Health information, research, evidence and knowledge
Data are crucial in improving health. The ultimate objective of collecting data is to inform health programme planning as well as policy-making and, ultimately, global health outcomes and equity. A well-functioning health information system empowers decision-makers to manage and lead more effectively by providing useful evidence at the lowest possible cost.
A health information system has been aptly described as "an integrated effort to collect, process, report and use health information and knowledge to influence policy-making, programme action and research". It consists of:
- inputs (resources)
- processes (selection of indicators and data sources; data collection and management)
- outputs (information products and information dissemination and use).
The role of a health information system is to generate, analyse and disseminate sound data for public health decision-making in a timely manner. Data have no value in themselves. The ultimate objective of a health information system is to inform action in the health sector. Performance of such a system should therefore be measured not only on the basis of the quality of the data produced, but also on evidence of the continued use of these data for improving health systems' operations and health status.
The availability and use of information enables:
- improved definition of a population
- recognition of problems
- setting of priorities in the research agenda
- identification of effective and efficient interventions
- determination of potential impact (prediction)
- planning and resource allocation
- monitoring of performance or progress
- evaluation of outcomes after interventions
- continuity in medical and health care
- healthy behaviour in individuals and groups.
It also empowers citizens by enabling their participation in health care, policy and decision processes; and empowers countries and international partners by enabling better transparency and accountability through use of objective and verifiable processes.
Health knowledge gaps are where essential answers on how to improve the health of the people in the WHO African Region are missing. This is an issue related to the acquisition or generation of health information and research evidence. The “know-do gap” is the failure to apply all existing knowledge to improve people’s health. This is related to the issue of sharing and translation of health information, research evidence, or knowledge. Although there are major structural constraints, the key to narrowing the knowledge gap and sustaining health and development gains is a long-term commitment to strengthen national health information systems.
This section of the health system profile is structured as follows:
In the last decade, understanding has been reached that creating an adequate knowledge, information and research infrastructure, and the means for managing it, is a powerful means of addressing the challenges of health status in the WHO African Region.
High-level summits have been held to this end, recognizing that health research in Africa requires an African perspective if present knowledge gaps are to be appropriately filled. Stronger commitment has been given to supporting health research, accelerating efforts to develop and implement appropriate research policies at national and regional levels, and fostering leadership and collaboration to these ends (see figure).
Equally, the need to channel research outputs into comprehensive, well-managed health information systems for wide dissemination to different audiences has been recognized. Some countries are making progress in this area, although most have still to put the fundamental organizational and coordination mechanisms in place.
These efforts culminated in the adoption in 2008 of the Algiers Declaration on research for health in the WHO African Region by all 46 countries. The Declaration calls on countries to:
- take specific steps to improve coordination and leadership of health information systems
- put in place clear policies, strategies, laws and other necessary mechanisms to improve and harmonize data
- increase the flow of information within and between countries, utilizing up-to-date information and communication technology.
With the current trend towards more funding throughout the health sector, the climate is right to address information needs that far outweigh data availability or country capacity. This trend, together with increasing information and communication technology use, provides an opportunity to strengthen data collection, processing, transfer, dissemination and use, as well as opportunities to enhance the use of evidence for policy-making and decision-making. Both electronic health (eHealth) and mobile health (mHealth) are proving to be useful tools in African countries, given the current shortage of fixed infrastructure.
The present climate provides a strong basis for many countries to accelerate measures to implement the provisions of the Algiers Declaration. Information and communication technology can serve as a valuable platform to enable health system development and transformation in the service of population health, equity and security in the Region.
Health gains cannot be achieved and sustained if health care delivery systems in countries, and the information systems that track them, are weak. Unfortunately, this is the state in a number of low-income African countries where an appropriately enabling environment does not yet exist. The essential prerequisites for a functioning health information system encompassing information, research, evidence and knowledge, require comprehensive intersectoral national polices to be in place to support it, together with:
- a supportive legislative and regulatory environment
- the human and financial resources to implement it
- strong leadership and coordination functions to manage it.
Putting these prerequisites in place, in conformity with the Algiers Declaration, enables countries of the WHO African Region to advance in a context of equity and protection for all sectors of society, taking into account the requirements of cultural diversity and multilingualism, and ensuring the free flow of information among all those needing to use a health information system.
Once established, an enabling environment of this nature can deliver benefits in terms of relevant and timely data, evidence and health information that is reliable, valid, comparable and meets ethical requirements. Based on enhanced use of electronic equipment and technology, this can be used by different audiences to inform policy, strategy and implementation measures in response to identified national priorities and facilitated by better access to existing global health information.
Given the specific health system challenges confronting the WHO African Region, an overall framework of adequate, reliable funding through strong public–private partnerships linked to technical support should be in place, calling on the present trend towards increase of funding for health in the context of public–private partnerships. eHealth measures, which are increasingly used in the WHO African Region, should be formally incorporated into national plans, with suitable standards for their implementation, monitoring and evaluation.
In summary, a key objective of a national health information strategy is to create incentives for a culture and environment throughout the global public health community that supports knowledge sharing, translation and reapplication. It should address the need for capacity-building and technical assistance in countries to build the skills and capabilities necessary for effective knowledge management practice.
There has been significant growth in the use of information and communication technology to enhance the capacity and performance of health information systems in the last decade. Information and communication technology is one of the main drivers in the trend towards greater data access and sharing, although access to individual level health data for public health purposes in low-income countries is still limited.
The increasing availability of information and communication technologies, particularly of the Internet and mobile telephony, has improved the prospect of narrowing the knowledge gap in the WHO African Region. The median increase in access to both mobile and fixed lines in the Region between 2002 and 2007 was over 50% (as measured by the compound annual growth rate), with some countries showing over 100% increase during the same period. However, only seven countries have existing coverage over 50%. Critical infrastructure needed to significantly improve the knowledge gap, such as broadband communication or electric power, is still poorly developed.
Information technology improves the quality of data collection, and communications technology improves time lines, analysis and use of information. However, computers are often used as part of separate vertical health information programmes, which results in the existence of a number of incompatible systems. Health managers at all levels should have access to an information infrastructure that includes computers, email and Internet access. All facilities should have such connectivity – a long-term objective in most developing countries. But health professionals are currently estimated to account for only 0.001% of Africa’s Internet use, and this use is mostly confined to major cities.
Information technology applications are changing the scope and modalities of data collection, transmission, storage, analysis, dissemination and sharing. United Nations organizations have invested heavily in standards for data collection, such as the International Statistical Classification of Diseases and Related Health Problems, and for data transmission, notably the Standard Data and Metadata Exchange. But the lack of common data architecture hampers the efficient generation and use of health information. While a general blueprint is not possible, it is essential to enhance interoperability between different data systems. An explicit data architecture – describing how data are collected, stored, managed and used – is needed to address the increasing diversity of actors and resources within the health system.
Advances in infrastructure and technologies are not uniform, and less developed countries have not made rapid progress in areas such as eHealth. While many countries have adopted a national eHealth policy (defined by WHO as the use of information and communications technology for health), these tend to focus on activities such as remote consultation and telemedicine. To comply with standardization requirements for eHealth, many countries have adopted one or more of the international standards for data management and exchange, including metadata standards. In due course, it is hoped that regional standards may emerge.
Mobile health (mHealth), implemented through mobile devices such as mobile phones, patient monitoring devices, personal digital assistants and other wireless devices, is a rapidly growing branch of eHealth. Once wider coverage can be achieved, mHealth may boost country capacity to monitor the incidence of public health threats and enable a more timely and effective response.
Cultural and linguistic diversity and cultural identity
Both formal and informal knowledge may contribute to a national health information system. Knowledge may be created locally, referring to local situations and circumstances, or created elsewhere and adapted to local circumstances. It is imperative that knowledge is made available in languages understood by the user communities if the knowledge gap is to be decreased.
There is also a distinction between local formal knowledge – such as research locally published in books and journals, locally generated epidemiological information, and medical patient records – and local indigenous knowledge, which embraces local customs, languages and practices, often in oral or other traditional forms of expression, including storytelling, song, theatre and dance. Knowledge acquired by elders over many years is recognized in Africa and other traditional societies.
