increasingly use explicit models to derive best estimates from uncertain, incomplete or contradictory population data. The focus has been on the national, regional and global levels, although estimates for local areas, including districts, are increasingly becoming available.
The problems and weaknesses of routine health service statistics are well known (45). Several countries have now made progress in developing routine health information systems, including the use of better technology, mapping, and focusing more extensively on local user needs. The introduction of new technology in a well-designed system allows better surveillance of key diseases and also more accurate and timely programme monitoring.
Improving information systems
In recent years, significant attempts have been made to reform health systems as a whole, with increasing attention given to the decentralization of resources and decision-making to district level. Such reforms entail the need for better health information systems at local level. At the same time it has been increasingly understood that local individuals and families have to be involved in the generation, dissemination and use of health information. Involving people in the planning and implementation of health care was a fundamental principle of Alma-Ata and still has important implications for the way that health information systems operate.
Equity in health is another of the key principles of primary health care. This requires the ability to measure inequalities in access to and use of health services, risk factors, and key health outcomes. It also means identifying which groups of people are the most disadvantaged -- often poor people, ethnic groups or women. This type of information imposes a considerable additional burden on health information systems and is not routinely available in many countries. Surveys are currently the most important method of collecting information on the equity dimension of health, but much more work is needed to integrate equity monitoring into health information systems, both with surveys and with other methods of data collection and analysis. The aim of the World Health Survey, launched by WHO in 2001, is to provide valid, reliable and comparable data on population health and health system performance, through a household survey. The programme emphasizes monitoring the MDGs and critical outcomes among poor populations.
Improvement in health information systems is needed at local, national and international levels, and more integration between these levels is required to deal with global health threats and the growth of knowledge (see Box 7.7). Countries will benefit greatly if health information systems are based on a national plan with a framework, indicators, and data collection, analysis and dissemination strategies. The strategic plan should also be specific about how the different tools and methods will be applied and complement each other, how health information needs are met at the subnational, national and global levels, and what kind of investments are needed. The latter include human resources, infrastructure (technology, laboratories, etc.), and operational budgets for health data collection efforts. National bodies with participation of stakeholders of different levels of users and technical experts need to guide and oversee the implementation of the national plans.
Box 7.7 Reliable and timely information for health
The Health InterNetwork (HIN), led by WHO, is an initiative of the United Nations Millennium Action Plan to meet the information needs of health professionals, researchers and policy-makers in developing countries.1 Since it began in September 2000, HIN has improved health by using the Internet to enhance the flow of health information, focusing on content, Internet connectivity, and capacity building.
HIN provides a vast online health library to personnel in government departments, teaching and research institutions, and other non-profit organizations. International agencies, national organizations and the academic and private sectors are contributing content, and HIN is working with local partners to publish local health information. The five priority content areas are: scientific and biomedical journals, education and training resources, information for health policy and practice, statistical data, and public health software for public health and clinical management.
During its first year, HIN achieved a major breakthrough in the provision of health content. Through an agreement reached by WHO with the world's major biomedical publishers, over 2200 medical and scientific publications are now available online to public and non-profit institutions in 113 developing countries. HIN's Access to Research Initiative (HINARI) is making the journals available online free of charge or at greatly reduced rates, based on a country's ability to pay.
HIN's second phase is providing the up-to-date information needed to educate and upgrade the skills of the health workforce. It includes online courses and references covering public health, medicine and nursing, as well as specialized topics for developing country practitioners.
Health personnel need easy, reliable and affordable access to the Internet if they are to use it in their work. Infrastructure and cost are important obstacles, and Internet use is limited outside many capitals where power sources are unreliable and service providers are rare. HIN India was developed to test the logistics, cost and partnership models for improving the flow of information with remote areas. It has established Internet access sites in hospitals, clinics, research and educational institutes and public health facilities in two states. Local partners played a key role by supplying, installing and maintaining computer hardware and software, and in establishing Internet connections. Capacity building is essential, and HIN provides training materials that institutions use to ensure that health workers, policy-makers and researchers have the skills needed to find, use and share public health information online.
Well-documented, successful strategies to bridge the digital divide in health information remain the exception rather than the norm. In the words of a tuberculosis programme coordinator in the field in India: "without computers and the Internet, we are fighting 21st-century health problems with 19th-century tools".
1 Web site: www.healthinternetwork.net.
The Health Metrics Network
The strengthening of these systems requires a collaborative effort. The Health Metrics Network, to be launched in 2004, will focus on improvements to the availability and utilization of reliable health information for policy-making and planning, programme monitoring and evaluation, monitoring of international goals, and measuring equity in health. Through the collaboration of many partners, and with careful planning and establishment of clear targets, the Network aims to strengthen the capacity of health information systems to provide high quality, timely information in a form that is useful for public health work at the national, subnational and global levels. It is a broad partnership that includes WHO, other international organizations, bilateral agencies, foundations, ministries of health, statistical organizations, academic institutions, and organizations representing civil society. This kind of network is necessary to enhance the efficiency and effectiveness of the assistance provided by investors in health information. The Health Metrics Network partnership should also be able to accelerate development and scaling-up of innovations in monitoring and evaluation of health status and health programmes. Standardization and enhancement of methods to assess quality of health information will greatly assist the measurement of progress towards achieving global goals such as the MDGs.