Information systems for health sector monitoring
in Papua New Guinea
R.E. Cibulskis
1
& G. Hiawalyer
2
Abstract This paper describes (i) how a national health information System was designed, tested and implemented in Papua New
Guinea, (ii) how the system was integrated with other management information systems, and (iii) how information has been used to
support decision-making. It concludes that central coordination of systems design is essential to make sure that information systems are
aligned with government priorities and can deliver the information required by managers. While there is often scope for improving the
performance of existing information systems, too much emphasis can be placed on revising data collection procedures and creating the
perfect information system. Data analysis, even from imperfect systems, can stimulate greater interest in information, which can
improve the quality and completeness of reporting and encourage a more methodical approach to planning and monitoring services.
Our experience suggests that senior decision-makers and political leaders can play an important role in creating a culture of information
use. By demanding health information, using it to formulate policy, and disseminating it through the channels open to them, they can
exert greater influence in negotiations with donors and other government departments, encourage a more rational approach to
decision-making that will improve the operation of health services, and stimulate greater use of information at lower levels of the health
system. The ability of information systems to deliver these benefits is critical to their sustainability.
Keywords Information systems/organization and administration; Management information systems/utilization; National health
programs; Information management/organization and administration; Papua New Guinea (
source: MeSH, NLM
).
Mots cle´s Syste` me information/organisation et administration; Syste`me information gestion/utilisation; Programme national sante´;
Gestion information/organisation et administration; Papouasie-Nouvelle-Guine´e(
source: MeSH, INSERM
).
Palabras clave Sistemas de informacio´ n/organizacio´ n y administracio´ n; Sistemas de informacio´ n administrativa/utilizacio´n;
Programas nacionales de salud; Gerencia de la informacio´ n/organizacio´ n y administracio´ n; Papua Nueva Guinea (
fuente: DeCS,
BIREME
).
Bulletin of the World Health Organization 2002;80:752-758.
Voir page 757 le re´ sume´ en franc¸ais. En la pa´ gina 757 figura un resumen en espan˜ ol.
Introduction
Information on health needs, the delivery of services, and the
availability and use of resources is important to all health
service organizations. Such information can help an organiza-
tion to increase its efficiency, effectiveness and responsiveness
in several ways. First, it can help managers to align health
system resources with client needs (a planning or prospective
role) and determine whether their plans are progressing
satisfactorily or whether there is a need for corrective action
(a monitoring or retrospective role) (1). Second , information
can be used to increase accountability within an organization
and allow the public, their elected representatives, or donors to
determine whether they are obtaining value for money (2, 3).
Third, information can be used to market health programmes,
secure appropri ate levels of funding or engage public support
(4). Fourth, information amassed over time can help an
organization to learn what works and does not work and
thereby provide valuable know-how, which can lead to greater
efficiency in the production process (3).
Experience suggests that health service organizations
have difficulty acquiring information for use in any of these
roles (5, 6). Successful information systems have been
developed on a small scale, such as for an individual district
or programme, but the sustainability of these initiatives is often
questionable and their relation to national information systems
development is not clear (4). This paper considers how a
national health information system (NHIS) was established,
how it was integrated with other information systems, and how
the informa tion collected has been used to plan and monitor
services. It then considers some of the factors necessary for the
development of successful and sustainable information
systems.
Background
Information systems re ceived much attention in Papua New
Guinea after health service administration was decentralized to
the provincial level in 1983. A management strengthening
project sought to improve the use of data from existing
systems by defining a core set of indicators and introducing
computers for data processing at provincial level (7–10). While
broadly successful in what it sought to achieve, the project did
not attempt to revise data collection systems or consider how
systems should be managed in a decentralized environment.
These issues became increasingly important since, after
1
Takemi Program, Department of Population and International Health, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
(email: [email protected]). Correspondence should be addressed to this author.
2
Department of Health, Waigani, Papua New Guinea.
Ref. No. 01-1177
Policy and Practice
752 Bulletin of the World Health Organization 2002, 80 (9)
decentralization, national le vel managers ceased to have
control over information systems; they could advise provinces
on what data should be collected, but lacked the authority,
capability or resources to ensure that their recommendations
were heeded. Provinces could develop their own systems if
they wished and differences gradually emerged between them,
induced partly by donor projects that introduced programme-
specific information systems in selected areas. Any uniformity
in systems appeared to be due to several provinces ordering
their stationery from the same printing company, which
provided a limited range of forms in its catalogue. The
haphazard state of the information systems made it increas-
ingly difficult to aggregate data on a national scale, compare
results between provinces, or maintain systems. This
prompted the Department of Health to embark on a major
programme to standardize its health management information
systems.
