National Health Information
Systems
Sierra Leone’s Presentation at the
National Health Information System,
Bobo, Dioulasso, Burkina Faso, 17-19
October 2012

Steps
• Background
• Goals and Objectives of Results and Accountability Framework
• Output
• Situation Analysis
• The Four main Information Systems in the Sector (HMIS, LMIS, IHRIS, IFMIS)
• Data management, storage and Feedback and ICT
• Roles and Responsibilities of Stakeholders
• Strengths, Weakness, Opportunity and Threats

Background
Sierra Leone in recent years has made significant progress in delivering interventions to address health goals in areas
such as maternal, neonatal and child health, HIV/AIDS, tuberculosis, malaria and non communicable diseases.
However, these gains have not been sufficiently broad based and sustainable. Progress at national level has not been
reflected in gains for most vulnerable population groups in specificly those in the rural settings.
It is evident that health systems that deliver services equitably and efficiently are critical to the achievement of health
goals. Global health initiatives have thus paid more attention to health systems strengthening as a key strategy to
addressing health inequalities and achieving health goals. Sierra Leone adopted this strategy and has developed its first
National Health Sector Strategic Plan (NHSSP) with a six year horizon (2010 – 2015), along the lines of health
systems strengthening, mainly focusing on its six pillars of governance, service delivery, human resources, health care
financing, medical products, technologies and health information
While the sector has welcomed the increased attention to health systems strengthening, it has also recognized the fact
that it will not be sustained in the absence of a solid monitoring strategy that enables decision-makers to track how
health systems are responding to increased inputs and the impact in terms of improved health indicators. This demands
the definition of core indicators of health system performance while concurrently developing and implementing
appropriate and sustainable measurement strategies to generate the required data.
The Ministry in collaboration with its partners and stakeholders have developed a document called the Result and
Accountability Framework (2010-2015 ) for the NHSSP with the overall goal of providing a comprehensive and
robust health sector wide framework for monitoring evaluation and review of the NHSSP 2010-2015 that serves as the
common platform for tracking progress and performance at national and district level, with alignment of specific
disease / health programmes as well as all key stakeholders and partners

Goals and Objectives
Goal
The overall goal of the Results and Accountability Framework 2010-2015 is to provide a comprehensive
and robust health sector wide framework for monitoring evaluation and review of the NHSSP 2010-2015.
Objectives
• To establish a strong, integrated and well coordinated country health information system, including
implementing a regular and coordinated programme of population-based surveys and facility assessments,
strengthened routine HMIS and civil registration systems supported by a functional Information Technology
infrastructure.
• To strengthen institutional capacity in all aspects of M&E including data collection, management, analysis,
synthesis, data quality assessment, performance reviews, reporting and data dissemination.
• To enhance use of results for planning and decision-making, including policy development and corrective
action as the basis for mutual accountability between country citizens, decision-makers and international
community.

Output
• An integrated and well functioning national health management information system that provides timely
and accurate monitoring at Villages, district’s and national level.
• A vital registration system that functions well, with increased quality of data and capacity for analysis.
• Strengthened maternal death surveillance and response mechanism including regular assessments of
quality of care in health services.
• A regular mechanism for data quality assessment, including regular data quality reports.
• Improved transparency of data, methods and analyses through the establishment of the National Health
Research Group, national health resource centre, including a national observatory and portal
• Regular and transparent evidence based performance review meetings as a mechanism to hold all
stakeholders to account, including district and national teams of the MoHS, bilateral donors, private
sector, civil society, etc.
• Establishing a Health Demographic Sentinel Surveillance (HDSS) Site

Situation Analysis
• Since 2007 the MoHS, with support from the Health Metrics Network (HMN), has championed re-forms in
creating a district based database. The MoHS/DP and DIC now collates district data through an electronic
District Health Management Information System (DHIS).
• In 2007, a National Health Accounts Survey was also completed in collaboration with DFID and WHO.
This NHA survey led to the establishment of the Integrated Financial Information Systems (IFMIS), which
now collects data on government expenditures and financial activities of the various Ministries,
Departments and Agencies (MDAs).
• UNICEF recently assisted the Ministry with Developing Logistics Management Information tool, which are
used to manually collect data on health commodities. These tools are now captured electronically through
the CHANNEL software introduced by the UNFPA. This systems has been modified to meet the needs of
Sierra Leone and now captures consumption data on drugs and consumables in health facilities across the
country
• The Ministry in collaboration with World Health Organization (WHO) has just completed the Integrated
Human Resource Information System (IHRIS). The key challenge has been the lack of ICT in the rural
area, but however the ministry has also developed plans of dealing with these challenge.
• All these systems are currently operating independently and not integrated into the DHIS, which at the
moment is focusing on capturing data on service delivery
• Data flow from districts to national has been inaccurate and untimely thereby undermining it dissemination
and usage by decision makers and stakeholders for proper planning

