I was appointed by Jørn Braa to adapt DHIS to the needs of the Tigray region. In this endeavor I was part of a team with four members. The members were; Solomon, Hirut, Netsanet and myself. All the members of the team except me were Ethiopian nationals. In this section I will give an account of our doings in this region.
I came to Ethiopia on Tuesday 6th of July 2004. I came with a open mid, you could say, because I didn’t have a very clear idea of what I was supposed to do in Ethiopia. I knew that I was supposed to work with a health statistical system called DHIS, and that I was assigned to a region in Ethiopia called Tigray. At the airport I met Solomon Bishaw, which was the leader of the Tigray team. The other members of the team, Hirut and Netsanet I met later on.
During my first month in Ethiopia we did not do much. Solomon had already been to Mekelle twice before I came. Mekelle is the regional capital of Tigray in which the administrative authority of the health sector in Tigray is situated, the Tigray Health Bureau. He had some sparse contact with the head of the bureau, Theodros, after the first visits, and the agreement was that we should come to start the process of adapting DHIS to the needs of Tigray. Solomon prepared a document on what we were planing to do in Tigray, which he sendt by e-mail.
I, for my part, spend the first month on adjusting my self to Ethiopia on many different levels. I lived in unfamiliar surroundings and in a way I was like a child again and had to learn basic skills from the ground. I will tell more about this in section number 8.7. As I did not know the DHIS software well, I used this month to learn this software better. Most of my time, however, was spent on familiarising myself with the new surrounding. Everything took time, from buying food to get a visa for the whole four months I was going to stay there.
On Monday the 26th of August we arrived in Mekelle by air. The day after we went to the regional health bureau. We had some previous contact by e-mail and we expected them to be aware of our arrival, but when we came to the bureau there was a sense of confusion. There seemed to me that there had been some shortcoming in the preparation for our visit. The bureau head was not present and there didn’t seem to be anybody there that knew about our initiative.
We had four subject we wanted to discuss with the bureau.
There were a lot of asking around. First we visited a team leader in the Health Management Information Systems (HMIS) unit. Most of the discussions were held in Amharic because we decided that it would be better if the bureau staff could express themselves in a language familiar to them. I don’t speak Amharic, so something might have been lost in translation, but from what I could understand from the translation Netsanet gave to me, he was skeptic of our initiative. He said he did not have authority to decide on what we asked for.
Therefore we were lead to an other office, were we met the head of the Evaluation and Surveillance unit. We discussed our plans with him and the team leader in HMIS. They expressed concern about the coming of the Ethiopian new year. They had to finish the yearly report for Tigray, and were therefore rather busy. They thought that it would be better if we came back in September. We had limited time in Ethiopia and could not agree to that. They said that they had been working on a minimal data set which they had sent to the federal authorities for approval. In September the data set would be available. It was decided that we could collect data from their existing computer based health statistical system (See section 8.3). So we spent the rest of the day collecting data from different departments.
From our visit to the different departments we understood that there was a lot of double reporting. Many of the departments in the bureau had its own reports they expected the district to fill inn. The same data was reported multiple times to different departments. There was already at this time a sense of distrust between the Decease Prevention and Control department (DPC) and HMIS. The DPC used exclusively their own reports.
It was later decided that we could visit two districts, or as they call them in Ethiopia; weredas. The two districts were Wukro and Hintalo-Wajirat. On the Thursday 29th of July the others on the team went to Hintalo-Wajirat. I stayed behind that day because I had an acing stomach. From what the others told I understood that there was some use of information in the district. They made a list of the ten most common deceases and bought in medicines accordingly.
The next day we traveled to Wukro. This time I felt well enough to come along. We found a mini-buss going to Wukro. The road there had recently been paved and parts of it was still under construction. The construction was done by a Chines firm. According to Solomon there was just a mud road there the last time he was there. It seems that at least some progress are being made in Ethiopia.
