Information Systems, Information Systems Support and Information Centres: A Quasi-Tutorial Contribution

Eduardo O C Chaves

The objective of this paper is to discuss and clarify the following notions, as they apply to the health sector:

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Information, today, is a most valuable asset. In the health sector, it is a key resource and a conditio sine qua non of effective health care.

In order to cope with it, information systems abound in every organization and in every area within an organization, those of the health sector included. Such systems can be used to help individuals (say, a clinician) better execute their tasks, to enable divisions and units (say, a division of epidemiological surveillance) to operate more efficiently, to assist managers of various levels (say, directors of health centres and hospitals, health programme coordinators, health authorities in local, regional and central governments) in the performance of their functions.

Information systems support is an expression which refers to the resources which make possible the development, maintenance and effective use of information systems.

Informatics is, today, an essential component of information systems support. In most areas, and the health sector is no exception, the amount of information necessary to take well-grounded decisions is so large, that it has grown beyond the capacity of human beings to handle it manually. Without the support of informatics, the information needed for decision-making will often be incomplete, inaccurate, therefore unreliable, or will even be unavailable at the right time or totally inaccessible.

Furthermore, it is often necessary today, in almost every area, health sector again being no exception, to tap information resources which lie outside the limits of the unit or even the organization where one is working. That is why informatics today must be supplemented by telecommunication resources, or by what has become know as telecommunications (the use of telecommunication in informatics and of informatics in telecommunications). Without telecommunications, computers cannot have access to data which are stored in other remote computers, nor exchange data with them.

The notion of an Information Centre is not very consistently employed. On the one hand, there are those who attribute to an Information Centre only the tasks related to the building and maintenance of information systems. On the other hand, there are those who attribute to it mostly the tasks related to information systems support, leaving to end-users the tasks of building and maintaining their information systems. And, of course, there are those who argue that an Information Centre should do both things.

o O o

In order to illustrate the role of informatics and telecommunications support to information systems, we will discuss here the challenges which face the task of monitoring and evaluating health programmes. Some of these challenges have to do with developing information systems as such. But they can only be met by means of informatics and telecommunications support.

(A similar discussion can be held, of course, in relation to almost every area of the health sector).

The fundamental general objective of any health system is to seek to improve the level of health of the population. The health system tries to improve the level of health of the population through a series of health actions, which, in their turn, in order that they be performed in a coherent, efficient and cost-effective manner, must be coordinated. The most frequent form of providing such coordination is to tie these actions to health programmes (which, in their turn, need overall coordination, in order not to duplicate actions or to try to promote contradictory goals).

Each health programme has its specific objectives (which must, naturally, be subordinated to the general objective of improving the health of the population) and must set its targets, which are mainly detailed and quantified objectives to be achieved within a particular time frame.

Health programmes, once implemented, must be monitored and evaluated. According to WHO definitions, "monitoring is the term used for the continuous follow-up of activities to ensure that they are proceeding according to plan. ... The information gained from monitoring is utilized for evaluation. Evaluation ... is the systematic assessment of the relevance, adequacy, progress, efficiency, effectiveness and impact of a health programme" (Glossary of Terms Used in the "Health for All" Series No. 1-8, "Health for All" Series, No. 9, World Health Organization, Geneva, 1984, pp.23-24).

The strategies developed to reach the specific objectives and the targets set up for the various health programmes of a health system can only be monitored and evaluated through the use of health indicators, such as, for example, indicators of the state of health of the population (reduction in the rates of morbi-mortality, for instance) indicators of the quality of health services (higher indices of efficacy and greater capacity for resolving problems, increase in efficiency and performance, etc), and so on. Some indicators measure primarily the efficacy of programmes, that is, the degree to which they are achieving the targets proposed for them, without measuring whether they are doing this in an efficient manner, that is, at the lowest possible cost.

Other indicators will be primarily oriented to measuring the efficiency of programmes, that is, whether the results obtained by the programmes are being achieved with a reasonable adequation of means, generally characterized in terms of cost/benefit.

But why are indicators needed, and what is their function?

If the term "health" had only one meaning for all people, and if it referred to a single state, easily identifiable and quantifiable, there would hardly be any need of health indicators. But such is not the nature of health. The reality represented by the term "health" is highly complex and its presence or absence can only be detected through the use of certain referents and measuring instruments which have been conventionally called "health indicators". Indicators are frequently used when a given reality cannot be directly or easily measured as is the case of the health of a population -- or of the economic "health" of a country, which is measured by such indicators as the rate of employment, industrial production, balance of external commerce, wholesale and consumer price index, and so on.