Introducing a national health information
system
System design
A task force to review information systems was established in
1994, consisting of programme managers from the Papua New
Guinea Department of Health and an international consultant.
Nine out of the 20 provinces were visited and discussions held
with health workers, managers, training schools, other
government departments, nongovernmental organizations,
and donors. One district was visited on a monthly basis for a
year to understand information needs at health facility level.
The review identified several problems in data collection,
reporting and analysis, but indicated that there would be little
benefit in collecting radically different data, changing reporting
procedures or establishing different methods of analysis, as this
would require major investments in training and support that
could not b e delivered using available resources. The major
change proposed was to limit monthly reporting to a single
form, which consisted of a folded sheet of A3 paper, and which
combined the essential features of the seven or more forms in
use. This would reduce the reporting burden on health facility
staff and make it easier for provincial and national level staff to
compile and analyse data. The form would contain data
elements for calculating key indicators already in use and a few
additional indicators for monitoring the latest national health
plan. Instruments were also designed to support data capture,
such as tally sheets, daily summary books, and monthly analysis
books. These represented the minimum amount of stationery
required for data gathering. Health facilities would still need
registers, patient record cards, and other materials but this
stationery could not be afforded at the time the work was
undertaken.
Testing
The propose d system was tested in only one province of the
country owing to financial and time constraints. Stationery and
training materials were prepared and computer software for
processing data at provincial level was re written. The software
was deliberately similar to the appl ications already in use but
was upgraded to accommodate new data items and new
possibilities for analysis, and made yea r 2000 compliant. A
3-day training workshop was held for staff from every health
facility.
The system was allowed to run for 6 months. Testing
suggested that the number of disease categories should be
increased to prevent health workers misclassifying certain
conditions. Otherwise the new system was found to be more
useful and easier to operate than previous systems.
Implementation
The need to train staff from all health facilities prevented the
simultaneous implementation of the revised information
system in all health facilities. Instead the system was introduced
province by province over 12 months. This enabled visits to be
made to the first provinces to check that the system was
functioning as intended, that supplies of stationery were
adequate, and that training was appropriate. Thereafter
implementation was intensified and follow-up visits reduced.
Most provinces started using the new system within
2 months of training, although workshops were repeated in
three provinces where implementation was incomplete.
Provinces were provided with a 2-year supply of stationery,
but it soon became obvious that larger quantities were required
if occasional shortages were to be avoided.
Integration of systems
Department of Health systems
Health information systems are part of a wider management
information system tha t provides data on population, resource
availability and use (Table 1). While the NHIS was being
developed, other components of the management information
system were strengthened. A national inventory of health
facilities was undertaken to obtain data on the number of
facilities, staff, buildings and equipment. Such data are useful in
their own right but are more valuable if they can be linked to
health information. A major impetus to link information
systems came from a reform of provincial and local-level
government in 1995, in which district boundaries were revised
to coincide with political electorates. This required health
facility codes to be updated on all computer systems (the
middle two digits of a health facility code represent a district)
and allowed databases to be merged. Inputs could then be
related to outputs and the effici ency of resource use explored.
For example, performance in family health programmes was
found to be related to staff:population ratios.
Other sectors
The health management information syst em was also linked to
other sectors using the national census as a common base.
Each health facility was traced to its nearest census unit.
Because the approximate location of census units was known,
maps could be drawn showing the distribution of health
facilities, health conditions or any other feature that uses the
common coding systems of the Department of Health. The
maps are a convenient way of summarizing data and are useful
for influencing decision-makers who are not overly interested
in numbers (Fig. 1).
Because of its intrinsic link to population, the system can
also be used to determine how many peo ple live within a
certain distance of a health facility with specific attributes, e.g.
the nearest facility with a doctor or radio. Such information is
important because geographical distance influences use of
services and is critical in deciding where to open, close, or
upgrade facilities and locate staff (11–13). Other government
753Bulletin of the World Health Organization 2002, 80 (9)
Health information systems in Papua New Guinea
departments are using a similar scheme to identify the location
of schools and other infrastructure. When such data are linked
with health information they provide a tremendous resource
for intersectoral plan ning and the targeting of pove rty-
reduction programmes (14).
Using information
Attempts were made to increase the analysis of information at
all levels of the health system. Health workers were provided
with tools and training in data analysis including a ‘‘Health
centre record’’ — a booklet designed to assess trends over time
and provide a permanent record of a health facility’s activities.
At provincial level, strategies for analysing indicators were
reinforced by revising computer software and training
provincial managers.