The Indigenous Knowledge Systems Initiative in South Africa exemplifies the creation and dissemination of local indigenous knowledge. The Initiative develops and coordinates research on health-related indigenous knowledge. It establishes national and regional networks promoting the integration of traditional and contemporary scientific knowledge, and identifies research programmes with commercial potential for transformation into economically sustainable initiatives.
For this purpose, the Indigenous Knowledge Systems Initiative provides indigenous communities in South Africa with the support, resources and tools they need to understand external influences on their environment and to adapt to changes, while at the same time preserving their own practices. An online database of traditional medicines has been set up to encourage indigenous communities to use computer technology to advance traditional health practices. The aim is to promote and advance indigenous knowledge systems that can serve as valuable models on a global scale.
How health systems acquire, create, use, disseminate and improve knowledge has rarely been studied. For this reason, a study on two elements was conducted by the WHO Regional Office for Africa. The first comprised an analysis of key data regarding knowledge management processes, obtained from leading public data sources. The second consisted of a questionnaire-based key informant survey that collected data on two key aspects of the health system: health policy and clinical services provision. This provides a partial picture of knowledge management processes in the health sector.
Concerning access to knowledge resources for health purposes, only teaching hospitals in the southern and eastern areas were found in this survey to report adequate access to libraries, information centres, information resources and computers, and in these, Internet connections were few. Health centres everywhere had few computers or Internet connections. The group most likely to use electronic medical records was physicians in private practice, although only a minority of even this group systematically accessed computers. The use of computers by nongovernmental organizations varied by subregion, while the traditional medicine sector reported almost no use of either medical records or information resources.
Ministries of health were overwhelmingly identified as the chief source of all types of knowledge used by clinical service providers in all countries of the WHO African Region. Pharmaceutical information is commonly obtained from the Internet and from sources outside the country. In the Western Subregion, knowledge related to immunization and disease control campaigns often comes from regional and nongovernmental organization sources, in addition to health ministries. Knowledge about healthy lifestyles and behaviour also comes from outside the country, other ministries and nongovernmental organizations.
Printed documents and publications are cited as the main format for all knowledge used by clinical service providers. The different subregions of the WHO African Region showed varying patterns of use of electronic information for health policy, operational procedures, guidelines and methods, drug information, and surveillance and epidemiological data. As well as printed materials, healthy lifestyle and behavioural advice is frequently transmitted orally in 27 of 39 countries. Sources of surveillance and epidemiological data include newspapers and informal media, the Internet and e-mail.
Electronic subscriptions to international journals are very low in the WHO African Region. This problem is, inevitably, linked to low levels of Internet access and use. Only South Africa publishes a significant number of books, with most African countries reporting low numbers.
The Knowledge Index is a Word Bank initiative that measures a country’s ability to generate, adopt and diffuse knowledge, based on analyses of the three pillars of the Index:
- education and human resources
- the innovation system
- information and communication technology.
The Knowledge Index value indicates the overall potential for knowledge development in a given country. Of the countries in the WHO African Region, only 25 countries with adequate data on knowledge indices are ranked. All these countries are in the second half of the scale, with 18 African countries in the bottom 32.
This potential for knowledge development and management is inextricably linked to literacy and education levels in a country. Literacy rates in the Region for the population aged 15 years and over were shown to vary from a low of under 30% in four countries, while eight countries reported literacy rates over 80%. The average for the reporting countries is 61%. Secondary education rates were lower than for primary enrolment, with only four countries (Algeria, Botswana, Mauritius and South Africa) showing figures above 70%. Most countries reported levels below 50%. For tertiary education, most countries have rates below 5%.
In respect of medical education, only 10 countries are known, from information currently available, to require continuing medical education in order to remain licensed, although the key informant survey carried out by the WHO Regional Office for Africa established that local training programmes for health workers had been established in more than 75% of responding countries.
An initiative fostering continuing medical education was recently initiated in French-speaking African countries. In collaboration with Geneva’s University Hospital, weekly webcast courses are developed and followed by hundreds of health care professionals. Known as RAFT – or the Reseau en Afrique pour la Telemedecine – it now spans 10 French-speaking African countries.
Similarly, the adoption of the WHO Knowledge Management Strategy in 2005 has provided opportunities to expand eHealth applications to improve health care delivery, within the constraints of present information and communication technology capacities.
Structural organization of health information
Organization and management
Multiple institutions produce and use health-related data. A country health information system therefore needs a supportive policy and institutional environment, with clearly defined roles and responsibilities for the different sectors and stakeholders. The core institutions will be the health ministries and national statistical offices, but the private sector, civil society organizations, academic institutions, donors and United Nations agencies will also play important roles in generating and disseminating health information.
Given the large number of actors in a fully functioning health information system, high-level leadership and coordination are critical to avoid overlap and duplication of effort, as well as to ensure efficient collection and use of data. In many countries of the WHO African Region, this kind of leadership and coordination is not yet present.
Assessments carried out by WHO have shown that in low-income countries, a national coordinating mechanism comprising key stakeholders is frequently either non-existent or non-functional. Lack of a clear health information policy contributes to this problem, although there are recent signs of progress both in respect of policies in this domain and in the statistical area as a whole. A process known as the National Strategies for the Development of Statistics has been advocated in low-income and middle-income countries. Many African countries are among those following this course, although specific plans often remain to be drawn up and implemented.
Although data on levels of investment in health information systems in developing countries are scarce, it is understood, in most cases, to remain below the 5% of total health resources called for by the Global Health Information Forum in Bangkok in 2010. Of this, it was recommended that 2% should be allocated to sound civil registration and vital statistics systems. Given the modest resources available to most countries of the Region, external partners play a critical part in supporting data-gathering exercises such as surveys and censuses. Chief among these are the United States Agency for International Development and the Centers for Disease Control and Prevention, supporting the Demographic and Health Survey and disease surveillance.
With investment in the information system frequently minimal, and major lacunae in the availability and statistical capabilities of those charged with collecting, compiling and analysing data, it comes as no surprise that routine data are rarely assessed for their quality or used to support decision-making. Few, if any, countries compare and contrast their routine statistics with survey data or other relevant sources.
However, routine statistics are the by-product of an administrative process, which makes them relatively inexpensive to generate. With improvements, it should be possible to use these for policy guidance and programme reviews.
The majority of countries in the Region suffer from shortage of staff with appropriate training and skills in statistical methods and public health disciplines. Retention of such staff in the public sector, once trained, is a further issue, with low remuneration and reward levels relative to the private sector or work abroad. These shortages apply at all levels.
The lack of adequate numbers of personnel with sufficient skills in computer technology and health information system issues emerges as a universal problem. Staff lack training, and there is little career development or motivation. Remuneration systems are poor, and donors or the private sector often lure away the best staff. Many information systems are caught in a vicious circle, in which inadequate resources restrain outputs and undermine the quality of data, while the poor quality of data leads to lower demand and hence fewer resources.
As part of present policy initiatives to give greater priority to health information systems, some countries in the Region are now focusing more strongly on national statistics development, particularly vital statistics systems. These countries include Cote d’Ivoire, Ghana and Mali.
Overview of the flows of information
Today’s strong focus on monitoring and evaluation has given rise to a great proliferation of indicators and related reporting requirements in diverse time frames and formats. In addition to the reporting requirements of the Millennium Development Goals subscribed to by all countries of the WHO African Region, there is also:
- frequently a high reporting burden in relation to HIV/AIDS
- the obligation to report disease outbreaks and public health events in the context of the International Health Regulations
- the need to carry out continuous systematic disease surveillance
- the requirement to report on grants received from external donors
- the maintenance of internal health and social indicators required at national and subnational level.
This proliferation of indicators, with its concurrent reporting requirements, takes excessive amounts of time or may be inaccurately performed by staff lacking appropriate skills and training.
For these reasons, countries are being encouraged to select a core set of indicators in line with key objectives of strategic health policies and plans. These are often in the range of between 15 and 40 core indicators, although many more will exist to cover all aspects of national health plans.
