J.5_Liberia_HIS_Strategy.pdf

Liberian Health

Information System

& ICT Strategic Plan

2016-2021

February 19, 2016

2016-2021 Liberia HIS Strategic Plan Page 1

FOREWORD

The goal of the 2016-2021 Investment Plan is to ensure Liberians have access to safe and quality health services, a robust health emergency risk management system, and an enabling environment that restores trust in the government’s ability to provide services. Good health statistics are a critical resource for monitoring and evaluation of the 2015-2021 Investment Plan for Building a Resilient Health System. Data to inform the output, outcome and impact indicators will be obtained mainly from the National HIS including the routine health information system, population and facility-based surveys and related activities such as national program assessments. Therefore, increased and regular investment in the health information system is a critical need for a country like Liberia, with a growing demand for quality health information. In recognition of this, global initiatives under our global partners like USAID, CDC, UNFPA, UNICEF, EU, WHO and World Bank have been working towards strengthening the Health

Information Systems (HIS) in all countries, especially the developing world.

We are presenting here the Second HIS strategic Plan which reflects the great efforts and solid cooperation among concerned stakeholders that were brought together by MOH in order to harness efforts to strengthen the

Liberia’s health information system. This was achieved through increased coordination and integration of health information from all programs and health system interventions. The continued collaboration will contribute to reduced duplication in collection of data and creation of a central repository for data to facilitate easy retrieval, analysis, dissemination and utilization.

This Health Information Strategy is a product of collaborative efforts by health institutions (health departments, national programs, and county health staff), and health related data producers, especially the Liberia

Institute of Statistics and Geo-Information Services (LISGIS), and Ministry of Finance and Development Planning.

This joint document provides an overview of the HIS vision, goals and strategies that respond to the findings and gaps of the six components of the HMN framework assessed in a multi-sectoral group comprising of practitioners from the Ministry of Health and Social Welfare, bilateral organizations, UN development partners, and non-governmental organizations. The Core Team consulted widely, and it is hoped that this document will address all information needs across the various health related sectors and consumers for the next five years. This joint document provides an overview of the HIS vision, goals and strategies that respond to the findings and gaps of the six components of the HMN framework and ICT Infrastructure assessed in July 2015 and covers the expectations of the country for HIS improvements and reforms. I believe that the HIS Strategic Plan will be used by national institutions involved in health and by external development partners as a guide for their activities and investments in the monitoring and evaluation of health sector performance. In addition to being a policy initiative, the document presents a key business strategy for the health sector, as improved health information management is an integral part of achieving better health outcomes for all Liberians.

I would like to acknowledge the Bureau of Vital Statistics under the Department of Planning, Research and

Human Development, for taking the lead in the development of this strategy, as well as the great efforts and contributions of all members of the HIS stakeholder working group.

Hon Dr. Bernice T. Dahn, BSC., MD., MPH

Minister of Health

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ACKNOWLEDGMENTS

The Ministry of Health would like to acknowledge the contribution of all members of the HIS Stakeholder Technical

Working Group (Annex A) and Core Team for tirelessly working on the development of the HIS strategy: 2016-2021.

We would like to thank the staff of the Ministry of Health and Social Welfare, particularly Assistant Minister C.

Sanford Wesseh, Luke Bawo, HMER Coordinator, Beatrice Lah, Director of IT unit and Stephen Gbanyan, HMIS

Director; Nelson K. Dunbar, The Director for Research, Mike Mulbah, M&E Director, and Patrick Konwloh, Deputy

Director, HMIS. Without their time and commitment, 2016-2021 HIS Strategy development would not have been possible.

The process of developing this HIS Strategy has benefitted from the input of many organizations and individuals to whom we owe gratitude. MOH is grateful to all our Development Partners for the support not only provided in developing this Strategy, but also extending tremendous support to the national response. The Core

Team provided invaluable technical leadership and guidance throughout the entire processes for which we are most grateful.

We owe a great debt of gratitude to MEASURE Evaluation, the Collaborative Support for Health (CSH) project and John Hopkins University (JHU), who provided embedded staff under the guidance of the HMER Unit. The

MEASURE Evaluation embedded staff was led by Theo Lippeveld and consisted of Romain Tohouri and Walter

Obiero (MEASURE Evaluation), Tashrik Ahmed represented JHU, and Alex Blidi CSH.

At national and county level, MOH wishes to register its sincere gratitude to all the technical and management teams including OFA staff, Directors of National Programs, and all the County Health Officers, and other staff who devotedly participated in meetings and workshops and provided valuable information as well as reports for additional analysis.