After an hour we came to the district health administration. The administrations facilities were good according to Ethiopian standard. We met the head of the administration. The conversation where conducted in Amharic, which left me out. I will give some main points to the conversation as translated to me.
He claimed to be interested in using information for the administration of the districts health sector. The tour he gave us at the administrations facilities confirmed this. We saw a lot of hand made charts and tables. They had made the charts and tables based on raw data and indicators. This show that you don’t need computers to manage information. Computers, however, makes it easier (with the right software) to make meaningful information out of raw data, and give better protection against errors in the raw data.
They had some computers at the administration, but they were not used much, except that they used Epi-info to type in information about out-patients. They had one man hired as a computer clerk, but the head was not very pleased with him. The computer clerk had some training in Epi-info, but he found it difficult to use. He also had some beginners training in Java. The next time we came to Wukro, over one month later, I gave him Eclipse and a Sun JDK. We visited the man responsible for the malaria office. He showed us the different reports that the clinics, community workers and hospitals had to fill inn. A community worker are responsible for a variety of tasks in a geographical unit like a village. They are not health workers, but register information about malaria.
After lunch we went to visit the district hospital. There we met the computer clerk from the administration. He introduced us to a lady who was responsible for data collection at the hospital. She had no education for the work, but she had work experience. The data collection at the hospital was exclusively paper based. The lady had a computer installed in her office a couple of weeks back, but she had not started using it. She had no computer experience and the computer only contained Epi-info, which requires computer knowledge beyond the “point and click” level.
The next week I struggled a lot with my stomach and eventually had to go to a clinic to get subscription for some antibiotics. This effectively hindered me to do much work that week. On Monday we spoke to the team leader in HIMS again. He expressed even more of his skepticism. He thought that we, as students, were only interested in our paper and that our initiative would not be sustainable. He didn’t want to help us. The next day the others on my team got to speak to the head of the planning department, as I laid in bead with fever. The head of the planning department was much more positive to our initiative. We made an agreement to demonstrate DHIS for the bureau.
On Thursday I felt well enough to participate in the negotiation with the bureau. This day we finally had a chance with speak to the head of the bureau. He sowed himself to be very courteous, and spoke good English. Because of this we held the meeting in English. We explained what DHIS is and the philosophy behind HISP. He mentioned many of the problems we had noticed. There was a lack of coordination between the departments. Because of this the information flow was like spaghetti. DPC department mistrusted HMIS for managing information. He mentioned that the bureau had a big reporting burden. They had to fill inn many forms for both the federal authorities and NGOs. He mentioned a need for a minimal dataset at the federal level, but he didn’t expect that a minimal dataset would be agreed upon for quite some time. He asked us for a milestone plan for our initiative.
The time after our meeting with the bureau head was hectic. We got some problems importing data from epi-info. We decided to convert the datafile format used in epi-info into the format used by DHIS’s import/export system. Both are purely text based formats. Solomon used MS Access for this purpose, but didn’t manage to import the resulting datafile into DHIS. I, on the other hand, made a python script to automate the conversion. At first I didn’t mange to import the file, but when I changed the separation character (the character used to separate columns in the import file) from comma to semicolon it worked. There was an issue with the localisation setting in MS Windows. Different locales use different separation character and this influenced MS Access.
The plan was to present our system on Friday next week. Solomon worked on the milestone plan that the bureau head requested and on the presentation. Hirut typed in the organisational hierarchy for the regional level and for the two districts we planned to use as pilot sites. I worked on importing data and making a presentation of the software. Before Friday Solomon got news about Sundeep Sahay being in Ethiopia. Sundeep is a professor at the University of Oslo and have long experience from HISP in India. He could not come to Mekelle before Saturday. Therefore we asked the bureau to postpone the presentation until Monday next week. Sundeep was a great asset in editing the milestone plan and for the presentation we held at the bureau. It gave our initiative more credibility to have an experienced professor compared to only three master students and a PhD student.