At national level, analysis and dissemination were initially
limited to an annual booklet on family health indicators. By
limiting the analysis to a small area of activity in which data were
readily available, and considered important, the publicatio n
could be prepared in advance of an annua l meeting of
provincial h ealth m anagers where t he performance o f
individual provinces was publicly disclosed. Such feedback
helped to increase reporting rates from 73% in 1994 to 85% in
1995 and to 93% in 2000.
Improvements in information systems eventual ly al-
lowed the government to undertake more extensive analysis
and use information for assessing priorities in the national
health p lan. Targets were set on the basis of previous
performance statistics and they helped managers to assess
which health programmes were proceeding as planned and
how each province was performing.
Information was also used to market the plan to other
government sectors and parliamentary leaders. Each Member
of Parliament was presented with a graphical summary of
health indicators, which showed the status of their constitu-
encies in comparison to others (Fig. 2). The aim was to inform
national leaders about the health situation and bring health
issues to the forefront of the political agenda. More specifically
it was hoped it would secure health budgets and persuade
Members of Parliament to pay attention to health development
in their own constituencies.
Discussion
System design
The definition of management functions at each level of the
health system and the identification of information needs and
indicators are crucial steps in revising information systems (15,
16). It is customary to seek the involvement of health service
managers in this task to ensure that systems meet their needs
and to facilitate eventual implementation (16, 17). In practice,
however, managers are not always sure of the information they
Table 1. Components of a health management information system
Type of information Information system
a
1 Population National census
Demographic and health surveys
2 Morbidity and mortality Health information system
Demographic and health surveys
3 Health service activities Health information system
Demographic and health surveys
4 Facilities and equipment Asset management systems
Survey of health facilities
5 Human resources Workforce registration
Employment and training records
Survey of health facilities
6 Medical supplies Procurement and distribution system
Health information system
7 Financial information Budgeting and accounting systems
8 Other sectors Government-wide systems
Geographical information systems
a
Surveys and censuses are considered as part of a routine information system if they gather similar information at periodic intervals (as opposed to surveys and rapid
assessments conducted on a one-off basis to answer specific questions).
754 Bulletin of the World Health Organization 2002, 80 (9)
Policy and Practice
require and the process can result in long lists of indicators,
many of which cannot be measured (17, 18).
In Papua New Guinea the definition of information
needs was assisted by four factors. First, managers were
familiar with concepts of indicators and monitoring as a result
of previous management strengthening efforts (7–10). Second,
existing information was analysed and dissemina ted before
system revision commenced — decisions on what indicators
should be generated by an information system are easier if
managers have data in front of them and can see how various
indicators compare with targets, between geographical loca-
tions and over time. Th ird, revision of systems coincided with
the development of a national health plan that provided
guidance on what should be measured. Fourth, the decision to
use a single form for monthly data collection — which was
taken following extensive consultation with health workers —
placed limitations on the amount of data that could be
collected. These factors resulted in an information system that
was not very different from previous systems, but was more
clearly defined, making it easier for health workers to adapt to
it, reducing the need for major retraining and ensuring
consistency in time-series.
Implementation
Good information systems may fail to take hold if they are
poorly implemented. In Papua New Guinea several strategies
were used to reduce the risk of failure (18–20). Widespread
consultation ensured that staff were aware of the changes and
had contribut ed to them, and that the system’s design was
realistic. Testing on a limited scale helped to confirm the
system’s appropriateness. Improved analysis and dissemina-
tion of information before implementation created a more
favourable climate in which to introduce new systems. It
stimulated interest in information, generate d support from
senior levels in the Department of Health, and gave credibility
to programme managers leading the change.
Atten tion was given to how the system would be
introduced to each province, with the organization of work-
shops, printing and distribution of stationery, revision of
computer software, and discontinuation of existing systems.
Private printing companies and training schools were kept aware
of the changes. At national level, procedures were established
for follow-up of missing reports, data quality control, updating
coding systems, data summary and provision of feedback.
Provisions were included in the National Health Administration
Act, 1997, to compel all health facilities to report using the
NHIS. Certificates were awarded to health facilities and
provinces that provided the best reports. Financial support
was secured for stationery, training, freight/postage, commu-
nications, periodic upgrading of computers, and software.
Management of systems
Our experience suggests that tasks required for the smooth
functioning of information systems are best managed and
755Bulletin of the World Health Organization 2002, 80 (9)
Health information systems in Papua New Guinea
financed by a single unit at national level rather than being
devolved to provinces or split among separate programmes at
national level. Such an arrangement provides more stable
funding, greater consistency in approach, and avoids duplication.
There is no standard model, however, and in other situations a
different strategy may be preferred, particularly if the monitoring
capacity of indiv idual programmes is well developed and
programme staff are motivated to seek and use the information.