Mrs. Yah Zolia

Deputy Minister, Planning, Research & Development

Ministry of Health

2016-2021 Liberia HIS Strategic Plan Page 3

TABLE OF CONTENTS

FOREWORD

ACKNOWLEDGMENTS

TABLE OF CONTENTS

ACRONYMS

1 INTRODUCTION

1.1 BACKGROUND AND RATIONALE

1.2 THE ASSESSMENT & STRATEGY DEVELOPMENT PROCESS

1.3 STAKEHOLDERS OF THE HEALTH INFORMATION SYSTEM

1.4 LIBERIA HIS PROBLEMS & CONSTRAINTS

2 LIBERIA HIS VISION, MISSION AND PRINCIPLES

2.1 VISION STATEMENT

2.2 HIS GOAL STATEMENT

2.3 PRINCIPLES AND DESIRED CHARACTERISTICS (BASED ON 2009 HIS POLICY

3 STRATEGIES AND INTERVENTIONS FOR HIS STRENGTHENING, 2016–2021

3.1 STRATEGIC OBJECTIVES AND BENCHMARKS

3.2 STRATEGIC INTERVENTIONS

3.3 PHASED IMPLEMENTATION PLAN

3.4 OPERATIONAL PLAN JULY 2015 – JUNE 2017

3.5 HIS ARCHITECTURE

3.6 HIS RESOURCE REQUIREMENTS

3.7 CRITICAL ASSUMPTIONS AND RISKS

3.8 MECHANISMS FOR COORDINATION

3.9 M&E OF THE IMPLEMENTATION OF HIS STRATEGIC AND OPERATIONAL PLANS

4 CONCLUSION

5 APPENDICES

ANNEX A: MEMBERS OF THE HMER STAKEHOLDER WORKING GROUP AND THE HSCCC

ANNEX B: GLOSSARY OF TERMS USED IN THE HMN HIS STRATEGIC PLANNING PROCESS

ANNEX C: NATIONAL CORE HEALTH INDICATORS

ANNEX D: LIBERIA HIS ASSESSMENT SCORES BY HIS COMPONENT

ANNEX E: MILESTONES AND INTERVENTION PHASING FOR HIS SUBSYSTEMS

ANNEX F: HIS PHASED IMPLEMENTATION PLAN 2016-2021

ANNEX G: HIS 2015-2017 OPERATIONAL PLAN AND BUDGET

ANNEX H: INVENTORY OF ON-GOING AND PLANNED HIS STRENGTHENING EFFORTS

ANNEX I: HIS CAPACITY BUILDING ACTION PLAN

ANNEX J: HEALTH INFORMATION SYSTEM (HIS) SUBSYSTEMS AND PROBLEMS IN LIBERIA

ANNEX K: INFORMATION SYSTEM ARCHITECTURE

ANNEX L: HIS ICT INFRASTRUCTURE ASSESSMENT IN LIBERIA

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ACRONYMS

ACCEL Academic Consortium for Combating Ebola in Liberia

C-BHIS Community-Based Health Information System

CEBS Community event-based surveillance

CDC Centers for Disease Control

CHAI Clinton Health Access Initiative

CHO County Health Officer

CHSWT County Health and Social Welfare Team

CHT County Health Team

CHW Community Health Worker

CMO Chief Medical Officer

CSH Collaborative Support for Health

DHIS2 District Health Information Software version 2

DHO District Health Officer

DSIS Disease Surveillance Information System

DSO District Surveillance Officer eDEWS Electronic Disease Early Warning System

EOC Emergency Operation Center

EVD Ebola Viral Disease

EPR Epidemic Preparedness and Response

ETU Ebola Treatment Unit

EWARN Early Warning and Alert Response Network

FMIS Financial Management Information System gCHV General Community Health Volunteer

GDL Global Development Lab

GIS Geographical Information System

GOL Government of Liberia

GPS Global Positioning System

HF Health Facility

HIS Health information system

HIV Human immunodeficiency virus

HMER HMIS, M&E, and Research

HMIS Health management information system

HMN Health Metrics Network

HRIS Human Resource Information System

HSCC Health Sector Coordination Committee

ICD International Classification of Diseases

ICT Information and Communication Technologies

IDSR Integrated Disease Surveillance and Response

IHR International Health Regulations (2005)

IMC International Medical Corps

IMS Incident Management System

IPC Infection Prevention and control

ITU Information Technology Unit iHRIS Integrated Human Resource Information System

JHU Johns Hopkins University

LAN Local Area Network

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LISGIS Liberia Institute of Statistic and Geo-Information Services

LMIS Logistics Management Information System

M&E Monitoring and evaluation

MIA Ministry of Internal Affairs mHERO Mobile Health Worker Electronic Response and Outreach

MOA Ministry of Agriculture

MOH Ministry of Health

MOHSW Ministry of Health and Social Welfare

MOE Ministry of Education

MOGCSP Ministry of Gender, Children, and Social Protection

NGO Non-governmental organization

NHSWFPP The National Health and Social Welfare Financing Policy and Plan

OIC Officer In Charge

PACS Partnership for Advancing Community Based Services

PCI Project Concern International

PCR Polymerase Chain Reaction

PHC Primary Health Care

PIH Partners in Health

RBHS Rebuilding Basic Health Services

QA Quality Assurance

QI Quality Improvement

RITE Rapid Isolation and Treatment Ebola

RRT Rapid Response Team

SOP Standard Operation Procedures

SQS Standard Quality Services

TOT Training of trainers

TWG Technical Working Group

UN United Nations

UNDP United Nations Development Programme

UNICEF United Nations Children Fund

UNMEER UN Mission for Ebola Emergency Response

USAID United States Agency for International Development

WHO World Health Organization

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1 INTRODUCTION

1.1 Background and Rationale

In the aftermath of the Ebola crisis, strengthening the National Health Information System (HIS) has been recognized by the Ministry of Health as one of the key interventions of the Investment Plan for Building a Resilient Health

System. Indeed, during the Ebola epidemic it became clear that the fragmentation of the current health information system made it impossible to have the “right information at the right time and in the right place”. Many HIS subsystems, such as HMIS and DSIS were not interconnected, and various stakeholders did not coordinate and contributed even further to the fragmentation by setting up separate reporting systems.

