An Overview of the District Health Information System Software (DHISv1.3)[1]

An open source, user friendly, flexiblefreeware named district health information systems software (DHIS) has been developed by HISP for use in a public health MIS.It has been continuously adapted for field conditions by participatory effort between health care and software professionals in several developing countries since 1994. This has resulted in the DHIS software addressing vital issues such as user friendliness, data accuracy, adaptation to local language (Kannada,Telugu, Hindi,etc) and design and use ofindicators based on local need. This software allows data to be transmitted to other users, both horizontally at PHC, tehsil or district levelsor vertically up the hierarchy. Keeping in mind the dynamic nature of health care management, the software has been designed to be extremely flexible to address changing needs at the field level over time and space. Besidesserving as a tool for gathering, transmitting and storing data, DHIS is designed especially to address data analysis and hencethe use of health information.

DHIS is a flexible, open source, free software developed for public healthmanagement information systems by the international HISP group. DHIS was initially piloted in1994. Since then, DHIShas been piloted in South Africa, Mozambique, Tanzania, Malwai, Ethiopia, Vietnam, India, etc. DHIS has been accepted for national roll outby the government of South Africa in the year2000. In India, DHIS has been piloted in Chittoor district in Andhra Pradesh from 2001 to 2004. HISP has now entered into a MOU with the government of Andhra Pradesh to implement a HMIS in two districts using DHIS integrating it with the existing name basedFHIMS software of the government of AP.A HISP pilot project was also implemented in Kanakapura taluk in Karnataka state during2003-04. Kerala state has evinced interest in HISP and negotiations are on to implement a HMIS using DHIS in three districts in Kerala based on the HISP model.

DHIS software is developed by theinternationalHISP team in accordance with the principles of“Free and Open Source Software” philosophy, and is therefore freely available to anyone who wishes to use it, as long as it is not abused for commercial purposes. Open software may be freely probed, customised and modified. This is the cheapest way of generating software suited to the needs of a state. Wherever the software has been used,any one with programming skills who wishes to make changes is encouraged to do so. All such developers are in turn encouraged to share their improvements as Open Source.

DHIS supportsfunctions of accurate and valid data collection, aggregation, storing, sharing, transmission, analysis, reporting, displayand use of health dataat andbetweenevery level of a district health system from sub centre to district and at the state level. It allows drilling down or aggregation of data at any and every level of the health system such as sub center, PHC, taluka, district and state.

DATA ENTRY

The software allows sub centres, primary health centres, taluk and district health offices and hospitals such as taluk hospitals and community health centres administered by the district health officer, state health departments,to enter data and generate reportsrelating to their services if they have access to a computer. Thesoftware can be customized for entry of both hospital and primary health care data.If computers are made available on site, at primary health centre level, the health data can be entered directly at that level.Alternatively, as is usually the case,if computers are available only at higher levels of administration, data entry from all organizational levelscan be done at the taluka or district levels.

Fig 1: Screen showing data entry and maximum minimum ranges for each data element. The ranges can be entered either manuallybased on experienceor generated by the program based on earlier data.

DATA ACCURACY

Considering that the data entered can often be inaccurate, a number of validation checks have been built in to the software to ensure data accuracy. At the simplest level this involves setting maximum and minimum limits for data entry. More complexvalidation rules such as ‘number of still births cannot exceed number of total births’ can also be built into the software to support accurate data entry.

Fig 2: Screen shot of pop up screen appearing when data is entered outside the range giving 3 options,’add comment’, ’correct entry’, ’modify min max’. This supports data accuracy.

Fig 3: Screen Shot of Validation rule definition. Absolute rules apply when one value cannot be higher than another. Expert rules are more flexible and are designed to ensure that the ratios between data elements are not transgressed. Example above shows an expert rule. Similar rules can be designed and built in to be applied after completing routine data entry. These rules support data accuracy.

DATA TRANSMISSION

Data can be transmitted (imported and exported)through floppies, CDsore-mail to other horizontal or vertical organizational levels for report generation.When data is sent (exported) to the next level, the system allows users to choose only suchdata elements and indicators that need to be exported.Thus the principle of the information pyramid(where not all information is needed or relevant to all levels) can be applied by the software. If at any time, organizational facilities such as sub centres or PHCsor added or deleted, these can be included or excluded from the exports so that data integrity at higher levels of aggregation is maintained.

Fig 4: Information pyramid

This in essence means that all data aggregation, analysis,comparison and report generation requirements at everylevel between the sub centre and the district can be handledby the computer once data is entered sub centre wise at the PHC.

FLEXIBILITY AND ADAPTABILITY

Keeping in mind the dynamic and evolving nature of a health information system, the system allows users at every level to adapt the system for their needs. Therefore, in addition to data entry, the system allows trained usersto ‘add new facilities’ (organizational units such as subcentres and PHCs), ‘define and add new data elements and indicators’, ‘define and add new validation rules’ and ‘set maximum and minimum limits for data entry’as and when new needs arise.

