Directorate: National Health Information System (NHIS)
Cluster: Health Monitoring and Evaluation
Ms Oumiki Khumisi
Tel: 012 – 312 0673
Email: khumio@health.gov.za
Primary Health Care was formally introduced to South Africa from April 1994 as the driving principle for health care provision in South African with the implementation of two policies, "Free Health for pregnant mothers and children under the age of six years" as well the "Universal Access to Primary Health Care for All South Africans". This gave special emphasis to the development of clinics and basic health care programmes such as safe motherhood, child health and nutrition, expanded immunisation, management of communicable disease and the treatment of chronic ailments. The Minister: Health was then charged with the responsibility of ensuring that these services are not only rendered but also monitored for equity, accessibility, appropriateness and quality.
The data is collected:
Manually (paper-based system) at facility level using forms and registers to date.
Electronic at the some of the clinics (Alexander Health Clinic) and districts.
One of the electronic systems was the Regional Health Management Information System (ReHMIS) that was developed as a decision support system for regional health service managers. It was to be used to investigate alternatives for the restructuring of primary health care services rendered by local authorities and to develop models for provincial and district health services. The primary goal of ReHMIS was to improve the access of regional health service management to objective and structured data regarding health resources and to strengthen their ability to analyse this information in a flexible and easy way. It was also developed to provide easy access to this database of more than 5300 health facilities and almost 1 million individual data items using the Regional Health Query. The ReHQry was not restricted just to the original ReHMIS database, but it allows the import or export of data to other popular decision support software such as spreadsheet and data base packages. The information was limited to demography and health care system data. Some provinces collected data as early as 1991 for inclusion into the ReHMIS database. However, the bulk of the data now dates from late 1993 and early 1994 though the data for the former Eastern Transvaal, now Mpumalanga dates from 1992 and for Gauteng Province from middle 1993.
Despite the availability of theses systems data remained unreliable and this was a major obstacle in planning. The department was thus obliged to develop a new health information system, the National Health Information System for South Africa (NHIS/SA), with an aim of contributing to the promotion of an information culture. As a result the then Minister of Health established the NHIS/SA Committee in 1994 to develop a national strategy for the implementation of a comprehensive NHIS/SA that would begin at the local level and feeds into district, provincial and national levels, and includes the private and public sectors..
All this was entrenched in the White Paper on the Transformation of the Health System in South Africa (Notice 667 of 997) that was published in 1997. Chapter 6 of the paper deals with Health Information and two principles are outlined:
The NHIS/SA should be nationally coordinated in order to support the effective delivery of services at all levels of the health system
The NHIS/SA should be used to monitor the implementation and success of the health priority programmes, both of the DoH and the RDP
The Reporting of NHIS/SA data at all levels should be timeous, accurate and complete.
The NHIS/SA started functioning in August 1995 as a sub-committee of the Provincial Health Restructuring Committee (PHRC). The NHIS/SA Committee was charged with the responsibility to oversee the whole process that moved from paper-based to electronic-based method.
Priority areas in the development of the NHIS/SA were Administration and Finance with the National Health Care Management Information System (NHC/MIS) being one of the components. A tender to carry this work forward was published in 1996, however, it was cancelled and provinces were given the go ahead to acquire the NHC/MIS using the initial specifications. Most of the provinces started with the implementation of the NHC/MIS at hospital and concurrently the committee:
initiated a PHC Monitoring System
developed a PHC Form
identified the Cluster: Health Monitoring and Evaluation as the programme responsible for the coordination of this system.
The strategy to develop the District Health Information System was led by a Task Team that comprised officials from the Directorates: National Health Information System and District Health System as well as other professionals with a history of working on district health system’s development. The work of this Task Team culminated in the developed of District Health Information System Guidelines in 1998. Some of the members of the Task Team, specifically those from the Health Information Pilot Project (HISPP) were simultaneously involved in district health information system pilot projects.
The HISPP was a collaborative research project between the University of Cape Town (UCT), the University of Western Cape (UWC), the Norwegian Computing Centre (NCC), and the Provincial Administration of the Western Cape (PAWC). The Norwegian Agency funded the 1st phase of the project for the Development Co-operation (NORAD) from mid-96 to the end of 1998. Work from these pilot projects resulted in the development of a system, Health Information System Programme (HISP), designed for collection and management in the Western Cape Metropole.
In early 1998 MSH: EQUITY made funding available for the Eastern Cape to implement the HISP capturing, analysing, and distributing routine monthly data/information. The programme was successfully implemented and following this MSH: EQUITY took a decision to move the HISP out of the Eastern Cape to Mpumalanga Province. A presentation was made by the HISP Team at the PHC workshop in 1998 and following the presentation the NHIS/SA Committee adopted the HISP in early 1999 and it was agreed that it be rolled-out to other provinces. MSH: EQUITY made funding available for training for the rollout. In some of the provinces the staff attended the University of the Western Cape Winter School in July 1999 and is providing most of the relatively simple user support required in this initial phase. Some districts are getting support for other donors such as ISDS, CHESS and UNICEF.
The programme was renamed the District Health Information System (DHIS) Software and is currently being implemented in all provinces using Provincial EDS (see next chapter). The DHIS Software itself is free and released into the public domain called "Open Source" software, where the software is distributed for free and complete with all source code. This approach can be seen as an extension of basic academic principles for international sharing of knowledge. Any user is free to utilise, reproduce, or adapt the software as they see fit – as long as it is not abused for commercial gain (e.g. through selling the software to unsuspecting customers). All users are, likewise, encouraged to develop new functionality or new uses for the software and share this with others. To date various functionalities such as, Tuberculosis, Environmental Health, Emergency Medical Services, Hospital EDS are being captured on the software.
As part of the implementation several provinces started defining their first Essential Data Sets (EDS) previously called Minimum Data Set (MDS) in 1997 and 1998. The results from a survey of existing data sets, combined with recommendations from a NHIS/SA working group, resulted in a national Essential Data Set for PHC being adopted by the NHIS/SA in April 1999. This EDS for Primary Health Care is still in use and contains 20 compulsory and 18 optional items. All nine provinces have during the last three years developed their own Essential Data Sets for both Primary Health Care and hospitals. Almost all provinces are also currently using or are about to implement version 2 of their EDS, having revised the data set after gaining experience on what is useful or not or after getting new stakeholders.
The DHIS Software has resulted in data for the period 1998 in the Eastern Cape and data from other provinces is also being captured as from 1999 to Dec 2001. A National Report, based on provincial comparisons and using a few indicators has produced and will be presented to management. A synopsis of a few indicators will be made every month and a report will be produced every six-month and yearly as a form of feedback.