Based on the National HIS Strategy and Implementation Plan of 2009 and on the National Investment Plan for Resilience of 2015, and on the lessons learned from the Ebola crisis, the Ministry of Health decided to conduct a comprehensive HIS strategic and operational planning with a particular focus on leadership and coordination.

1.2 The Assessment & Strategy Development Process

The HIS strategic planning process involved a range of steps, which were systematically conducted to build broad-based consensus among key stakeholders inside and outside the Ministry of Health. The process was implemented in four stages. First, a one-day meeting was held to mark the launch the HIS strategy development process. All HIS stakeholders were invited to discuss leadership and coordination, and to reach consensus on the methodology, processes and tools of strategic planning. The second stage was the assessment stage, which included the development of HIS assessment tools as well as an assessment workshop with all the stakeholders. The third stage was to conduct a HIS Strategic Planning workshop, again with the stakeholders, where the assessment results were presented and formed the basis for the identification of strategic objectives and interventions. Also, priority interventions were identified and costed, and put together into a two year operational plan. Lastly, the HIS strategic and operational plan was validated by the Health Sector Coordination Committee (HSCC), and senior management committee led by the Minister of Health. The whole process took 4-5 months.

1.2.1 Leadership and Coordination

The HIS strategy development used three coordination mechanisms: (1) a Core Team constituted by around 10 HIS professionals from MOH as well as from technical agencies; (2) the HMER Stakeholders Workgroup; and (3) Health

Sector Coordinating Committee (HSCC). The HSCC serves as the highest decision making body in the health sector.

Chaired by the Minister of Health, it is comprised of senior MOH managers, representatives of the Ministry of Finance and of Economic Planning and Development, country representatives of United Nations agencies and of major donors active in the health sector, civil society, and non-governmental organizations representatives. The HSCC served as the Steering Committee (SC) that validates both the HIS Strategic Plan 2016-2021 as well as the costed operational plan for 2015-2017. The HMER Stakeholder Working Group (SWG) was created under the Chairmanship of Assistant Minister for Vital Statistics with wide participation from all programs and departments (see Annex A).

This group varied in size and organization as the process moved from assessment through strategic planning activities. This group contained appropriately qualified staff from the offices and programs that are in a position to contribute to the design of the information system improvements, and then eventually will take the responsibility for implementing strategies and activities that fall in their functional areas of work. The day to day technical management and coordination of the process was provided by a small core team created under the coordination of the Coordinator of the HMER Unit within the Department of Policy, Planning, and Research in the MOH. The Core

Team was made up of MOH/HMER professionals as well as short and long-term Technical Advisors provided by

USAID-MEASURE Evaluation, USAID-CSH, CDC, UNICEF, WHO, and the Last Mile Project.

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1.2.2 Stakeholders Consultation

To have a shared and broader vision of a more resilient, coherent, integrated, efficient and useful HIS system, stakeholder consultation was conducted in two ways: (1) one-on-one meetings with partners, and (2) joint meetings.

Individual meetings were held with MOH program directors; with donors such as USAID, CDC, UNICEF, and WHO;

and with technical partners including CHAI, GEMS, PACS, CSH, DELIVER, IntraHealth, and eHealth Africa. During the first week of the strategic planning process a one day meeting was held on June 26, 2015 at the Emergency

Operations Center (EOC), with all major stakeholders to agree on the methodology, processes, and tools used for assessing the Liberian HIS. The meeting was highly representative of all internal and external stakeholders. The

Assistant Minister of Vital Statistics Mr. Wesseh chaired the meeting. During the meeting it was agreed as a first step in this process to conduct an assessment of the current HIS in Liberia, based on consensus building between the stakeholders, to serve as a baseline for the strategic and operational planning process.

1.2.3 Assessment tool development and workshop

To carry out the general HIS assessment, the Core Team used the framework, tool, and methodology provided by the Health Metrics Network (HMN) framework, version 4. The framework enables all partners to harmonize and align their efforts around a shared vision of a sound and effective national health information system. The HMN

Assessment Tool provides a universally agreed upon standard for guiding the collection, reporting and use of health information by countries and global agencies. The questionnaire was slightly contextualized by adding specific questions mainly to the “resources” section to suit the current HIS situation in Liberia. To strengthen the policy, planning and coordination section of the questionnaire, questions on governance and partnership were adapted from MEASURE Evaluation Capacity Assessment Tool (MECAT). MECAT is a generic data collection tool that captures various dimensions of capacity: organizational, technical, and behavioral. Acknowledging that the HMN tool was not strong in assessing in depth the underlying HIS ICT infrastructure, the team developed a specific HIS ICT

Infrastructure Assessment Tool (ICTIAT) and conducted a separate survey using this tool to complement the findings from the HMN tool.

