Elsevier

Public Health

Volume 122, Issue 9, September 2008, Pages 914-922
Public Health

Original Research
The Data for Decision Making project: assessment of surveillance systems in developing countries to improve access to public health information

https://doi.org/10.1016/j.puhe.2007.11.002Get rights and content

Summary

Objective

By using timely, high-quality information, ministries of health can identify and address priority health problems in their populations more effectively and efficiently. The Data for Decision Making (DDM) project developed a conceptual model for a data-driven health system. This model included a systematic methodology for assessing access to information to be used as a basis for improvement in national health surveillance systems.

Study design and methods

The DDM surveillance assessment methodology was applied to six systems in five countries by staff from the US Centers for Disease Control and Prevention (CDC). Ministry of health personnel at national, regional, district and local levels were interviewed using either informal conversation or an interview guide approach, and their methods for collecting and using data were reviewed. Attributes of timeliness, accuracy, simplicity, flexibility, acceptability and usefulness were examined. Problems and their underlying causes were identified.

Results

The problems preventing decision makers from having access to information are many and complex. The assessments identified no fewer than eight problem areas that impeded decision makers' access to information. The most common deficiencies were concerning the design of the system, ongoing training of personnel and dissemination of data from the system.

Conclusions

To improve the availability of information to public health decision makers, it is recommended that: (a) surveillance system improvement begins with a thorough evaluation of existing systems using approaches outlined by the CDC and the Health Metric Network of the World Health Organization; (b) evaluations be designed to identify specific causes of these deficiencies; (c) interventions for improving systems be directly linked to results of the evaluations; and (d) efforts to improve surveillance systems include sustained attention to underlying issues of training and staff support. The assessment tool presented in this report can be used to facilitate this process.

Introduction

In 1990, the US Centers for Disease Control and Prevention (CDC), in collaboration with the US Agency for International Development (USAID), designed the Data for Decision Making (DDM) project with the goal of enhancing the use of data in the decision-making process through capacity building at national, regional and district levels, and increasing decision makers' access to health information. During its design phase in 1990, the DDM project developed a conceptual model for a data-driven health system that outlined the roles of decision makers, technicians and information. This model included three components: (a) decision makers who are knowledgeable about the usefulness of relevant epidemiological information for problem-solving; (b) advisors who are capable of analysing epidemiological data; and (c) information systems that make relevant, valid and timely data available for use at all levels of the health system. Also included were technical assistance for improving access to information, and interdisciplinary training for programme managers at central and decentralized levels of the ministry of health, tailored to the needs of the country.1

Between 1990 and 2003, DDM project personnel assisted 15 countries in identifying and addressing barriers to the use of data. Assessments identified multiple barriers to data use. These barriers and the constellation of interventions put in place to address them, including the interdisciplinary training programme, are described elsewhere.1 In five of the 15 countries, improving access to information was identified as important to increasing their use of health data. This report focuses on one of the three components of the DDM project: information systems.

By using timely, high-quality information, ministries of health can identify and address priority health problems in their populations more effectively and efficiently. Health information systems are necessary for ongoing disease surveillance and evaluation of the implementation of public health policies, strategies and interventions.2 Data from health information systems can be used to detect, investigate and control an outbreak of acute infectious disease; monitor disease morbidity and mortality; provide a basis for predicting the future course of an infectious or non-infectious disease; assess the need for various interventions; support policy formulation and resource allocation; guide research; and aid the clinical care of patients via the appropriate allocation of limited resources.3 Such data can also be used to improve the management of resources for the delivery of public health services and programmes, project future needs and monitor costs.4

Although they are widely perceived as being a necessary component of effective health programmes, information systems in developing countries do not yet generally provide sufficiently useful information for effective public health management. Problems cited in the literature include:

  • lack of trained personnel, diagnostic laboratories and funds to support surveillance5;

  • inadequate data-collection systems;

  • an apparent lack of interest and motivation among personnel;

  • a lack of data analysis among data managers6;

  • overly complex systems;

  • delays in reporting urgent events;

  • incomplete reporting7, 8, 9;

  • a lack of dissemination and feedback of information7;

  • a lack of reliability in case reporting10; and

  • a perception that data users did not have input into the collection of information.1

Much attention has been paid to the need to improve the quality of information provided and to the evaluation of surveillance systems. The CDC and the World Health Organization (WHO) have both published guidelines for the systematic, quantitative evaluation of disease surveillance systems11, 12, 13, 14 that can also be applied to health and management information systems. Although several evaluations of surveillance systems have been published,7, 8, 9 these tend to focus on a single system and only identify problems in the most general terms. To the authors' knowledge, no report has been published to bring together the lessons to be learned from various evaluations.