Core health indicators are required to assess change in three domains:
- determinants of health
- the health system
- health status.
In the 14 countries that have undertaken national health information system assessments, all scored high for existence of indicators. Eleven countries had a score of "adequate", reflecting that national minimum core indicators, including those covering the health-related Millennium Development Goals, have been identified. While indicators are prolific, the availability, quality and relevance of data to measure them are much more problematic.
In Ghana, a conceptual framework established for health sector reforms generated indicators for health information. Sector-wide indicators were divided into three main categories:
- health status (including mortality and morbidity)
- performance in public health and clinical interventions and other health-related indicators
- systems development.
A minimum data set covering at least 20 indicators is collected and used at all levels, although further level-specific indicators may be used.
A crucial step in improving information flow is linking the national health information system to the central statistical system. This is essential as health is a broadly intersectoral issue and aspects of great relevance to the health system, such as registration of vital statistics, are managed by other government departments. It is essential that the national health information system is linked to the central statistical system providing information for national development planning. All components of the national health information subsystems should be progressively integrated at central, regional, provincial and district levels. Health information from the private sector should be included with a view to reducing the knowledge gap, and reliable maps prepared and disseminated.
Specific regulatory framework
The current deficiency in many African countries of a regulatory framework linking private sector input to a national health information system needs to be rectified.
Appropriate norms, standards and regulations are the key for sustainable progress in knowledge management, especially in eHealth and telemedicine. These should be adapted to national needs from best international practices.
Data sources and generation
Sources of health data can be divided into two broad groups:
1. Those that generate data relative to populations as a whole. Population-based health information sources include:
- vital events monitoring (civil registration, as well as sample or sentinel surveillance of births, deaths and causes of death);
- population-based (usually household) surveys and surveillance;
- vector and environmental quality surveys.
2. Those that generate data about the operations of the health service. Health service-based sources generate data as an outcome of health-related administrative and operational activities:
- facility-based data on morbidity and mortality among those using services;
- types of services delivered;
- drugs and commodities provided;
- information on the availability and quality of services;
- financial and management information (human resources and logistics).
The main sources of data for a health information system are thus either based on administrative or clinical information, or derived from household surveys. National health information system assessments in 14 African countries found household surveys to be a generally "adequate" source of data and only "inadequate" in exceptional cases. While the high score reflects significant international investment in household surveys, the limitations of these include an inability to disaggregate data to local levels or to provide information at short time intervals.
Deficiencies in quality, availability and relevance of vital statistics are perceived as major problems. In the countries assessed, they are considered "inadequate" in eight countries and "adequate" in only one country. Most low-income and middle-income countries find it difficult to maintain routine data collection exercises, let alone improve them. As development of vital registration systems is limited, most developing countries depend on surveys and censuses to estimate population morbidity and mortality. The assessment exercise scored census output as "adequate", although a number of countries have been unable to complete a census in the past 10 years.
The Statistics Division of the United Nations Department of Economic and Social Affairs has developed guidance principles, recommendations and manuals to assist countries in carrying out the population and housing censuses that are conducted in almost every country. Key criteria for a modern census include:
- individual enumeration
- universality within a defined territory
- defined periodicity.
All data collected and analysed through the census should be widely disseminated and made publicly available.
Some censuses include cause of death, particularly where this can be defined clearly, such as pregnancy-related or injury-related death. Accurate estimation and correction for the level of underreporting of recent deaths, which is a common problem, is important. A census also collects information that permits estimates of mortality, and some also collect information on number of deaths, and age and sex of those who died within 12 or 24 months prior to the census.
Although a census is in effect a snapshot of a population at a given time, in many African countries the population census functions as a key source of data on fertility, mortality and population dynamics. Comparison of censuses taken at different time periods provides information about the growth or decline of the population, while the counts themselves serve as denominators for a variety of health indicators. Although the census is usually only conducted every 10 years, extrapolation is used to generate population data for the intercensal years.
Ideally, data from the census and a comprehensive civil registration system are used together to generate an accurate picture of population change in a country. For example, census fertility questions generate data for calculating lifetime and cohort fertility that are not easily available from civil registers. Other advantages of the census include the ability to tabulate for small geographic areas and its use for drawing up the sampling frame for health and social welfare surveys.
The census also serves as an important source of data on people with disabilities, and their social and living conditions. The census is also one of the few sources of data on the distribution of health care workers.
In practice, where civil registration systems are weak, the census serves as the sole source of comprehensive population data. Census data should not be viewed as a substitute for reliable birth and death statistics from civil registers, but are particularly valuable in countries, such as those in the WHO African Region, where birth or death registration is frequently incomplete.
The available data show that four countries – Angola, Democratic Republic of the Congo, Eritrea and Togo – have not conducted a national census in the past 20 years. An additional three countries – Guinea, Liberia and Madagascar – conducted only one census over that period. Three countries – Lesotho, Seychelles and South Africa – have conducted the census every 5 years, although most countries have a decennial census programme.
Civil registration and vital statistics systems
Civil registration provides important public health information through universal recording of the vital events and legal requirements of a country, such as births, deaths and changes in marital status.
The civil registration system has a number of advantages over other methods of obtaining vital statistics. Critically, it provides universal and continuous registration of vital events, enabling the routine production of vital statistics at all geographic levels essential for monitoring health outcomes. Because the resulting statistics are a by-product of an administrative process, civil registration is relatively inexpensive to maintain.
Although the primary purpose of civil registration is the establishment of legal documents required by law, the system generates continuous data on births and deaths at all levels of a country – national, regional, district and subdistrict. In addition to crucial information on vital events (births and deaths), the civil registration system may also be able to supply additional data, for example on:
- birth weight
- place of delivery (home, maternity centre or hospital)
- medical assistance during childbirth
- maternal age and parity
- medical attention received prior to death.
When civil registration of deaths is coupled with medical certification of cause of death using the principles and standards set out in the International statistical classification of diseases and related health problems, it is possible to generate accurate and timely data on causes of death in the population.
Such information permits the study of mortality differentials by age and sex and other stratifiers, and provides the key input for constructing life tables and estimated probabilities of death at various ages. Information on the number of live births over time, classified by maternal characteristics, is essential for analysing reproduction dynamics. The vital statistics generated through the civil registration system enable regular updating of population size and structure, which are the denominator data needed to calculate population indicators.
In the absence of functional civil registration systems, data on births and deaths can be generated through alternative strategies, including household surveys (for births and child deaths), the census, or demographic surveillance.
For the majority of the countries in the WHO African Region, the reported birth registration rate is calculated on the basis of mothers’ responses to questions in household surveys about their most recent births; it is likely that the true coverage for the general population is much lower.
With regard to mortality data (see figure), of the 46 countries of the Region, only four – Algeria, Mauritius, Seychelles and South Africa – have coverage rates of 75% or higher.
Given the weakness of civil registration in the WHO African Region, population-based (household) surveys are the main source of population health information. Household surveys vary in complexity and emphasis. They can be:
- single or multi-round
- multi-thematic or focused on one issue
- part of an international survey programme
- purely national in orientation.
The gold standard is a well-integrated, demand-driven household survey programme that is part of a national health information and statistical system and generates essential, high-quality information on population health and socioeconomic status on a regular basis.
Household surveys can provide data on any health or behavioural issue. A significant number of surveys include questions on the characteristics and socioeconomic condition of respondents, such as living standards, education and employment. By linking such information with data on health care use and health status, it is possible to generate important information on the links between health and its socioeconomic determinants.
Although household surveys are routine and effective instruments to generate data on levels of child mortality, they are less effective in respect of adult mortality or cause-specific mortality because of the limitations of sample size. Another disadvantage is that they do not generate recent data – a factor of concern in relation to Millennium Development Goal monitoring. In addition, all household surveys generate data that have margins of uncertainty associated with both sampling and non-sampling errors.
Finally, the vast majority of household surveys are funded and supported by external agencies. Inevitably, this means that country planners are not the main, or only, decision-makers when it comes to determining when and where a survey will be carried out. The increasing number and frequency of single-disease-focused surveys increases the risks of overlap, duplication and overloading of country capacity. Although considerable efforts have been made to use externally supported surveys to build national capacities in data generation and analysis, the fact remains that, in the absence of external technical and financial support, few countries in the Region would be able to maintain household survey programmes at the current level.