At the end of July 2015, a two-day workshop was organized by the MoH which brought together health information producers and users from various institutions (central MoH departments, implementing partners, 15

County Health Officers, health development partners, and LISGIS,) to assess the national health information system.

The workshop was conducted using the contextualized HMN assessment tool, based on standards for the development of the national health information system, with technical support provided by MEASURE Evaluation.

Six components of the HIS were assessed: resources, indicators, data sources, data management, information products, and dissemination and use.

1.2.4 Strategic Planning Workshop

The HIS Strategic Planning workshop was held on September 22-24 2015 with the following objectives:

To assess the current HIS problems as identified during the assessment stage

To make an inventory of ongoing and planned HIS strengthening interventions in Liberia.

To develop consensus around a common vision around the HIS

To prioritize interventions for the period 2015-2021

To develop a 2015-2017 operational plan

A total of 100 participants from MOH, donors, and implementing partners (the “stakeholders”) attended the workshop and were divided into seven smaller groups to provide inputs into specific sections of the Strategic Plan documents. The seven groups were:

1. Disease Surveillance Information System (DSIS)

2. Laboratory Information System (LIS)

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3. Health Management Information System (HMIS) and Electrical Medical Records (EMR)

4. Logistic Mgmt Information System (LMIS) and Human Resource Information System (HRIS)

5. Community Based Information System (CBIS)

6. Information and Communication Technology (ICT) and Geographic Information System (GIS)

7. Research and Financial Management Information System (FMIS)

Each of the seven groups reviewed the priority problem statements ordered by HIS Component and decided which problems were important enough to carry over into the intervention design. The seven groups provided inputs to the following sections of the Strategic and Operational Plan: (1) HIS vision and objectives; (2) Strategic interventions;

and (3) Operational interventions and activities.

1.2.5 Prioritization Workshop

During the strategic planning workshop, a total of 73 strategic interventions were identified and all but two were planned to start implementation in the first two years, and all but 6 were planned to start in the first year. Therefore a prioritization workshop was held in December 16-17 in Buchanan to prioritize the 73 interventions in the strategic plan. A total of 50 participants attended the workshop which included members from MOH, CDC, USAID, WHO, and relevant implementing partners. The workshop consisted mainly of group work sessions. Groups were placed in seven teams representing most of the HIS sub systems. Each group was tasked with the responsibility to: (1) set the bench mark for each systems, and update the current interventions; (2) review the expected vision, mission, and objectives HIS Strategic plan; (3) revisit the HIS problems and proposed interventions; (4) score interventions in terms of priority; and (5) select interventions that would go into an operational plan. For the prioritization the following criteria were used: (1) implemented over the next two years; (2) cost; (3) sustainability; and (4) uncertainty of desired effect. The workshop managed to:

(1) prioritize 30 interventions for 2016 that scored highest based on the prioritization criteria

(2) reduce strategic objectives from 21 to 17

(3) reduce strategic interventions from 73 to 68

Participants expressed difficulty in developing a 5-year plan due to the drop-off in committed funding starting Year

3. This drop-off was referenced as the primary motivation for stacking key interventions in the first two years. Tied to this, was a basic lack of coordination between the MOH, partners, and donor agencies. To respond to the deficiencies in coordination, all groups discussed the need for a dedicated coordination mechanism and governance in the form the existing HMER TWG, for which subgroups for each subsystem should be created. To guide interventions, each subsystem also developed milestones for each year shown in Annex E. All groups shared a need for sustained capacity building in basic ICT, data analysis, data management, data use, and visualization competencies.

1.2.6 Drafting of the HIS Strategic and Operational Plan

The Core Team, based on the inputs of the stakeholders, drafted the 2016-2021 HIS Strategic Plan and the costed

2015-2017 Operational Plan. The plan is divided into three chapters with the first chapter giving the background information, strategy development process, situational analysis of HIS. The second chapter addresses the vision, mission, and principles of the HIS strategic plan. Chapter three presents the objectives, strategic interventions, phased implementation plan, electronic HIS architecture, resources required for implementing the strategic plan, and the monitoring and evaluation plan. Other detailed information is provided in the annexes.

1.2.7 Validation Meeting

The drafted 2015-2021 HIS Strategic Plan and 2015-2017 Operational Plan were presented to the HSCC for validation in February 2016.

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1.3 Stakeholders of the Health Information System

1.3.1 Stakeholders of the Health Information System within the Ministry of Health The stakeholder for HIS within the Ministry of Health can be broadly divided into two groups: (1) stakeholders at the central level and (2) stakeholders at the county level. The central level includes the various departments, which are directly involved in implementation or overseeing the implementation of planned strategies and plans. They also include the vertical disease programs (MCH, malaria, Tuberculosis and Leprosy, HIV/AIDS, NCD, etc.). The county level includes the County Health Offices, the District Health Offices, the Health Facilities (health centers and hospitals), and the Community Health Workers and Volunteers.