Health Management Information System (HMIS)
• The routine health management information system typically yields regular administrative reports on inputs to the
health system, including finances, human resources, commodities, equipment and infrastructure. These
administrative reports is supplemented and validated with findings from periodic surveys.
• Weaknesses and Gaps
– There are problems with timeliness, completeness and quality of data. There are significant capacity issues at the PHU level which
are compounded by fragmentation and the burden of reporting systems (HIV, TB, malaria)
– Difficulty in accessing data from private sector
– Challenges in accessing HMIS data at all levels
Planned Activities to Address those Weaknesses and Gaps
– Develop and implement plans for strengthening of nationally integrated routine HMIS that provides timely and accurate data
quality checks and monitoring, including convening stakeholders to have a common plan
– Design and implement harmonized data collection forms/tools
– Customization of DHIS, including revised electronic forms, electronic medical records and improvement of overall performance
and functionality
– Strengthen and integrate IDSR into DHIS
• Strategic options for improving hospital Information Systems
– Development of software to capture information.
– Training of staff in the use of the system.
– Procurement of computers
– Networking of computers for capturing data in hospitals.
– Strengthen ICT for DHMTs and hospitals
– Building capacity at PHU level for proper capture of data on manual tools
– Research mobilization

Logistics Management Information System
• Logistics Management Information System, (LMIS) provides information on the stock status, between levels of the health
system. LMIS can be either paper or other forms of communication to transfer data which can improve day-to-day
management of commodities and inform forecasting and procurement decisions at the district or national level.
• As part of the process of strengthening the LMIS, the Ministry of Health and Sanitation, in collaboration with UNICEF, has
developed standards for recording the essential data items. These include:
– Stock Keeping records such as Stock Cards
– Transaction Records such as the Report, Request and Issue Voucher (RRIV)
– Consumption Records such as daily commodity dispensing register which tallies the amount of each drug used or
dispensed to each patient on a daily basis
In addition to the above, UNFPA has introduced a computerized form of Inventory Control mechanism (CHANNEL),
which has been installed in the District and Hospital Medical Stores. The CHANNEL software has been recently
modified to capture consumption data. However, the modified system is yet to be used effectively to get consumption
data. To address this situation:
– 13 IT CHANNEL operators have been recruited and deployed in all 13 districts to operate the electronic tool
– Additional training will be provided to all health workers that handle drugs, to efficiently perform their respective roles
in the LMIS chain.
– Supervision will be increased to strengthen the capacity of health workers to use the paper-based LMIS.
– An electronic LMIS system has been developed to help automate most of the LMIS processed. This system will be
designed to take advantage of the supply distribution process and operate throughout the varying levels of
telecommunication available in remote and rural areas.

Human Resource Information Systems
• The existing HRH information systems in Sierra Leone depend on different sources such as payroll records,
district staffing list, health facilities staffing, health training institutions, faith based organizations, censuses
or surveys, payroll records and various other services in statistics for which the completeness, timeliness
and comparability are widely variable, added with the challenges of combining and compiling information
from multiple sources.
• To address the critical need to improve the existing Human Resource Information System, a properly
functioning HR information system has been established. The following will be done to ensure its
effectiveness:
– Health workers at district and central levels will be trained in the use of the system.
– A computerized database on the health workforce will be developed using a unique identifier assigned
to each health professional, to track health professionals from entry into health training institutions,
through recruitment into public or private sector institutions, to transfer within the country or
movement between public and private sector or emigration and retirement or death.
– A national database will be launched to track the annual numbers graduating from all health training
institutions.