Between 1985 and 2007, a total of 211 household surveys were conducted in the Region. Of these, 121 took place after 2000. The number of surveys has increased over the years, reaching a peak of 50 from 2002–2004 alone. Given that data covering 17 of the 23 health-related Millennium Development Goal indicators can be generated through household surveys, the increase in surveys is understandable. However, national statistics offices have expressed valid concerns that the increasing frequency of surveys is burdensome, given limited country capacity, especially for data analysis. In addition, there tends to be insufficient coordination across the different surveys, almost all of which are externally supported and many of which are driven by disease-specific programme interests.
The most commonly applied survey instrument in the Region is the United States Agency for International Development-supported Demographic and Health Survey. Since 1985, 98 Demographic and Health Surveys have been conducted, with 29 occurring after the establishment of the Millennium Development Goals in the year 2000. The second most common survey instrument is the United Nations Children's Fund-supported Multiple Indicator Cluster Survey. A total of 58 such surveys have been carried out since 1995. In recent years, a number of disease-focused surveys (such as the Malaria or AIDS Indicator Surveys) have been undertaken. In addition to these internationally sponsored surveys, many countries conduct their own surveys. WHO undertook a survey programme – the World Health Surveys - in 18 countries in the Region between 2002 and 2003.
Health facility assessments
All countries routinely collect data from health facilities and assemble and report them in annual, biennial or 5-yearly health statistical abstracts or reports. The information generally derives from:
- reports from health facilities on health status (leading causes of death in hospitals, admissions and discharges by diagnosis, institutional maternal deaths, case-fatality rates, outpatient morbidity, deliveries and complications);
- service provision, including type and utilization of services;
- statistics on supplies and financial and human resources available for the provision of services.
In general, only public sector facility information is included in a health management information system, although it is essential that information from private facilities should form part of the overall health information system.
Information on health facility performance is systematically underreported, inadequately analysed, and underutilized for planning and programme reviews. Completeness, timeliness and quality of reporting are often described as problematic, and the data reflect only those attending public health facilities.
Health facility assessments can provide data on the availability and quality of health services and the health system resources that are required for their success. Facility assessments are a unique source of statistics on service availability, generating data on facility infrastructure, infection control, services offered, staffing, laboratory facilities, treatments, guidelines and supplies.
Indicators can be calculated to track the percentage of health facilities in a given country or region that offer a specific, measurable treatment or service. For example, infection-control indicators include the presence or absence of disposable syringes, sharps containers and other equipment, while laboratory indicators measure whether or not a facility can test for HIV, syphilis, tuberculosis and other diseases. An additional aspect of facility assessment is the ability to associate each service delivery point with specific geo-coordinates, which enables comparison with geographic, population and epidemiological profiles.
Five kinds of health facility assessments can be identified, all of which have been applied in the Region:
- facility census
- facility survey
- service provision assessment
- district key informant survey
- operational research study.
A facility census involves a visit to all public and private health facilities in an area and collection of detailed information about the physical assets of all the public and semi-public health facilities in a region or nation. The aim is to identify health facilities that do not meet criteria in the following areas: *availability and condition of physical infrastructure
- availability and condition of equipment
- availability of services and location of health service delivery points
- head counts of health workers.
By identifying facilities that lack these resources or abilities, the facility census provides a baseline assessment to guide decisions on resource investment. In the Region, facility censuses have so far been conducted in Malawi and Zambia.
In a facility survey, instead of conducting a census of all facilities, a sample of facilities is selected and detailed data are collected through inventory and by interviewing health workers in facilities. Facility surveys:
- collect information on staff qualifications, training and supervision (from provider interviews)
- examine adherence to standards in practice (by observation of client–provider interactions and from client interviews)
- assess the adequacy of available infrastructure and resources for providing a given service.
They thus fill the gap in service quality that is often missing in facility censuses. The recommended frequency of implementation is once every 3–5 years.
Service provision assessment is designed for system-wide national-level monitoring. An example is the United States Agency for International Development-supported service provision assessment conducted in several African countries, including Ghana (2002), Kenya (1999 and 2004), Rwanda (2001) and Zambia (2005). Current service provision assessment modules include monitoring of the quality of services provided in family planning, child health (outpatient services), maternal health, sexually transmitted infection services, tuberculosis services, and an extensive module for HIV/AIDS services.
District key informant surveys constitute a rapid method to assess service availability, human resources, supplies, and coverage of national programmes through interviews with the district medical officer and the district health management team.
To help national decision-makers obtain information rapidly on health systems statistics, WHO is working with individual countries to develop a tool called Service Availability Mapping to collect and present basic information on health services: health infrastructure, human resources and services offered. Using the WHO Health Mapper (a geographic information system-based software package) and a questionnaire loaded on personal digital assistants, district health teams collect critical information on health resources, public health risks,and programme implementation, in order to provide updated maps of health services.
A rapid version of a national Service Availability Mapping has been applied in 14 countries, providing a rich picture of services across districts. Data on human resources include the density and distribution of health workers by major cadre and training exposure in the last 2 years, unfilled posts and absentee rates.
Operational research studies are conducted in a small number of facilities to assess the quality of care (e.g. waiting time) or patient flows.
Facility assessments are one of the few sources of health statistics for which the health sector has primary responsibility. In addition to these health-sector-specific assessments, many countries also conduct establishment censuses and censuses of buildings, which can be used to assess the status of health facility infrastructure. However, the potential of these is yet to be realized and their success will also depend very much on the extent to which the health sector will work closely with the national statistical agencies that are mandated to conduct such censuses.
Disease surveillance is an essential component of any health information system and the information gathered depends on health objectives. For example, early-warning systems based on epidemiological intelligence produce information on communicable diseases to:
- detect events rapidly
- manage outbreaks
- support response
- document outcomes in an integrated manner.
Systematic documentation of contextual and qualitative data
While a great many socioeconomic indicators remain outside the remit of the health system, it has long been recognized that these can be powerful determinants of health. Issues such as education, access to knowledge sources, and telecommunications capabilities are, among other factors, crucial to research and health information systems and for knowledge management. Data on these and related topics need to be monitored regularly and made available to Member States in a format that permits intercountry and interregional comparison.
Health systems observatories and similar entities and initiatives aim to systematically review all qualitative and quantitative information to assess the performance of the health system. Health observatories are increasingly being created across the world for this purpose, with the outputs used to inform the development of revised strategic plans.
WHO has developed an ontology- and Wikimedia-based platform, together with a participatory process of engagement to systematically document qualitative and other information on health systems. Currently used in more than 10 countries, mainly in sub-Saharan Africa, the intention is for the output to inform a policy dialogue.
Health systems research is a hitherto neglected source of health information, providing valuable data on the health status of the population, coverage of interventions and the status of the health system under review. Few countries in the WHO African Region have an institutionalized mechanism to support, translate and disseminate health system research to relevant stakeholders.
In many countries, links are still weak between population-based research and the monitoring and evaluation of the health situation and trends, despite the value of such information to the development of national health plans. The extent to which health research outputs are disseminated in countries, and their timeliness, remains an obstacle to optimal use of the results of health research. It is therefore critical for health systems research to achieve a higher profile, so that questions of coverage, quality, efficiency and equity in health systems can be comprehensively addressed.
Health data are obtained from a wide variety of sources. The most common sources, other than those obtained from health facilities, are data from household surveys containing health components, and administrative data collected by the government on topics such as the health workforce or health financing.
However, the quality and comprehensiveness of these data remains questionable in many countries. Birth and death registration, together with cause of death, is the weakest source of data in almost all developing countries.
Data compilation, storage, management
Data compilation and storage usually takes place under the aegis of the health ministries and national statistical offices. However, the existence of data is only useful if supported by a robust and adequately resourced data management policy and system. In many countries of the WHO African Region, these are not yet in place. If data management protocols are in place, it is often the case that these are not yet adequately implemented. While there have been investments in data management systems in recent years, these may derive from donor activity and can result in the establishment of parallel systems in the context of specific grants or disease programmes. The data thus generated may not even be known to the central statistics authorities.