1.3.2 Other Government Stakeholders outside the Ministry of Health The concept of health information system is not limited only to the health sector, since health information is generated and used by a variety of different organizations and institutions. These include LISGIS, other sectoral ministries, the private sector and many development agencies

Liberia Institute of Statistics and Geo-Information Services (LISGIS)

LISGIS is the other key institution for data collection and basic analysis, with offices in all counties. LISGIS is the national bureau of statistics which has a national strategy for the development of statistics, conducts the census and surveys, and is responsible for the analysis and dissemination of statistics. LISGIS conducted the housing and population census in 2008 (next will be in 2018) and large health surveys, in close collaboration with the MOHSW including the LDHS 2007 and 2013, as well as Malaria Indicator surveys in 2007, 2009 and 2011. The quality of the field work by LISGIS is good, but the analytical capacity is still limited. Maintaining and strengthening the capacity of LISGIS to conduct high quality surveys in collaboration with MOH is required.

Key Line ministries involved in issues that affect health of Liberians:

Ministry of Justice: Takes over the responsibility for revitalization of registration of births and deaths especially at community level from Ministry of Health

The Ministry of Gender and Development is responsible for gender main-streaming. It also keeps track of cases of domestic/ sexual violence

Ministry of Education: Caters for the school health program and is responsible for the health training in schools

Ministry of Finance: Financial resources for health are often mobilized through this ministry.

Ministry of Water: This ministry has information system on distribution of water sources in the country

1.3.3 Additional Key Partners

Development Partners:

Development Partners also participate in production and utilization of health data. They do so through provision of technical, financial and/or material support. There are multilateral partners and bilateral partners. Multilateral partners involved in health include WHO, UNICEF, UNFPA, UNAIDS, UNHCR, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and the Global Alliance for Vaccines and Immunization (GAVI). The main bilateral partners in Liberia are USAID, CDC, JICA, Swiss Cooperation, Irish Aid, DFID, French Cooperation, and GIZ.

Implementing Partners (IPs)

Non-Governmental Organizations (NGOs) such as Johns Hopkins University, Africare, CARE, IRC, Last Mile Health, are operational at national, district and community levels. Other IPs are better known under their project name such as CSH, PACS, DELIVER, PACS, MCSP are involved in health service delivery and therefore contribute to production and utilization of health data.

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Academia:

A vast range of research on health is organized and many times carried out by the academia including universities with medical-related courses or by students attached to these universities. University of Liberia (Social Science

Research) national ethics committee has played a big role in conducting research on health issues. Research organizations like The Liberian Institute of Biomedical Research (LIBR) manage and implement most biomedical research conducted in the country.

Private Sector:

Privately owned healthcare providers (including traditional healers), pharmaceutical suppliers and pharmacies, advocacy groups, corporations, and other stakeholders are a sizeable and growing segment of the health care sector in Liberia. Identifying and engaging appropriate stakeholders in the private sector to provide input into the health information system, and use the resulting information to improve service delivery and health of their clients.

1.4 Liberia HIS Problems & Constraints

As indicated earlier, the Liberian Health Information System was assessed using a combination of assessment tools and methodologies. It was based on HMN framework which divides the health information system in six components: (1) HIS resources; (2) Indicators; (3) Data Sources; (4) data management; (5) information products; and

(6) Dissemination and use.

The HIS TWG reviewed around 234 questions related to various components of the health system scoring the performance of each HIS components out of a maximum score of 3. Generally, the performance of the current

HIS in Liberia was found to be inadequate. With an unsatisfactory resource environment for HIS (policy and planning, financing as well as institutions and human resource), there is limited capacity among program managers to analyze data and use information for program improvement and resource allocation. Although there is reasonable performance in terms of capacity of the data platform, some of the data sources (including vital registration, health and disease records, health services records, human records and financial records) require special attention. The assessment has revealed reasonable performance in terms of capacity to generate information products (with exception of generation of information products related to risk factors for health) along with quality of those products in terms of the data collection methods, timeliness of the products, consistency, representativeness, disaggregation and estimation methods (with an exception of periodicity).

Based on the assessment of the components the following areas were identified for improvement. For full details on the findings of the HIS assessment, the reader is referred to annexes D, J and L.

1.4.1 Data Management

There is no written set of procedures for data management including presentation, visualization and dissemination for target audiences, and these are implemented throughout the country. A metadata dictionary providing comprehensive definitions about the data does not exist, and only a limited number of staff at national level and county levels are competent in routine data management (queries, merging, data cleaning, and aggregation).

1.4.2 HIS Infrastructure

As internet is the main channel of data transmission, the ICT assessment found very limited internet coverage and the quasi inexistence of ICT policies documents in place to guide the use of Internet at work, the network security, computer maintenance, data backup and disaster recovery, etc. at central MOH level as well as at county level. In terms of human resources there is great need of skilled ICT staff and at the MOH central level, there is an important need for computer programmers, database administrator, network security and Linux systems administrators.

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1.4.3 Health Legislation and coordination

The current National Public Health Law (like the 1976 National Public Health Law) does not adequately cover aspects of vital registration, notifiable diseases, private sector data, confidentiality and fundamental principles of official statistics. There is a national HMER committee but due to limited resources and competing priorities, is not fully functional.