m - HEALTH Overview
Background: Through research and case studies , the potential of mhealth and the use of mobile communication through its
(mobile phones and PDAs) for health services and information. This field has the potential to transform and approach to a variety
of healthcare challenges in Sierra Leone by accelerating the collection and storage of patient data, training rural staffs with health
updates and guidance, and personalizing to new levels the process of patients receiving and engaging in available medical
treatment. Governments, companies, and non-profit groups are engage in the mHealth applications to improve healthcare and
consequently save lives. These new mobile applications, bypassing the fixed-line solutions, are creating new pathways for sharing
health-related information, even in the most remote and resource-poor environments.
Source: World Vision Sierra Leone has incorporate the need for implementing mHealth, in Sierra Leone to enhance the health
sector by:
• Increased access to healthcare and health-related information, particularly for hard-to-reach populations
• Improved ability to diagnose and track diseases
• Timelier, more actionable public health information
• Expanded access to ongoing medical education and training for health workers
• Aims:
• Reduce child mortality specifically the under-five mortality rate.
• Improve maternal health: Reduce, the maternal mortality ratio.
• Combat HIV/AIDS, malaria, and other diseases: Have halted by 2015
• Objectives:
There is a great pride in MOHS/WVSL in trying tremendously in their effort to improve the lives of their citizens. Yet formidable
obstacles remains. Health challenges present arguable the most significant barrier to sustainable development. Disease and the
lack of adequate preventative care take a significant toll on populations.
Depending on whether governments make the link between telecommunication policy and health, and the extent to which donors
encourage transparency in sourcing and the participation of local entrepreneurs. Ultimately, the takeup of mobile communications
in the health sector isn’t really about technology at all

Data Management, Storage, Feedback and ICT
Data Management
• Routine data is collected in the public sector through a network of 1,119 Peripheral Health Units (PHUs),
and 25 hospitals that are distributed throughout the country across 13 health districts.
• The PHUs and hospitals gather data from client/patient registration forms, using tally sheets. These are
collated onto paper based integrated reporting forms which are sent to the district office. Data from the
community is included in the PHU’s reporting forms.
• DHMT capture this data into an electronic District Health Information System (DHIS) and the electronic
data is forwarded to the Directorate of Planning and Directorate of Information and Communication in the
MoHS.
• The electronic DHIS database also allows integration of Open MRS software that will permit development
of a Hospital Information System.
• This electronic medical recording process has started with data for anti-retroviral patients being recorded at
the nation’s teaching hospital and will be scaled up to all hospitals as a second step.
• The DHIS database will progressively be extended to capture data from other sources such as specific
surveys, civil registration (births and deaths), research, supervision, private sector, civil society, resources
and administrative records to give a broad picture of the country. Data and reports on key indicators and
reports of National reviews will be stored in a National data repository/observatory.

Data Flow Chart
MOHS/DP and
DIC
DHS, Surveys,
Births and
Deaths
Registration
Tertiary
Hospitals
DHMT
PHUs
District &
Regional
Hospital
Private,
NGOs,
FBOs

Data Storage
Data is received and stored at all levels:
• At PHU level, monthly paper based data reports are stored locally in files
• At district level, data is captured into a district database application using the DHIS 2.0 application software
and stored in the district’s Integrated Data Ware house (IDW).
• At central level, DP and DIC electronically compiles raw data (pivot tables) received from the 13 districts
and are stored in the central Integrated Data Warehouse (IDW).
The DHIS database is capable of producing standardized reports, providing monthly feedback to each health
facility and each district on its performance, thus giving an overall national health statistic

Information Communication Technology (ICT)
• Integration of health information is important for data from various programs at all levels to be managed as
a whole in a well coordinated and transparent fashion.
• Computers and internet communication facilities are already in use in most offices at national and district
levels to permit rapid compilation and transmission of health data as well as automation analysis and report
generation.
• A fully integrated health data warehouse is designed and installed at national and district levels. This pull
together data from all key health programmes and activities (routine services, surveillance, human
resources, drug supply, maternal and child health services, HIV/AIDS control, tuberculosis control) and
other data sources essential for health decision making (census, household surveys, vital statistics) and
provide decision makers at all levels with user friendly reports and access to essential statistics.
• The Directorate Information and Communication has been recently established.