Efforts to improve health information systems have focused on the development of new forms and computerization rather than taking a system-wide approach to identifying and solving problems. For instance, at the workshop entitled ‘Issues and Innovation in Routine Health Information in Developing Countries’ held in Potomac, Maryland, 14–16 March 2001, five of 10 reported initiatives centred on the creation of new forms. In a sixth initiative, computerization was the only activity proposed (http://www.cpc.unc.edu/measure/publications/html/rhino2001). These efforts, as documented in project reports, do not appear to be based upon the results of systematic evaluations.

DDM personnel developed and tested a systematic methodological approach for the assessment of surveillance systems that facilitates the development of appropriate recommendations and plans for action. This approach takes the decision makers', rather than the system developers', point of view. This paper presents a summary of the results of assessments done by the DDM teams. When viewed together, these assessments demonstrate the complex nature of surveillance systems and the requirement for multifaceted, sustained efforts in order to produce timely, accurate, useful information that can be used in decision making.

Section snippets

Definitions

Access to information is defined as a situation in which decision makers have information they feel they need, that is of adequate quality and is in a form they can understand, when they need to make a decision.

A health information system is defined as ‘a combination of vital and health statistical data from multiple sources, used to derive information about the health needs, health resources, costs, use of health services and outcomes of use by the population of a specified jurisdiction’.15

Results

Each system was judged to have deficiencies in at least four of the six attributes, with two systems having five deficiencies and three systems having six deficiencies (Table 2).

Overall, the lowest number of contributing factors identified by assessment teams was eight (System 5), while the highest was 15 out of the possible 26 identified by the DDM staff. The most common problems for the provision of high-quality, timely information among the six systems studied concerned the design of the

Discussion

The six systems evaluated in this project represent a range of developing countries in four geographic regions, with both low- and middle-income economies. The framework for the assessments was applicable in all six cases and allowed for a systematic, thorough examination of factors impeding access to health information. In some cases, this facilitated the design of workplans for the improvement of health information systems. While these assessments were conducted before the development of the

Acknowledgements

The authors wish to acknowledge the contributions of the following in the creation and support of this project: Jim Sheperd, Pamela Johnson and Celeste Carr, USAID/Washington; Drs. Joe Davis, Ronald Waldman and Andrew Vernon, CDC. The authors gratefully acknowledge the contributions of members of the assessment teams who devoted long hours to the evaluation of information systems: Dr. Douglas Klauke, Mr. Robert Fagan, Mr. Bradley Otto, Dr. Steve Yoon, Dr. Daniel Fishbein, Dr. Michael Malison,

References (19)

  • M. Pappaioanou et al.

    Strengthening capacity to use data for public health decision making: the Data for Decision Making project

    Soc Sci Med

    (2003)
  • A. Trebucq et al.

    Information management in national tuberculosis control programmes and national health information systems

    Int J Tuberc Lung Dis

    (1998)
  • D. Morris et al.

    The costs and effectiveness of surveillance of communicable disease: a case study of HIV and AIDS in England and Wales

    J Public Health Med

    (1996)
  • G. Janes et al.

    Descriptive epidemiology: analyzing and interpreting surveillance data

  • R.A. Cash et al.

    Impediments to global surveillance of infectious diseases: consequences of open reporting in a global economy

    Bull World Health Organ

    (2000)
  • M.C. Azubuike et al.

    Health information systems in developing countries: benefits, problems and prospects

    J R Soc Promot Health

    (1999)
  • M. Tshimanga et al.

    The health information system in the City of Bulawayo, Zimbabwe: how good is it?

    Cent Afr J Med

    (1997)
  • D.D. Chadee

    Evaluation of malaria surveillance in Trinidad (1988–1998)

    Ann Trop Med Parasitol

    (2000)
  • V.M. Ferreira et al.

    Variables associated with underreporting of AIDS patients in Rio de Janeiro, Brazil, 1996

    Rev Saude Publica

    (2000)
There are more references available in the full text version of this article.

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