There are hundreds of possible health indicators. In order that they may be used with greater ease and effectiveness, a selection has to be made, which is normally governed by the health profile of the country, by the interests which govern the process of monitoring and evaluation and by the availability of information required to utilize that indicator.

Even if we take only one indicator, as, for example, the morbidity rate, there are innumerable diseases which can be monitored in this form. So, even using only this one indicator, a selection often has to be made and only some diseases are monitored. Consequently, only the health programmes which have impact upon this disease will be monitored and evaluated through this indicator.

The monitoring and evaluation of health programmes aimed at primary health care are normally done on the basis of the following groups of basic indicators:

To these types of indicators others could be added, such as, for instance, indicators of the cost of health services, etc, but here we will not go into them. It must also be clear that other indicators have to be developed in the case of monitoring and evaluation of hospital-based secondary and tertiary health care.

One of the hardest tasks of one who is ultimately responsible for monitoring and evaluating health services (be it at the central, regional, sub-regional, district or local level) is to obtain agreement from specialists, first, on a set of basic indicators which is discrete, harmonious and at the same time sufficient for the needs of the monitoring process, and, second, on parameters, or minimum levels of performance, against which to evaluate health services.

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In the process of selection of the health indicators which are going to be used, one factor is very important: the careful characterization of the information requirements of each of these indicators. Otherwise, indicators may be chosen which cannot be applied, because they require information which is not being collected or which, sometimes, does not even exist.

Indicators of mortality, for instance, can be divided into non-specific (those in which death is not related to any specific cause) and specific (those in which death is related to a cause or group of causes). Although the latter are obviously more interesting, from the point of view of health, in many countries death certificates do not report, as a rule, the cause of death.

Some countries may not even have a system of regular reporting cases of death.

Indicators of morbidity may require that all births be registered, with the length and weight of the child, or that there is data on the nutritional status of children, pregnant and breast-feeding women, maternal mortality, etc, in order to establish some indices. This information is not always available.

Indicators of coverage and concentration require, as a rule, population data divided by region, sub-region, district, town, and broken into sex, age groups, etc. These data sometimes do not exist. Other times the data do exist, but are greatly out-of-date, and there are no effective means of making population projections on the basis of such data as do exist.

Most indicators of coverage and concentration also require statistics about the production of health services broken, in principle, by health unit, and this is sometimes not available.

Finally, social and economic indicators are prepared by agencies outside the scope of influence of the health sector and many times are distorted for political reasons.

So, developing information systems for monitoring and evaluating health programmes faces considerable challenges. The development, maintenance and effective use of these systems today without support from informatics and telecommunications is inconceivable.

Demographical data and the data necessary to elaborate social and economic indicators are collected by agencies outside the health sector. Data about vital events (of which birth and death are the most important) is generally collected and often kept by agencies which are not under direct control of health authorities. The only data, relevant to our problem, which is collected and maintained by the health system itself are those related to morbidity (incidence and prevalence of diseases) and the inventory and production of health services.

Today it is difficult, without the support of informatics, to monitor and evaluate even the work of a primary health care centre of reasonable size or of a hospital of medium size. The difficulty increases exponentially if an entire health programme, a national programme of immunization, for example, has to be monitored and evaluated. In order to be planned, executed, monitored and evaluated, such a programme must have rather reliable information on the age and geographic distribution of the population at risk, the incidence rate and the pattern of each communicable disease, the demand for each vaccine, the total quantity available and the distribution of the stock, the facilities at the places to which the vaccines have to be sent (e.g., if they have refrigerators to store them), the coverage of each age group at risk for each communicable disease, the need to have special drives or campaigns, etc.

And we are speaking only of one health programme! Imagine the need for information, and consequently for information systems support, of a meta-programme such as "Health for All by the Year 2000".

Without informatics and telecommunications support to information systems in the area of monitoring and evaluating health programmes, the quantity, quality and timeliness of the information available will be so poor that any decision taken on the basis of it will face serious risk of being totally inadequate.

We would appreciate hearing about national and regional experiences related to the issue of providing informatics and telecommunications support to information systems aimed at monitoring and evaluating health programmes, in special Health-for-All strategies.


© Copyright by Eduardo Chaves

Last revised: 02 May 2004