Nevertheless it will still be necessary to ensure that opportunities
exist to undertake consolidated analysis of information if
management of systems is distributed over several units.
Coordination of systems development
Mechanisms are needed to coordinate system developments
across programmes (21). In Papua New Guinea, a committee
was established to review all information system proposals and
develop a coordinated strategy for improving systems. The
committee included representation from several programme
managers and donors but there were still some agencies that
preferred to bypass government procedures and install parallel
systems, sometimes employing consultants who use non-
standard software and fail to work with local systems developers
(19). This approach is partly explained by the perception that
governments are not capable of managing information systems
and it is easier for a donor to bypass dysfunctional structures
than to strengthen them. However, such short cuts do not help
to develop the management capacity of health systems.
Moreover, experience suggests that independently developed
information systems rarely outperform government systems
and rapidly collapse once donor support is withdrawn. They put
undue pressure on government staff, disrupt normal operations,
and are ultimately detrimental to information system perfor-
mance and sustained development.
What should donors do?
In most cases it is preferable to channel donor support into
existing monitoring units, with funds for stationery, equipment
and technical assistance wher e necessary. If several donors are
operating in a country, it may be advantageous to employ
common indicators of performance and c ommon d ata
collection methods. Clearly, there are difficulties in developing
a coordinated monitoring strategy where donors do not share
common objectives. However, they can be assisted if
government objectives are clear. In Papua New Guinea, the
national health plan defines the goals and objectiv es of the
health sector and how progress will be monitored. The plan has
helped to ensure donor support for national programmes and
how they are monitored.
Human resources
A critical factor governing the sustainability of information
systems is t he availability of qualified and experienced
personnel. Many systems are developed with external
assistance because necessary skills are not available locally. It
is unrealistic to expect these skills to be developed rapidly.
Certainly, it would help to strengthen the capacity of local
institutions to offer training in statistics, epidemiology, and
computing to diploma or degree level. But it is difficult to
recruit or retain staff without signifi cantly improving pay or
working conditions. Many countries are therefore faced with
the stark choice of neglecting information systems or relying
on external assistance whose goals may be at variance with
those of the government.
Creating a culture of information use
It is hoped that lower levels of management, including health
care providers, will use information for p lanning and
monitoring health services, and it is possibly at this level that
information use can have the greatest impact on the efficiency
and effectiveness of health servic es (22). This can be
encouraged through training and the provision of tools for
data analysis. While necessary, such initiatives are seldom
sufficient to change the way staff use information. Our
experience suggests that an important way of developing the
periphery in this respect is by setting a good example at the top.
If seni or management seeks information and uses it openly
then the importance of information is reinforced throughout
the health system. A promising initiative has been to
summarize health statistics according to parliamentary con-
stituencies and ensure their widespread circulation. This is not
only of interest to health managers but also to a wider audience
who wish to see accountability among public serva nts and
politicians (23). It has given a readily observable purpose for
the health management information system and helps to
legitimize requests for data from health workers and mid-level
management.
Information has also been used to defend the position of
the health sector in negotiations w ith other governme nt
departments and donors. Indeed, the ability to set priorities
and monitor progress was a key factor in attracting a health
sector programme loan in which national health plan targets are
used as benchmarks for assessing progress, and ultimately to the
adoption of a sector-wide approach for the coordination of
donor inputs. These benefits will ultimately be critical to
ensuring the sustainability of information systems. According to
UNICEF (24), sustainability is the ability of a system to produce
benefits valued sufficiently by users and stakeholders to ensure
enough resources to continue activities. Hence, information
systems can be sustainable if they deliver benefits to senior
decision-makers and donors who control resources, and if there
is sufficient motivation for health workers to support them. n
Acknowledgements
The work described in this paper was undertaken while
Dr Cibulskis was Adviser in Health Information Systems for
the Asian Development Bank Third Rural Health Serv ices
Project and Dr Hiawalyer was Deputy Director of Monitoring
and Research in the Department of Health, Papua New
Guinea. We recognize the efforts of staff from the Monitoring
and Research Section and provincial health in form ation
officers who have been re sponsible for building the country’s
information systems. Special credit should be given to Ahouta
Badu, Ila Rouka (discharge information); Gahusi Gahusi,
Kheila Tawai (national health information system); Mikes
Arere, Tware Teka (health facilities); Steve Mellor, Jojie
Urbiztondo, John Mondo, George Tuges (computer systems);
and Kwalu Ora (publ ications). We also acknowledge the
efforts of all health workers who routinely submit their
monthly activity reports through the NHIS. Dr Tonya
Villafana and three anonymous referees reviewed and made
helpful com ments on the manuscript.