Data management comprises a set of procedures for the collection, storage, analysis and distribution of data. Once data have been collected, a sound management approach is essential. This includes the development of a metadata dictionary, and sound data storage procedures with a well-designed logical structure that permits data retrieval and comprehensive analysis.
The 14-country health information system assessment carried out by the WHO Regional Office for Africa revealed that data management is problematic in a majority of these countries, where there are no clear procedures for the collection, storage, analysis and distribution of data, or for a centralized data depository. In many countries, more than one agency is involved in collecting and disseminating information and each uses different methods and approaches. This further complicates data management.
Furthermore, ministries of health gather data through their administrative reporting systems, whereas central statistical offices collect data at a household level. Differences in sources and methods mean that data obtained from administrative records and data from surveys are not directly comparable. This is a further source of difficulties in data management. As indicated elsewhere, excessive data and reporting demands overburden health workers who may not have the necessary skills or time to address uncoordinated and non-standardized reporting requirements.
Data sharing and access
Public access to health data is essential to ensure accountability and transparency. The sharing of aggregate data, for example on vaccination levels or prevalence of a specific disease, is a means of facilitating the preparation of reliable statistics for use in advocacy, health education and public awareness as well as for policy and action. Although high-income countries may maintain online data repositories of government data, most countries of the WHO African Region make little data publicly available on a systematic basis. Archiving data is also essential to ensure public access and continuity of information. Two African countries – Ghana and the United Republic of Tanzania – have commenced cataloguing and disseminating survey and census data through the national statistics offices.
Data quality is a matter of concern in most developing countries, with quality assurance rarely featuring as an integral part of data processing. Poor data quality has been identified as a major factor affecting the utility of health facility data for local and national decision-making. Virtually no low-income country has a regular and transparent process for data verification and adjustment.
Data analysis is a core function of health information systems. However, developing countries frequently lack analytical capacity due to limitations of skills and staffing in ministries of health, national statistics offices and other related institutions. Statistical modelling, together with the application of global standards, tools and methods to prepare trends and estimates for planning purposes, are rarely used. Moreover, global estimation methods may be perceived at country level as too general, or too far removed from the national reality, to be relevant and national personnel may not be deeply involved in such processes.
Access to existing global health information, evidence and knowledge
Availability and use of indexes of local, non-English, and unpublished
Poor access to existing global health information results in wasted opportunities and duplication of effort. Poor access may be due to a variety of factors, including lack of knowledge about the existence or whereabouts of specific information, or inability to retrieve it due to technology shortfalls. Information may also be presented in a manner inaccessible to some users or be available only in an unknown language. Copyright regulations and cost are also factors that limit full access to and use of existing global health information. Much valuable information deriving from the WHO African Region itself may never be formally published or, if so, may not be indexed as indexing of materials from developing countries is frequently deficient.
The African Index Medicus, coordinated by the WHO Regional Office for Africa, is an example of knowledge storage, diffusion and dissemination of African journals and other materials that have not been formally published (i.e. grey literature). While very few African health and biomedical information sources are included in the world’s leading bibliographic databases, there is a wealth of information potentially available in reports, studies and other documents covering work carried out by international agencies, nongovernmental organizations and local institutions.
Information of this kind is now being given global exposure in the African Index Medicus. The intention is to encourage authors to publish in their national or regional journals, hence facilitating the much-needed flow of information from developing to developed countries as well as enhancing information-sharing between African countries addressing similar health conditions. To date, 113 medical journals are indexed in the African Index Medicus, some with full text. Reports, medical theses and other grey literature are also gathered and recorded.
Availability and use of search engines, networking platforms
Although most subregions operate formal networks for health care providers, the African Index Medicus is expected to provide a major support to all levels of the health workforce. This is particularly important as printed documents and publications have been identified as the main source of all knowledge for clinical service providers, together with information provided by ministries of health. Data from clinical trials and the Cochrane Collaboration systematic review are not regularly used. The cost of subscription journals restricts access to global information, as most health institutions do not have sufficient budgetary resources allocated for this purpose.
Access to copyrighted publications
A recent initiative aimed at overcoming cost and copyright barriers is the Health InterNetwork Access to Research Initiative (HINARI). A joint venture by WHO and leading health publishers, the Initiative enables developing countries to gain access to one of the world’s largest collections of biomedical and health literature. Depending on a country’s circumstances, access to the collection is free or subsidized. Many countries of the WHO African Region are beneficiaries of this scheme, and most of these have free access. Nearly 4000 titles are available through this scheme, enabling health staff to use the information for teaching, training and research purposes.
Regulatory frameworks on intellectual property
To encourage the proliferation of initiatives such as the African Index Medicus and the Health InterNetwork Access to Research Initiative (HINARI), and other measures to increase knowledge generation and dissemination, national policies on health information, evidence and knowledge should examine and adopt the application of intellectual property rights. North–South and public–private research partnerships should be supported within the context of a global strategy and plans of action on public health, innovation and intellectual property.
Storage and diffusion of information, evidence and knowledge
This part describes the storage and diffusion of information, evidence and knowledge of the African Region.
Consolidating and publishing existing evidence for policy and decision
There is, at present, insufficient attention to making health information understandable to policy-makers, front-line health workers or the public. Data production is only weakly connected with data use, and more attention goes to data collection than to analysis and end use. Opportunities may be missed through presentation of data too late. Data remains largely directed towards specialists and its uptake by policy-makers and decision-makers is limited. It is essential to develop and strengthen the evidence base for health systems by consolidating and publishing existing evidence and facilitating knowledge generation in priority areas.
A remedy would be to greatly increase the availability and use of interactive and user-friendly data sources to better advocate, plan and monitor the health situation in countries. An effective health information system should link the issue of data production with that of data use by those delivering care, and also those responsible for management and planning.
The African Health Observatory now in development will, in due course, be in a position to communicate widely the health situation and trends in the WHO African Region. This will occur via a web portal, an annual report providing key statistics and a monograph providing an in-depth description of the Region’s health. Special reports on priority health topics will be issued. The Observatory is expected to serve as an information source for policy-makers and decision-makers needing to make strategic decisions and health plans and resources.
As a greater body of information and experiential practice becomes available, it is anticipated that policy-makers and decision-makers will be better placed to articulate their need for evidence and information, and can be drawn more effectively into processes for generating information and evidence.
A barrier to the use of presently available evidence and knowledge may be that policy-makers and decision-makers do not value the evidence presented. This can occur if they do not understand the evidence, do not trust it, or there are other competing interests, for example through pressure groups. If decision-makers are to trust available evidence and make greater efforts to apply it, they should be encouraged to articulate their needs for evidence and to require its presentation in formats they can best understand and use. This in turn requires research personnel to become more skilled at knowledge brokerage.
Policy-makers and decision-makers should also be encouraged to work closely with the research community as the producers of evidence. While there are some positive examples, systematic use of evidence for policy-making and decision-making is rare in most countries of the Region. Ghana and Senegal have made some progress in this respect.
Mapping and sharing experiential knowledge, including best practices
A number of mechanisms for sharing experience, knowledge and best practice are emerging in the WHO African Region.
The Academic Model for Prevention and Treatment of HIV/AIDS operating in western areas of Kenya has developed innovative peer-to-peer discussions for sharing and solving problems. These discussions enhance individual capacity and also contribute to a body of knowledge that can help define best practices. In a similar spirit, the African Medical and Research Foundation offers access to information about antiretroviral therapy through a knowledge hub that offers information targeted to health care workers, plus a discussion forum to enable peer-to-peer sharing. This has proved a popular approach and the hub is currently documenting best practices in decentralization of antiretroviral services in Kenya.