1.4.4 Health and Disease Records (Including Surveillance)

HIS assessment results revealed that health and disease records (including surveillance) are present but not adequate, and that not all key epidemic-prone diseases and diseases targeted for eradication and/or elimination have appropriate case definitions established. Moreover, not all cases can be reported using the current reporting format.

The current disease surveillance information system that is used to identify disease outbreaks for rapid response is paper-based

1.4.5 HIS Institutions, Human Resources and Finance

In regard to HIS institutions, human resources and financing, the assessment has revealed that the Ministry of

Health does not have adequate capacity in core health information sciences, including epidemiology, demography, statistics, and ICT. Capacity of the Liberia Institute of Statistics and Geographic Information System on demography, statistics, ICT at national, county and districts was evaluated as not adequate. The HIS assessment has revealed that finances are present but not adequate. National HIS and LISGIS budget-line items are still limited and do not allow for adequate function of all relevant data sources.

1.4.6 Census

Liberia conducted its Population and Housing census in 2008 and published results are currently available. HIS

Assessment results revealed that the content of census data is highly adequate, meaning that mortality questions on estimating both child and adult mortality were included in the 2008 census. This is particularly important because the civil registration in the country covers less than 50% of deaths (2015 HIS Assessment). This means that at the moment there is no reliable and functional vital registration system. The only problem is that a post enumeration survey (PES) was never completed to assess the quality of the 2008 census data.

1.4.7 Vital Registration

The HIS assessment revealed that there is no national system in place to capture coverage of deaths registered through civil registration; and there is limited capacity to implement data collection, process the data, and analyze the data from civil registration or Demographic Surveillance System (DSS) at all levels. According to the 2015 Liberia

Health Assessment Report birth registration among under-5 children has increased to 25% in the last 5 years and death registration is still below 2% even though the Liberian Public Health Law of 1976 mandates the MOH to register all deaths within 24 hours after their occurrence. The ICD-10 classification is not used for cause of death registration. Demographic Surveillance System (DSS) sites have not been developed.

1.4.8 Resource Records

There is inadequate and inconsistent tracking of health system finances including program budgets and expenditures at the county levels; there is inadequate tracking of procured and distributed health system commodities including pharmaceuticals; the tracking system of health work force (HR database) has certain shortcomings:

It is not integrated with (linked to) FMIS

The private sector health providers are not systematically inventoried and tracked.

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Community health workers are not systematically inventoried and tracked.

1.4.9 Research studies

Research information can play an important role in ensuring support for health service delivery and health system strengthening. While the MOH has a Research Unit under the Bureau of Vital Statistics, it lacks institutionalization within the framework of the National HIS in Liberia: (1) no research policy nor strategy; (2) no research regulation nor legislation; (3) no research coordination between health programs and Academic institutions; and (4) weak human resource capacity for research.

1.4.10 Information Products, Risk Factors

The overall performance was poor (40 percent). It was noted that indicators for measuring risk factors are not collected on a regular basis in Liberia. It follows that the HIS may not have adequate high quality information regarding risk factors for health to be used for decision making.

1.4.11 Analysis, dissemination, and use of information

Implementation of data analysis and use of information is “present but not adequate”. Demand for data from managers is ad-hoc, usually as a result of external pressure and such demand does not follow a proper channel.

Regular meetings held with stakeholders to share information, review relevant activities and impact are mainly organized at central and county levels but very limited use of data for patient management at the facility level.

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2 LIBERIA HIS VISION, MISSION AND PRINCIPLES

The vision for a strong national health information system is a direct result of the National Health Plan (2011) and the Investment Plan for Building a Resilient Health System in Liberia (2015-2021). These foundational documents outline the need for a robust health information system capable of providing evidence for decision-making, monitor and evaluate programmatic functions, and assessing the health status of the population.

Understanding the internal relations and rationale driving the Health Information System is valuable to identify actions and roadmap toward a more efficient and functioning health system. Learning from others disciplines such as Enterprise Architecture (EA), developed over the last 20 years to guide planning, development and management of complex systems in all sectors can help in achieving such a task. The Enterprise Architecture is a comprehensive description of all the key elements and relationships that make up the Liberian health system.

Therefore, concomitant with the development of a HIS strategic plan, the Ministry of Health, with technical assistance of MEASURE Evaluation, developed a first outline of the Liberia HIS Enterprise Architecture (see Annex K). Combined with the vision of the National Investment Plan, this document outlines the mission and goals of the Liberian health information system between 2016 and 2021.

2.1 Vision statement

The Health System of Liberia is supported by a comprehensive and interoperable Health Information System, leading to improved health outcomes for individuals and communities in Liberia.

2.2 HIS Goal Statement

By 2021, the National Health Information System of Liberia will produce quality data and information used in support of the health system functions at all levels, with a solid governance and management structure, using appropriate information and communication technology, including data confidentiality and security, at an affordable cost to the

Government of Liberia. The five year goals for each subsystem as defined by technical subgroups are:

2.2.1 HIS Subsystems Goal Statements

HIS subsystems are defined as the major population-based or institutional information sources comprising the health information system. These subsystems include both paper-based and electronic systems to collect, manage, analyze, and use data; as well as the resources required to operate and maintain the system.