A preliminary draft of this paper was presented at the
Twelfth Meeting of Commonwealth Health Ministers,
Barbados, 1998.
Conflicts of interest: none declared.
756 Bulletin of the World Health Organization 2002, 80 (9)
Policy and Practice
Re´ sume´
Syste` mes d’information pour la surveillance du secteur de la sante´ en Papouasie-Nouvelle-Guine´e
Le pre´sent article de´ crit comment un syste` me d’information
sanitaire national a e´te´ conc¸u, teste´ et mis en œuvre en
Papouasie-Nouvelle-Guine´ e, comment ce syste`me a e´te´ inte´ gre´
avec les autres syste` mes de gestion de l’information et comment
l’information a e´te´ utilise´ e dans la prise de de´ cision. S’il est vrai
que la performance des syste`mes existants d’information peut
souvent eˆ tre ame´ liore´e, il arrive qu’une trop grande place soit
accorde´ea` la modification des me´ thodes de collecte des donne´es
et a` la conception d’un syste` me d’information parfait. L’analyse
des donne´ es, meˆ me quand elles proviennent d’un syste`me
imparfait, permet de de´velopper l’inte´reˆ t pour l’information, ce
qui peut ame´ liorer la qualite´ et la comple´ tude des signalements et
favoriser une approche plus me´ thodique de la planification et de
la surveillance des services. Les strate´gies possibles sont
nombreuses pour ame´ liorer l’utilisation de l’information dans le
secteur de la sante´ mais l’adoption de nombreuses initiatives est
variable. D’apre` s notre expe´ rience, les responsables des de´cisions
et les responsables politiques peuvent jouer un roˆ le important en
suscitant une culture de l’utilisation de l’information, en sollicitant
l’information sanitaire, en l’utilisant pour formuler les politiques et
en la disse´minant par les moyens a` leur disposition. On peut
s’attendre a` en retirer plusieurs avantages, et notamment la
capacite´ d’exercer une plus grande influence dans les ne´gocia-
tions avec d’autres services gouvernementaux et les donateurs,
une plus grande rationalite´ des de´ cisions qui ame´ liorera le
fonctionnement des services de sante´ et une incitation a` utiliser
l’information aux niveaux infe´rieurs du syste`me sanitaire. La
faculte´ des syste`mes d’information a`ge´ne´ rer des avantages pour
les divers inte´resse´ s est en fin de compte capitale dans leur
maintien.
Resumen
Sistemas de informacio´ n para la vigilancia del sector de la salud en Papua Nueva Guinea
En este artı´culo se describe co´ mo se disen˜o´ , ensayo´ e implanto´en
Papua Nueva Guinea un sistema nacional de informacio´ n sanitaria,
co´ mo se integro´ dicho sistema con otros sistemas de informacio´n
para la gestio´n,yco´ mo se ha utilizado la informacio´ n para apoyar
la adopcio´ n de decisiones. Si bien pueden identificarse a menudo
diversas posibilidades para mejorar el funcionamiento de los
sistemas de informacio´ n existentes, se corre el riesgo de hacer
demasiado hincapie´ en la revisio´ n de los procedimientos de acopio
de datos y en el perfeccionamiento incesante de esos sistemas. El
ana´ lisis de los datos, aun de sistemas imperfectos, puede suscitar
ma´ s intere´s por la informacio´ n, lo que puede traducirse en una
mejora de la calidad e integridad de los datos notificados y propiciar
un enfoque ma´s meto´ dico de la planificacio´ n y vigilancia de los
servicios. Pueden utilizarse diversas estrategias para mejorar el uso
de la informacio´ n en una organizacio´ n de salud, pero el intere´sde
las iniciativas es desigual. Nuestra experiencia parece indicar que
las altas instancias decisorias y los dirigentes polı´ticos pueden
contribuir considerablemente a promover una cultura del uso de la
informacio´ n solicitando informacio´ n sanitaria, utiliza´ ndola para
formular polı´ticas y difundie´ndola por los circuitos a su alcance.
Cabe prever como resultado diversos efectos positivos, como la
capacidad de ejercer mayor influencia en las negociaciones con
otros ministerios y donantes, la adopcio´ n de decisiones ma´s
racionales que mejorara´ n el funcionamiento de los servicios de
salud, y el fomento del uso de la informacio´ n en los niveles
inferiores del sistema sanitario. La capacidad de los sistemas de
informacio´ n para beneficiar a los interesados directos es en u´ ltimo
te´ rmino decisiva para su sostenibilidad.
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