Integrated Data Warehouse
Common User Interface
Decision Support & Executive
Dashboard
Information
Services (SSL)
Data
Warehouse
at DP and
DIC
Extract, transform and load data into warehouse
Census
Vital
Event
Registry
Surveys
Admin
Records
Service
Records
Health &
Disease
Records
Formerly fragmented data collection methods and tools

Reporting and Feedback
The success of reporting on Key Performance Indicators depend on feedback between and amongst the various levels of service
delivery in the health sector
Table 1: Reporting and Feedback Processes for Key Performance Indicators
Feedback Process Deadlines Responsible Party
Facility monthly reports received by District M&E Office 5th Facility Head/ Nurse
District Monthly Report received by DP and DIC 15th DMO
Feedback received by facility from District 30th M&E Officer
Feedback report received by District from National Level 30th DP and DIC
District Monthly data received by programs (EPI, RCH, Malaria,
HIV, TB, etc)
25th DP and DIC
Feedback Report from DP and DIC/National to Districts 30th HMIS
Notifiable diseases and diseases under epidemic alert, reports
received by DPC
weekly M&E Officer

Analysis, Synthesis and Quality
Analysis and Synthesis:
• Analysis of data is done at various levels of the health sector. Data is analyse and presented in the form of
tables, charts and graphs. Data from routine HMIS are disaggregated by district/local Councils and when
required by chiefdom or facility. Data from surveys further disaggregated by sex, urban/rural and wealth
quintiles. The main focus of analysis is:
– Tracking progress and trends (based on measurement of baselines and targets for core indicators (as in
the progress and performance report)
– Equity analysis (main stratifies: region, district, level of income, gender etc)
– Efficiency (value for resources)
Data Quality:
This involve more details and includes.
– Involvement of independent groups (national institutes, universities) for data quality ascertainment
– Processes for data quality assessment and adjustment including assessment of completeness of
reporting, assessment of denominators, comparison/analysis of results from facility data, population
surveys data and use of well documented methods for adjustment .
– An annual system of verification through annual facility surveys (combined with the service readiness
surveys - as described above)
– Development of data quality report cards
– Sharing of data, reports, and methods in the public domain,
– training and supervision

Evaluation Exercises
• Evaluation is carried out periodically to assess the health status of Sierra Leoneans as a result
of implementing the NHSSP. The major evaluations are (i) Annual Programme Reviews; (ii)
Mid Term Evaluation; (iii) End of Term Evaluations and (iv) Participatory Community
Monitoring and Accountability Evaluations. Specific questions in these evaluations focuses
on:
– Relevance of programme (s) objectives
– Relevance of strategies employed
– Effectiveness of the programmes
– Efficiency of implementation
– Sustainability of programme(s)
– Gender mainstream in programme(s) implementation
– Human rights approach to programme(s) implementation

Data Dissemination
• In order to facilitate the usage of information for decision-making among the different
stakeholders, a number of communication and feedback mechanisms are instituted as part of
the Health Information System. Table below shows the stakeholders and the HIS products that
are required. HIS products are disseminated as appropriate through:
• Email
• Post
• Courier
• Quarterly Bulletin
• Delivered by hand
• Website

Table 3 : Health Sector M&E lines of Communication and Feedback Mechanisms
Stakeholder M&E Information Requirement and Use Communication and Feedback
Mechanism
District Councils Performance of the district to assess progress,
experiences, challenges and resolution process
National Quarterly Bulletin, Quarterly
and Annual Reports; Briefs, meetings
DHMTs Performance of the project to assess progress,
experiences, challenges and resolution process
National Quarterly Bulletin, Quarterly
and Annual Reports; Briefs, meetings
PHUs Performance of the facilities/PHUs to assess
progress, experiences, challenges and how they
have been resolved
National Quarterly Bulletin, Quarterly
and Annual Reports; Briefs, meetings
HSCC, HSSG Compliance with the NHSSP, rules and regulations.
Challenges impacting project implementation
National Quarterly Bulletin, Quarterly
and Annual Reports; Briefs, meetings
MoHS Contribution in progress towards MDG indicators
4, 5 and 6. Compliance with rules and regulations.
Challenges impacting project implementation
National Quarterly Bulletin, Quarterly
and Annual Reports; Briefs, meetings
Funding Development
Partners
Compliance with NHSSP rules and regulations.
Challenges impacting project implementation
National Quarterly Bulletin, Project
supervision missions, Quarterly and
Annual Reports; Briefs, meetings
Non funding
development partners
(NGOs, CBOs, FBOs)
Compliance with NHSSP, rules and regulations.
Challenges impacting project implementation
National Quarterly Bulletin, Quarterly
and Annual Reports; Briefs, meetings