An ambitious approach by the Academic Model for Prevention and Treatment of HIV/AIDS is linking the provision of antiretroviral therapy to HIV/AIDS patients with the requirement for food supplementation. This is done through the Highly Active Antiretroviral Therapy and the Harvest Initiative. HIV patients undergo a full nutritional assessment and, as needed, are provided with a nutritional prescription together with their antiretroviral therapy. The food is provided through a series of farms on donated land, tended by local workers and some patients. There are now nine farms providing food for thousands of people, with further support from the World Food Programme. Control through informatics systems avoids waste or distribution problems.
This project has successfully created new knowledge about what works and how improvements can be made, as well as representing a significant example of intersectoral collaboration on health, nutrition and sustainable development.
Indexing of local publications in international indexes
The output of all these efforts, mechanisms and examples can be utilized most effectively if procedures are established to ensure that all local publications – in all formats and languages – are included in appropriate international indexes.
Strengthening health research systems in the WHO African Region is essential to narrow the knowledge gap. The health research system is an integral part of the health system as a whole and has been defined as the people, institutions and activities involved in the generation and dissemination of knowledge. It should produce research findings that are synthesized into high-quality information and knowledge, and inform creation of services to be delivered by the health system.
However, the health research system is not confined to the health system. It is a component of both the national health system and the national research system. It is of concern that in an analysis of health research systems in 10 countries of the Region, nine had no legislation relating to health research and seven had no health research policy. More investigation is needed to identify shortfalls at the institutional level of the research system, which has to date received little attention compared with the traditional focus on individual research capacity.
According to a framework developed by WHO, the requirements of stewardship, or governance, of a health research system comprise four main functions, namely:
- defining and articulating a vision for a national health research system
- identifying appropriate health research priorities
- monitoring and evaluating the health research system
- setting and monitoring ethical standards, and spotlighting inequities.
Every country requires a clear national research policy and agenda, to which all stakeholders should provide input. The agenda should reflect both national and subnational needs, focusing on priorities likely to optimize health benefit in the context of that country.. However, a survey carried out by the WHO Regional Office for Africa has determined that only 12 of 44 countries analysed have an official health research policy, and only seven have a strategic health research plan. Despite this shortcoming, nearly half of all research institutions in the WHO African Region contribute to some extent to the setting or coordination of national and/or health research priorities.
One of the main barriers to health research identified in this survey was limited perception of the relevance of research activities to existing health problems and systems. Closer engagement of all institutions in the health research priority-setting process is needed to reduce this barrier and enhance cooperation among stakeholders.
Given the paucity of health research policies in many African countries, there is little consistency in research prioritization processes. External partners are likely to exercise strong influence in determining priorities, which may not coincide closely with identified health problems on the ground. Without strong national leadership and clear prioritization processes, it is unlikely that research activities will correspond closely to need, or that health policy and systems research will have a high profile.
Monitoring and evaluation of the health research system in the Region is also rare. Independent evaluation of research institutions and their outputs is essential to ensure that research is carried out in line with established priorities and needs, and that funds are spent appropriately and transparently. Almost half of all research institutions surveyed reported a requirement to undergo independent evaluation; one third of institutions are required to carry out (external?) scientific review of directly funded research, while two thirds are required to review research not funded by the institution itself. However, review guidelines, and guidelines on conflict of interest, are frequently lacking.
Setting and monitoring ethical standards in medical research increasingly involves multiple sites and international collaboration. It is essential that human participants in research projects are adequately protected and that their well-being and rights are safeguarded. Research ethics committees are still lacking in many developing countries and studies may not undergo any form of review – either scientific or ethical – through ministries of health. National guidelines and legislation governing health research and related ethical conduct are fragmented within the Region and legislation on health research is scarce. Only half the institutions engaged in health research have a policy requiring informed consent by participants. Further training on research ethics, together with greater attention to ethics in medical curricula, and ensuring that policies to monitor ongoing research are in place, would be of particular benefit in the Region.
Networking for Ethics on Biomedical Research in Africa (NEBRA)
Networking for Ethics on Biomedical Research in Africa (NEBRA) is a community of practice operating in West Africa. NEBRA seeks to improve ethics review procedures in order to fulfil international requirements and thereby attract more clinical research addressing their own needs. It recommends that existing ethics committees should be incorporated into new national frameworks or replaced altogether. Its objectives include:
The Commission on Health Research for Development, in its 1990 report, recommended that all countries invest at least 2% of their national health expenditure in health research and research capacity. This followed the understanding that an estimated 10% of the world’s research funds are allocated to address the health problems or conditions of 90% of the population. In the last decade, there has been pressure to expand the monitoring and tracking of financial resources for health research, particularly in low-income and middle-income countries. But limited monitoring activities have so far been carried out in low-income and middle-income countries, particularly in the WHO African Region.
The estimated health research expenditures for the two main groups of countries in the Region are based on the recent survey of national health research systems in the Region. At the very least, an estimated total of US$ 517.5 million was spent on health research in 37 African countries in 2005. This total represents roughly 12.6% of the total expenditure reported by the Global Fund for Health Research for low-income and middle-income countries in 2003 of US$4.1 billion. It also represents about 1.3% of the combined total health expenditures for the 37 countries.
The pattern of expenditure for various health research topics varies from institution to institution in the Region. Each major research topic receives attention through research carried out in at least one type of health research institution, except for research on innovative practices and product development, which receives a small share of hospital research funds. The prevention and treatment of tuberculosis, HIV/AIDS and malaria, in particular, are studied by almost all types of institution and account for significant shares of institutional funds.
Creating and sustaining resources
Some countries in the WHO African Region have made considerable commitment to health research and information, and their health and information systems are increasingly effective. However, others are lagging behind in research capacity. In such cases there is limited capacity to generate, disseminate and apply knowledge, and the knowledge gap is therefore perpetuated. This handicap translates into inequalities in health. Lack of both institutional and human resource capacity persists, particularly as three quarters of all research institutions are in the public sector and hence most liable to capacity shortfalls. The private sector accounts for only 4% of all research in the WHO African Region. More than half of all research institutions possess laboratories, with national reference laboratories being accredited in all instances.
The improvements clearly needed in the domain of health research should focus on institutional level and the wider research environment, and should not be restricted to enhancing individual research capacity. Strengthening at district and local levels is critical, recognizing that improving the overall national research abilities enhances national science and technology capacity. Ensuring the recruitment of skilled research leaders and managers is a key step, given the intersectorality and wide range of disciplines involved in health research.
Significant shortfalls in human resources for health have been identified in the Region, with clear implications for research capacity. As well as in health disciplines, lack of statistical, analytical and managerial expertise has been identified. In African universities, shortage of staff – particularly senior staff – was noted in a survey of 13 countries. Issues of pay, benefits, working conditions and terms of service affect the ability of African institutions to recruit and retain staff. Gender imbalances persist in research settings, and less than 20 countries report producing graduates at masters or doctoral level. In these circumstances, it is difficult for African countries to acquire and maintain the capacity to conduct meaningful research within the public sector and the tendency for researchers to take positions in the private sector or go abroad persists.
The most successful research interventions involve innovative strategies and partnerships, as evidenced by recent good practice models in biomedical and vaccine research. Networks of health practitioners have been established in most subregions and communities of practice have also begun to yield very positive results. These outputs can, in time, contribute to the body of information available for policy-making and decision-making.
In summary, a supportive environment for health research has been defined as incorporating the following elements:
- a broad range of health researchers
- transparency in the funding process
- quality of workspace and facilities
- a collaborative approach
- opportunities to present, discuss and publish research findings
- relevance of health research to health and health systems
- suitable remuneration of researchers
- career development options
- training and continuing professional development
- access to and sharing of information, including through information and communication technology methods.
Applied research comprises 55% of all research conducted in the WHO African Region. Experimental research represents only 5%. Recent surveys show that research activities in the Region tend to be broader in scope and richer in form than studies reflected in databases such as Medline or the Thomson ISI Web of Science. African health research institutions produce important non-academic research output such as short policy reports, non-technical articles and media releases. Producing new and nationally appropriate knowledge, rather than publishing academic papers alone, is a top priority. A large number of African institutions also make significant efforts to disseminate and share their products with a wide audience, through distribution of edited or recast materials and by holding conferences, workshops, seminars and public forums. A small number of databases of current research exist, and are usually accessible to the public.