Fig 5:Flexibility andAdaptability:Screen shot of ’Insert new data element’. Redundant data elements can also be deleted.

Fig 6: Flexibility and adaptability:Screen shot of ’define or edit indicators’-allows new indicators to be inserted, redundant indicators to be deleted or altered.

FEEDBACKAND DISPLAY

Another principle is that the user should be given feedback on all the data that is entered into the system.Towards this end, the system allows users to generate reports. Reports can be customizedto user needs. This means that the reports can betailored to include specific data elements or indicators from sources such as routine monthly data or surveydata at any desired organizationallevel.In addition to existing reports based on the mandatory reporting requirements of the district health care system, new reports based on requirements for taluka and district monthly meetings can be produced by analysis of data that is already entered into the system by pivot table generation in excel. Pivot tables generation is a tool that allows data to be presented in different ways.If computers are available only at higher organizational levels, hard (paper) copies of reports can be sent back to different facilities.

Fig 7: Feedback and display: screen shot of Excel pivot table showing monthly routine data.

Attractive and informative graphs and charts can also be drawn and printed for the feedback reports.

Fig 8: Screen shot of Excel pivot tables showing chart and graph of BCG Measles drop out rates

GEOGRAPHIC INFORMATION SYSTEMS (GIS)

Definitions of different indicators can be built into the software. Indicators can also be interfaced with the free ArcExplorer software that allows data to be presented as thematic maps or analysed further in Geographical Information System software.

SEMI PERMANENT DATA

In addition to routine monthly and quarterly data, DHIS also supports collection and analysis of semi permanent datasuch as population estimates either from the census or from the field, equipment, infrastructure, staff position, etc., and survey data. This supports functions like calculation of population based indicators, equipment management and personnel management. Somedata onlyneed to be collected annually or six monthly and can be updated as and when changes occur.

Figure 10: Screen shot of ’semi permanent data elements’. This stores survey data, poulation data, etc, data which need not be updated monthly.

LOCAL LANGUAGE SUPPORT

Local language support is also built into the software. This is based onthe premise thatthe information system must contain data relevant to the smallest organizational unit in order to use the system to evaluate the services. Use of local language is common at the smallest organizational unit level. By using a multi language package, the DHIS software interfacecan be completely displayed in Hindi. The data elements can also be entered in Hindi.

The potential to adapt the software furtheris vast. For example,the south African team which is in a more advanced stage of development and implementation, is also working on further developing information systems related to the HIVpandemic particularly PMTCT, interfacinghealth information systems to financial systems, physical infrastructure such as water and sanitation, standard of living such as poverty and welfare and disease mapping and analysis.

DIAGRAMATIC REPRESENTATION OF DHIS OVERVIEW

Annexure-2: SystemsConfiguration Required

Configuration for State and District levels

  1. Intel Pentium 4, 2.8 GHz with H.T
  2. Intel Original 865 GBF Mother Board with AGP, SATA (Mother Board with 6 USB ports, 6PCI Slots)
  3. 80 GB Capacity Samsung SATA Hard Disk
  4. 1 GB, 400MHz speed Hynix RAM DDR
  5. Internal Modem
  6. 52x CD-Writer
  7. Floppy Drive
  8. Mercury Clevo Cabinet with Blower
  9. 17¨Colour Monitor
  10. Optical Mouse
  11. Multimedia Keyboard
  12. UPS
  13. Windows XP professional with MS Office 2000
  14. A3/A4 printer

Configuration for CHC and BPHC levels

  1. Intel Pentium 4/Celeron, 2.4 GHz with H.T
  2. Intel Original 865 GBF Mother Board with AGP, SATA (Mother Board with 6 USB ports, 6PCI Slots)
  3. 40 GB Capacity Samsung SATA Hard Disk
  4. 256, 400MHz speed Hynix RAM DDR
  5. Internal Modem
  6. 52x CD-Writer
  7. Floppy Drive
  8. Mercury Clevo Cabinet with Blower
  9. 15¨Colour Monitor
  10. Optical Mouse
  11. Multimedia Keyboard
  12. UPS
  13. Windows XP professional with MS Office 2000
  14. A3/A4 printer

Note:

  1. 52 x CD writer and MSOffice 2000 are currently not included in the specifications for procurement. These may kindly be included.CD writer is necessary for electronic transmission of data in case internet connectivity fails. DHIS software sits on MS Access which comes asa part of MS Office package.
  1. To ensure continuous operation of the hardware, earthing and wiring at the siteshould be checked and if necessary, redone before installationof the hardware. Sufficient budget should be provided for replacement of consumables such as printing paper and cartridges and for payment of telephone bills. Maintenance contracts should be entered into for the hardware.

[1] This overview has been edited and adapted. It originates from India (author unknown) and was part of a proposal for project funding. V.Shaw September 2005