Data Access
• At the district level, the integrated data warehouse automation, generate user-friendly
bulletins, other reports and maps to feedback to health facilities and inform DHMTs and local
councils. These will show comparisons between facilities and districts through indicators on
coverage and efficiency (e.g. outpatient attendances per health professional).
• Multiple agencies, partners and other information consumers (researchers, the media, civil
society organizations) have web-based access to statistics via the portal of the integrated
warehouse
• Government health services statistics and surveys and census data collected by public
agencies, in principle, are regarded as being in the public domain once the data has been
rendered anonymous. Public access to this data is guaranteed by law

Reviews
• As Partners are increasingly showing commitments to the health sector, regular annual multi-stakeholder
review meetings are conducted, as scheduled below. The reviews conducted by a good synthesis of the
available monitoring data. The results of the review meetings are used extensively in the planning process.
• The national reviews have a strong sub-national focus which is well informed by data. Programme specific
reviews (e.g MNCH reviews) also aligned with, and the results/decisions fed into the annual sector review.
• The National Annual review are culminated in an Annual Health Summit to which all stakeholders were
invited to discuss progress and agree on the way forward. The Summit consist of Local Council
representatives, District Health Management Teams, selected facility representatives, representatives of
Parliament, NGOs, CSOs, the private sector, donor partners and other stake-holders. The summit also
involves other key inter-sectoral ministries and partners in health, including ministries of, Education,
Science and Technology; Finance and Economic development; Local Government; Gender and Children’s
Affairs; Youth and Sports; Agriculture, Forestry and Food Security; Defense (ONS); and Information. The
Government coordinated and chair the Summit.
• In order to provide information to guide strategic direction, data from the HMIS is used to assess coverage.
Surveys and assessment are conducted to ascertain service availability and readiness. This, together with
other administrative data, formed the basis of a draft sector performance report for the previous year that
is expected to be completed by the end of May each year.

Table 4 : Timeline for Reviews
Milestone Timeframe
Sector performance report May
Joint review mission by Health Sector Steering
Committee
June
Health Sector Review Summit July
District Reviews March, June, September, December
Programme Reviews March, June, September, December

Roles and Responsibilities of Key Stakeholders
Some institutions have a critical role in the implementation of the Results & Account-ability Framework . These
include, the MoHS, Statistics Sierra Leone (SSL), University of Sierra Leone, Private Institutions, NGOs,
FBOs, CSOs and Development Partners.
• The MoHS monitors the implementation of the plan as well as create a monitoring system that starts from
the community, through the facility, the district to the national level.
• The Ministry also ensure that information collected through the country M&E system is disseminated and
available to all partners.
• SSL, in line with its mandate, support all the household and facility surveys. Some surveys out-sourced,
while for others SSL is requested to provide technical support for specific aspects, such as sample, data
entry and analysis.
• The University of Sierra Leone and its constituent colleges are responsible for providing basic, in-service
and post-graduate training of staff in Health Informatics and Epidemiology. It also has the responsibility for
conducting various assessments and research.
• Private Institutions, with comparative advantage in conducting evaluations and research, are contracted to
conduct such studies. They also contracted to provide training for staff in M&E and in the use of
Information communication Technology (ICT).
• Non-Governmental Organisations (NGOs) and Faith-Based Organisations (FBOs) work with the MoHS to set
up functional Monitoring systems at community, facility and district levels. Staff of these organizations are
required to provide technical support for the development of the National HMIS.
• CSOs are trained to support data collection at community level, conduct data verification and use the
information from the HMIS for advocacy. They also support, to conduct community monitoring systems
and use data collected through the system to motivate staff to improve performance.
• Development partners and Donors provide both technical and financial support for setting up the national
HMIS and sustaining it.

SWOT
The ministries has had difficulties incorporating the necessary access of internet communication, resulting in
lack of communication from all angles. Implementation of web designing is currently being initialize, with the
internet facility also need to be enacted upon to facilitate the needs of:
• Intranet communication within the ministry
• Upholding security mechanism, through the means of wired and wireless connection
• Server devices to collect and correlate data
• Application software for decision makers to provide statistical results.
• Collaboration and teleconferencing
• mhealth and eHEALTH technology
With the implementation of the internet facility, would create a fundamental results in the way we access and
make decision base on real time information.

The End
• Thank you for your Attention
• Merci
• Obrigado