Better use needs to be made of research tools such as systematic reviews. Few are undertaken to synthesize the vast amount of health information available in the Region. This is regrettable, as the purpose of a systematic review is to draw objective, unbiased conclusions from a wide range of studies. Syntheses of this kind can be a powerful tool in the hands of policy-makers.
More focus is also needed on translational and operational research in order to assess how scientific discoveries might be optimally utilized and strategically implemented to improve public health.
Use of information, evidence and knowledge
This section describes use of information, evidence and knowledge in the WHO African Region.
Formatting and packaging of evidence for policy and decision making
Success in overcoming the "know-do gap" depends on the ability to convert research findings and other knowledge into policy and strategy, and having the strategies implemented through nationally appropriate and adequately funded programmes and projects. This requires evidence to be timely, comprehensible, well analysed and made relevant to the local context. In the main, this is not yet sufficiently achieved in the WHO African Region, although there are some notable exceptions. More effective training and greater capacity in the area of knowledge brokerage is required to bridge present gaps.
The Community-based Health Planning and Services approach used in Ghana has now been widely adopted, following evidence that locally based, mobile nursing staff could reach and serve greater numbers than a subdistrict health centre. The Community-based Health Planning and Services initiative is now recognized as the key national strategy to reduce problems of distance and cost in overcoming health barriers. It has demonstrated how operational research findings can be applied to national health policy to improve access to health care.
Sharing and reapplying information and experiential knowledge
While producing new information is important, it is equally essential to identify and apply means by which the exchange and reapplication of knowledge – particularly experiential knowledge – can be enhanced, with a focus on understanding, facilitating and improving the effectiveness of knowledge networks and communities. As indicated earlier, current experience is demonstrating that creation, sharing and application of information, evidence and experiential knowledge can be facilitated through the establishment of networks and communities of practice.
To this end, appropriate mechanisms and procedures for documenting and disseminating experiential knowledge and best practice in relation to health care should be included in the process of formulating national health information system plans.
At present, international guidelines are commonly used as key sources of knowledge for policy formulation. National guidelines, and recommendations from surveillance data, are also seen as important sources of knowledge by many African countries. While such sources are clearly important, they should not exclude an increased reliance on national and local evidence and information as the initially preferred source for policy-making and decision-making.
A different barrier to use lies in the way evidence is currently produced and treated. This discourages its presentation in formats suited to different audiences, including policy-makers. As long as evidence is not packaged in a user-friendly format, or made relevant to local context, it may not be valued, trusted or adequately understood by policy-makers or decision-makers.
Policy and decision makers' articulation of their need for evidence
Transforming evidence and knowledge into policy and decisions will directly benefit health. But for this to happen, policy-makers and decision-makers have to be convinced that scientific evidence should be their first recourse. Convincing policy-makers to act on evidence they consider irreproachable also enables subsequent monitoring and evaluation of related changes in health indicators, which in turn ensures the generation of more data. This iterative process can only work when policy-makers turn primarily to a strong, reliable and easily understood national or regional evidence base as their primary source of information.
Policy and decision makers' participation in the research agenda setting process
Linking policy-makers and decision-makers firmly into the process for setting the research agenda will help to ensure that they can articulate their need for evidence and will contribute to ensuring that research outputs will be acceptably presented. Further capacities in the domain of knowledge brokerage are likely to be required to achieve this.
Policy and decision makers' capacity to access and apply evidence
Failure to bridge the existing gap between research and policy creates frustration for researchers, while policy-makers are deprived of all necessary information on which to base their decisions. Bringing the two elements together on a systematic basis should be a core function of a health information system, so that key policy needs are jointly identified and become an ongoing part of the national research agenda and priority-setting process. Without this approach, health policy will be inconsistent and open to influence by other internal and external agendas.
While there is evidence that donors are now recognizing the need for health systems research, much externally funded research still does not prioritize health systems and policy research, while publications policies continue to privilege publication in a peer-reviewed journal rather than relevance to national priorities.
Availability and use of networks and CoPs for better use of evidence for policy and decision
Two major initiatives have recently been launched in the WHO African Region to address the critical issue of use of evidence for policy-making and decision-making, namely:
- Evidence-Informed Policy Networks (EVIPNet), a partnership of researchers, policy-makers and programme managers;
- the Regional East African Community Health Policy Initiative (REACH), which operates across three countries of the East African Community (Kenya, United Republic of Tanzania and Uganda).
Leverage information and communication technologies
The present trend towards greater transparency and improved health governance in the WHO African Region is conducive to leveraging advances in the area of health information, research and knowledge systems. At the same time, access to information and communication technologies is increasing, although there is a long way to go. The currently fragmented approaches to narrowing the knowledge gap need to be overcome and more resources need to be allocated to the domain. For the present opportunities to be fully exploited, access to information and communication technologies needs to be accelerated in most countries.
Information technology applications are changing the scope and modalities of data collection, transmission, storage, analysis, dissemination and sharing. United Nations organizations have invested significantly in standards for data collection, such as the International Statistical Classification of Diseases and Related Health Problems, and for data transmission through the Standard Data and Metadata Exchange.
However, the lack of common data architecture hampers the efficient generation and use of health information. While no blueprint is possible, it is essential to enhance interoperability between different data systems. An explicit data architecture – describing how data are to be collected, stored, managed and used, by whom and for what purposes – is needed to ensure that the increasing diversity of actors and resources are coordinated in the interests of resolving knowledge gaps in general, and in the Region in particular.
The increasing availability of information and communication technologies, particularly Internet and mobile services, has generated technology advances in some countries of the Region, although only seven countries currently have coverage over 50%. Only six countries have more than 50 fixed telephone lines per 1000 population, with the average being less than 10 fixed lines per 1000. In virtually all countries of the Region, mobile users exceed fixed line users. Critical infrastructure (electric power, broadband connection) is still missing in many areas, and measured globally, the African fraction of electric power consumed is minuscule.
Increasing information and communication technology availability as part of national plans would require:
- a strong focus on strengthening web-based applications and databases;
- improving data management capacity, particularly at district level;
- careful evaluation of technologies to ensure capacity to meet local-level demands as well as interoperability between different parts of the health information system and other related systems.
This is essential if the different sectors involved in generating health-related data are to be effectively coordinated. Through coordination across the system, data warehouse functions can be created, comprising data stored at decentralized locations. This allows immediate reporting from all levels and broad data accessibility to stakeholders. This improves data quality and availability, system integration and patient care, while saving time for both patients and providers.
Extent of integration of the HIS
As well as integrating all components of a national health information system throughout each level, the entire system should be linked to the central statistical system that provides information for national development planning. Private sector information should be incorporated, and community health information subsystems fostered and included. Reliable maps should be incorporated into the health information system. In collaboration with other sectors, the national health information system should routinely provide information that contributes to early-warning systems for health emergencies and health needs assessments during emergencies, as well as providing information to the public during crises.
Regarding information provision, many countries of the WHO African Region still operate multiple reporting systems, often divided along programmatic lines, such as disease surveillance, tuberculosis control, immunization or HIV programmes. Operating multiple systems may assist individual programmes, but hinder the operation of an integrated health information system and increase the burden on individual health workers.
Some countries are now starting to rationalize and restructure their health information system to ensure greater integration and interoperability across all facets of the health system. This also permits a move away from current heavy reliance on paper-based records at health facility level, allowing data to be transmitted more easily between national, district and local levels by electronic means.
Several large electronic medical records systems have been implemented in African countries, notably Malawi and Zambia, in respect of HIV/AIDS and tuberculosis care. Kenya and Rwanda also have experience with electronic medical records regarding laboratory data. Some studies have shown that use of electronic medical records can help monitor loss to follow-up rates, and track and locate such patients.
The Mosoriot Medical Record System in rural Kenya, for example, compiled data on 88% of patients with acute respiratory infections using a personal digital assistant. An evaluation of the Mosoriot Medical Record System estimated that, after system implementation, visits by patients were 22% shorter. Patients spent 58% less time with providers and 38% less time waiting. Clinical staff spent 50% less time with patients and 66% less time with each other.