2.2.1.1 HMIS- Health Management Information System

Update the core indicators, and realign with the M&E needs of the country. HMIS will also retrain workers as part of the ongoing supportive supervision and monitoring, and extend utilization and data use of the web-platform to the district level, and the paper-based system to the facility level

2.2.1.2 CBIS- Community-Based Information System

Establish a community based information system in all counties to provide information for community level programs, assess the health status and service delivery in communities, and monitor and evaluate the community health worker and volunteer programs. Within 5 years, CBIS will be integrated into the DHIS2 platform and mHealth pilots will be piloted to improve training and data use.

2.2.1.3 HRIS- Human Resources Information System

Full utilization oh HRIS at all levels in tracking the recruitment and human resource allocation of all public and private sector health workers, including trainings, production, and interoperability between mHERO and FMIS.

2.2.1.4 DSIS- Disease Surveillance Information System

Develop a system which is able to detect, report, and manage the time-sensitive information needs of priority disease in the country. The system will also have a streamlined information flow from the entire country integrated within or interoperable with DHIS2

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2.2.1.5 LMIS- Logistics Management Information System

Routine tracking of supplies at the county, district, health facility and community level to inform resource allocation and procurement, and prevent the depletion of essential medicines and IPC commodities. The system would also be able to interoperate with the broader HIS.

2.2.1.6 LIS- Laboratory Information System

Develop a universal and functional laboratory information system at all major public health laboratories, which is fully interoperable with or integrated into DHIS2.

2.2.1.7 FMIS - Financial Management Information System

Strengthen and integrate financial information from all sources-donors, local authorities, user fees, etc. into the HIS and institutionalize National Health Accounts and other key sector monitoring tools such as Public Expenditure

Reviews, and Benefit Incidence Analysis.

2.2.1.8 Health Research

Strengthen capacity to conduct translational research on the health status of populations and public health conditions not captured by routine HIS systems.

2.3 Principles and Desired Characteristics (based on 2009 HIS policy)

2.2.2 Adherence to International Standards

This strategic plan endorses the adaptation of National HIS framework to attain the international standards set by the Health Metrics Network (HMN), the first global health partnership for developing and strengthening of health information systems in low and middle income countries (LMIC). HMN seeks to achieve standardization by adopting and adapting global health information standards that are aligned to broader efforts to improve the availability and quality of statistics

2.2.3 Equity, Quality and Social Justice

The strategic plan supports the establishment and maintenance of a simple, coherent, scientifically sound and easily understandable information system tracking the degree of achievement of the MOH objectives at all levels, taking into accounts the national values of universal coverage, equity, quality and social justice.

2.2.4 Accountability

The strategic plan recognizes the need to establish clear structures in support of the system and accountability for results by well trained and motivated personnel.

2.2.5 Communication

The strategic plan strives to build a system of effective communication, using appropriate technology and feedback and dissemination to all stakeholders.

2.2.6 Decentralization

Focus is shifted from data collection to transforming data into information for management. A holistic approach that seeks for a unified and decentralized HIS will be operated and only usable information will be collected.

2.2.7 Inclusiveness

Where practical, data will be disaggregated by gender, age groups, geographical areas and social income.

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3 STRATEGIES AND INTERVENTIONS FOR HIS STRENGTHENING,

2016–2021

3.1 Strategic Objectives and Benchmarks

Based on the deliberations of the stakeholders during the HIS strategic planning workshop, the following strategic objectives were identified. Short term benchmarks for each strategic objectives were developed. Monitoring and evaluation targets are listed in Section 3.9.

# Strategic Objective Target date

Benchmark

RESOURCES

1 To develop and disseminate adequate legislation, policies, regulations, and standard operating procedures in support of a functional

HIS at all levels of the health system.

2017 Updated legislation, policies, regulations, and SOPs available and disseminated to all stakeholders

2 To establish a functional national coordination mechanism for all relevant government institutions including financial and technical support agencies

2016 HMER Stakeholders Working group re-established and meeting on a regular basis

3 To ensure a dedicated budget for HIS implementation and operation at all levels.

2017 MOH budget includes HIS/ICT line item

4 To build HIS staff capacity to manage HIS functions and responsibilities including data collection, storage, management, analysis, research, use, and research

2017 90% of HIS targeted staff across all levels have been trained in data collection, storage, management, analysis, research and use

5 To establish appropriate ICT infrastructure at all levels including institutionalizing mHealth technologies

2018 All 15 counties meeting a 90% threshold in ICT readiness assessment.

(Baseline: 38%)

DATA SOURCES, AND INDICATORS

6 Develop, implement, and sustain basic functionality of LIS

2017 LIS requirements defined and electronic platform for LIS selected by end of Quarter one of 2016.

50% of targeted public health laboratories implementing a universal, functional and fully integrated web based eLIS

7 Develop implement and sustain basic functionality of DSIS

2017 All health facilities across all 15 Counties meeting the

100% threshold for early notification and response to priorities disease and public health events as per IDSR guideline.

8 Develop, implement, and sustain basic functionality of CBIS

2017 50% of targeted health facilities implementing an integrated community based Information system

(verifiable by CHIS reporting coverage)

All 15 Counties using integrated web based CBIS.