The current upward trend towards increased mobile phone use should be capitalized upon in the context of eHealth measures. Defined as the use of information and communication technologies to improve health system performance, eHealth represents a promising frontier with the potential to generate improvements in health system efficiency, equity and quality. In recognition of this potential, eHealth has grown as a policy-making priority in multinational and international circles worldwide. This strategy focuses on:
- identifying trends in the field
- advocating for evidence-based policy and guidelines
- identifying and sharing good practices, norms and standards
- facilitating networks of expertise and public–private partnerships in eHealth.
Endnotes: sources, methods, abbreviations, etc.
Africa regional health report. Brazzaville, WHO Regional Office for Africa, 2009 (unpublished)
Country health information systems. A review of the current situation and trends. Geneva, World Health Organization, Health Metrics Network, 2011
Knowledge management strategy. Geneva, World Health Organization, 2005 (WHO/EIP/KMS/2005.1)
Health research: agenda for the WHO African Region. Regional Committee for Africa, Fifty-sixth session, AFR/RC56/14, June 2006. Brazzaville, World Health Organization Regional Office for Africa, 2007
Knowledge management in the WHO African Region: strategic directions. World Health Organization Regional Committee for Africa, Fifty-sixth session, AFR/RC56/16, June 2006. Brazzaville, World Health Organization Regional Office for Africa, 2007
Priority interventions for strengthening national health information systems; World Health Organization Regional Committee for Africa, Fifty-fourth session, June 2004. Brazzaville, World Health Organization Regional Office for Africa, 2004
The African regional health report: the health of the people. Brazzaville, World Health Organization, Regional Office for Africa, 2006
Adjei S. Indicators for a health information dataset in Ghana. Bulletin of the World Health Organization, 2005, 83:637–638
Blaya J, Fraser HS, Holt B. Ehealth technologies show promise in developing countries. Health Affairs (Millwood), 2010, 29:244–251
Building foundations for eHealth: progress of Member States. Report of the Global Observatory for eHealth. Geneva, World Health Organization, 2006.
Chan M et al. Meeting the demands for results and accountability: a call for action on health data from eight health agencies. PLoS Medicine, 2010, 7(1):e100023
Diero L. et al. A computer-based medical record system and personal digital assistants to assess and follow patients with respiratory tract infections visiting a rural Kenyan health centre. BMC Medical Informatics and Decision-Making, 2006, 6, 21
Editorial: A window of opportunity for Africa’s health information. Lancet, 2004, 364:222
Geissbuhler A, Bagayoko CO, Ly O. The RAFT Network: five years of distance continuing medical education and teleconsultations over the internet in French-speaking Africa
Health InterNetwork Access to Research Initiative website
Hill K, Stanton C, Gupta N. Measuring maternal mortality from a census: guidelines for potential users. MEASURE Evaluation Manual Series No.4. Carolina Population Center, University of North Carolina at Chapel Hill, 2001
Human capacity. Training for research and staff movement in African national health research systems. Brazzaville, World Health Organization Regional Office for Africa, 2008 (unpublished technical report, 2008)
Ijsselmuiden CB et al. Mapping Africa’s advanced public health education capacity: the AfriHealth project. Bulletin of the World Health Organization, 2007, 85:914–922
Institutional facilities in African national health research systems. Brazzaville, World Health Organization Regional Office for Africa, 2008 (unpublished technical report)
http://www.tropika.net/svc/specials/algiers2008/technical-reviews/paper-5-abstract-en (accessed 16 January 2009)
International Household Survey Network website
International statistical classification of diseases and related health problems, 10th revision (ICD-10), 2nd ed. Geneva, World Health Organization, 2005
International Telecommunications Union Dataset
(http://www.itu.int/ITU/ict, accessed 13 May 2009)
Kirigia JM, Wambebe C. Status of national health research systems in ten countries of the WHO African Region. BMC Health Services Research, 2006, 6:135
Knowledge systems in health in the African Region: current status and future challenges. Brazzaville, World Health Organization Regional Office for Africa, 2008 (unpublished technical report)
Mathers C et al. Counting the dead and what they died from: an assessment of the global status of cause of death data. Bulletin of the World Health Organization, 2005, 83:171–177
Moodley K, Myer L. Health research ethics committees in South Africa 12 years into democracy. BMC Medical Ethics, 2007, 8:1
Morgan P. The concept of capacity (draft version). Maastricht: European Centre for Development Policy Management, 2006
Mouhouelo P, Okessi A, Kahore M-P. Where there is no Internet: delivering information via the Blue Trunk Libraries. PLoS Medicine, 2006, 3:e77
Pang T et al. Knowledge for better health – a conceptual framework and foundation for health research systems. Bulletin of the World Health Organization, 2003, 81:407–409
Principles and recommendations for a vital statistics system, revision 2. New York, United Nations,
Department of Economic and Social Affairs, Statistics Division, 2008
Research outputs, and use of evidence for policy and decision-making in African national health research systems. Brazzaville, World Health Organization Regional Office for Africa, 2008 (unpublished technical report)
http://www.tropika.net/svc/specials/algiers2008/technical-reviews/paper-6-abstract-en (accessed 16 January 2009)
Rotich JK et al. Installing and implementing a computer-based patient record system in sub-Saharan Africa: the Mosoriot medical record system. Journal of the American Medical Informatics Association, 2003, 10: 295–303
Schuenemann HJ, Fretheim A, Oxman AD. Improving the use of research evidence in guideline development: 1. Guidelines for guidelines. Health Research Policy and Systems, 2006, 4:13
Service Availability Mapping. Geneva, World Health Organization
Service Availability Mapping. Kenya, Ministry of Health, in collaboration with Geneva, World Health Organization, 2007
Service Availability Mapping 2005. Republic of Rwanda, Ministry of Health, in collaboration with Geneva, World Health Organization
and UNAIDS, 2007
Service Availability Mapping, 2005–2006. Ministry of Health and Social Welfare, United Republic of Tanzania, and Ministry of Health and Social
Welfare, Zanzibar, in collaboration with Geneva, World Health Organization., 2007
Service Availability Mapping. Republic of Uganda, Ministry of Health, in collaboration with Geneva, World Health
Service Availability Mapping. Republic of Zambia, Ministry of Health, in collaboration with Geneva, World Health Organization, 2006
Stanton C et al. Every death counts: measurement of maternal mortality via a census. Bulletin of the World Health Organization, 2001, 79:657–664.
Strengthening country health information systems, 2nd ed. Geneva, World Health Organization, Health Metrics Network, 2008
Tettey WJ. Academic staff attrition at African universities. International Higher Education, 2006, 44:1–3
The state of health information in the African Region. Brazzaville, World Health Organization Regional Office for Africa. Unpublished technical report, May 2008
UNESCO Institute for Statistics. Online database
United Nations Department of Economic and Social Affairs, Statistics Division. 2010 World Population and Housing Census Programme website
United Nations Department of Economic and Social Affairs, Statistics Division. Principles and Recommendations for Population and Housing Censuses, Revision 2. New York: United Nations, 2008
Volmink J, Dare L. Addressing inequalities in research capacity in Africa. Editorial. BMJ, 2005, 331: 705–706
World Development Indicators 2006. Section 2: People. Washington DC, World Bank
World health survey results. Geneva, World Health Organization
- ↑ Everybody’s business. Strengthening health systems to improve health outcomes. WHO’s framework for action (pdf 843.33kb). Geneva, World Health Organization, 2007
- ↑ Framework and standards for country health information systems, 2nd ed. (pdf 1.87Mb). Geneva, World Health Organization, 2008
- ↑ 3.0 3.1 The Algiers Declaration. Ministerial conference on research for health in the African Region. Narrowing the knowledge gap to improve Africa’s health, 23–26 June 2008 (pdf 1.26Mb). Brazzaville, WHO Regional Office for Africa, 2009
- ↑ World Health Organization knowledge management strategy (pdf 938.46). Geneva, World health Organization, 2005
- ↑ International statistical classification of diseases and related health problems (ICD 10) in occupational health (pdf 389.11kb). Geneva, World Health Organization, 1999