9 Expand HRIS functionality, indicators, and use at subnational levels

2017 iHRIS and mHero fully interoperable with other systems iHRIS data visualization and analytic capacity enhanced

10 Expand HMIS functionality, indicators, and use at subnational levels

2016 By end of 2016, eighteen (18) health district teams do data entry at district level using DHIS2

All District health teams have a dedicated HMIS personnel trained in HMIS processes and reporting.

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11 Develop, implement, and sustain basic functionality of LMIS

2016 LMIS requirements defined and electronic platform for

LMIS selected

12 Strengthen FMIS functionality, indicators, and use at subnational levels

2017 FMIS enhanced, rolled out and used at subnational levels

13 To develop HIS architecture and adopt an interoperability framework and standards interoperability and data sharing across and beyond HIS subsystems

2017 Validated HIS architecture and disseminated SOP (by end of 2017)

Pilot interoperability using existing reporting platforms of functional HIS subsystem ( DHIS2, eDEWS, CBIS, iHRIS, LIS, etc)

14 To establish a mechanism to ensure information security and confidentiality

2016 ICT strategy developed and disseminated to guide security and confidentiality

DATA QUALITY, MANAGEMENT, DISSEMINATION AND USE

15 To improve data quality, dissemination, and use of information in support of health services and health system functions at all levels

2017 Developed and implemented at all reporting levels, a comprehensive data quality assurance manual /SOP

HIS STRATEGIC PLAN MONITORING AND EVALUATION

16 To regularly monitor and evaluate the implementation targets of the HIS strategic plan

2017 Information products available timely and used for decision making

60% of HIS subsystems objective met as planned

17 To improve the governance, management, and coordination of health research and its translation to public health action

2017 Updated research guidelines on the processes and conduct of research for health in Liberia

3.2 Strategic Interventions

In the following pages, interventions for each of the strategic objectives are proposed for the duration of the strategic plan (July 2015 to June 2021). These interventions were put together by the participants of the strategic planning workshop, who worked in seven small groups.

HIS Sub-

Components HIS Strategic Objectives Proposed Strategic Interventions

Legislation, Policy

& Planning

SO1 To develop and disseminate adequate legislation, policies, regulations, and standard operating procedures in support of a functional HIS at all levels of the health system

1.1. Develop, implement, and disseminate SOPs and

policy guidelines for all HIS functions including health research, ICT infrastructure, and HIS subsystems

1.2. Establish mechanisms to ensure compliance

with legislation adopting International Health

Regulations.

1.3. Develop, strengthen and ensure compliance of

legislation on information sharing regarding health workforce, publishing of OFM financial statements, NHA reports, Aid tracking, and other relevant statistical data among public health sector, private sector and health insurance companies

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1.4. Review and update the current legislation like

the 1976 Public Health Law, National Public Health

Law, and data sharing policies to cover vital registration, notifiable diseases, private sector data, confidentiality and fundamental principles of official statistics, private health sector hea lth care providers etc.

1.5. Develop policy to enhance the implementation

of national standards, accreditation and quality assurance on research for health

Partnership &

Coordination

SO2 To establish a functional national coordination for all relevant government institutions including financial and technical support agencies

2.1. Establish coordination mechanisms between

MOH, line ministries, private sector, and other government agencies to improve coordination on data sharing and development of the broader HIS

2.2. Establish a HMER TWG and subgroups to

ensure participation of all subsystem and cross-cutting stakeholders and coordinate subsystem development, piloting, implementation, interoperability and evaluation

2.3. Develop and implement clear communications

policy within MOH, and for linking MOH with other organizations for data sharing and knowledge management

2.4. Establish research partnerships and

collaboration among research stakeholders to enhance the implementation of national standards, accreditation and quality assurance on research for health

HIS Institutions

Human Resource

& Financing

SO3 To ensure a dedicated budget for HIS implementation and operation at all levels

3.1. Advocate that budget line items are included

MOH, and County Budgets to cover HIS and ICT costs

3.2. Advocate for 2% of health budget to cover

health research financing

SO4 To build HIS staff capacity to manage HIS functions and responsibilities including data collection, storage, management, analysis, use; and health research

4.1. Strengthen the technical capacity of staff

involved in the HIS through in-service training in

ICT, including competencies in: use and maintenance, GIS, health informatics capacity building (training, coaching, mentoring) especially in the area of developing and maintaining technology for health information exchange

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4.2. Strengthen the technical capacity of all users of

HIS in MOH in basic competencies though in-service trainng on data management, analysis, use of information, ethics, GIS and the design and conduct of health research

4.3. Strengthen institutional capacities of pre-service

programs through curriculum development and resource mobilization for various research activities;

including epidemiology, biostatistics, HIS, laboratory system and software development

4.4. Recruit and train epidemiologists, biostatisticians, demographers, data clerks, database administrators, computer programmers, lab technicians to increase capacity of the HIS workforce

ICT Infrastructure

SO5 To establish appropriate ICT infrastructure at all levels including institutionalizing mHealth technologies

5.1. Procure critical ICT assets, including hardware

and software requirements, appropriate for operating the HIS subsystems

5.2. Develop an ICT strategy to guide…