At Monday 16th of August we gave a presentation of HISP for the bureau. The meeting was held at the bureau head’s office. There were many people there. The head had obviously called many leaders at different level in the bureau to the meeting. First Sundeep presented HISP with examples from India. Then I demonstrated the functionality of DHIS, based on the data we had imported from epi-info. Solomon closed our presentation by presenting our milestone plan.
After our presentation there were a lot of questions. One question related to whether DHIS had support for capturing community data, not just data about people visiting health facilities. Sundeep answered that DHIS was not well suited for that kind of application. DHIS is designed for the primary health sector, with clinics, health centers and hospitals etc. There were also some questions about how DHIS did data validation, to answer this I demonstrated some data validation support in DHIS.
Two days later the answer to our proposal came. They had approved it. A team was set from members of the bureau to decide on data elements and report formats. The mandate of the team was to make a proposal on the data elements and reports to be included in DHIS. This proposal was then submitted to a group consisting of leaders from different departments who finally approved the data elements and report formats. Hirut and Netsanet agreed to be our representative during this process. Solomon went back to Addis Ababa because he was soon to go to England for some lectures there. The next week I went back to Addis Ababa too.
I spent a little over one month in Addis Ababa. This time was an important time for me personally, I met a lot of interesting people. In connection with the HISP project we had one tasks; adapt DHIS to support the data elements and reports the bureau team decided on. In other words we could now start the coding related task of the project. Hirut and Netsanet came back to Addis Ababa a little less than two weeks later. They had the data elements and the report formats with them. The details of this work is described in section 8.4.
The 2nd of October Hirut, Netsanet and I came back to Mekelle. This time we had Kalkedan with us. Kalkedan was hired by the HISP Ethiopia project to take care of the work in Tigray after we left. Kalkedan’s responsibility would be to give support for DHIS to the health bureau. Kalkedan had some basic computer education from Mekelle University, where he had learned C++ and some VBA and the MS Office suite.
Our plan for this visit was to install the software and conduct training at the bureau and our two pilot districts. As mentioned in section 8.4 the report formats given us by the bureau was not well suited to be used in a computer based system like DHIS. Therefor one of my tasks was to go to the different departments in the bureau to get a better understanding of what they wanted their reports to contain.
The first week we conducted training at the bureau. The first couple of days we talked to different leaders at the bureau, among others the new bureau head. The former head had become a State Minister of Health. The former head of the planning department had stepped into his place. We also discussed with the head of HMIS on how to conduct the training. Because we were only able to make the extended version of DHIS made by Woinshet to run with the XP version of MS Access there were some issues. The bureau had MS Office 2000 as a standard and was reluctant to install MS Office XP. For training purposes we agreed to install MS Office XP and DHIS on three computers.
The next week Kalkedan and I stayed at the bureau to finish the training while Hirut and Netsanet conducted training in the pilot districts. They first spent the Monday and Tuesday in Hintalo-Wajirat and then the Wednesday in Wukro. Kalkedan and I continued the training until Wednesday at the bureau, and at the same time we talked to people at the bureau about report formats. We finished the training at the bureau with a test that was well received. My goal with the test was not to test what the individual clerk knew, but to let them in cooperation use a broad range of important functionality offered by DHIS. It tested data input and validation, import/export, making reports and doing data analysis.
Because Hirut and Netsanet left Mekelle after Wednesday, Kalkedan and I had to finish the training in Wukro. So on Thursday we drove to Wukro, this time the bureau had given us a car and a driver. That day there was only one man that participated in the training. It was the computer clerk I met last time we were in Wukro. We used a modified version of the test we gave at the bureau. The computer clerk expressed approval for DHIS, especially that data input was done through one interface. Unlike the current system with Epi-info and multiple paper based reports.
All the training material we used at the bureau I had to make myself. I tried to find some training material on the Internet without avail. During the training sessions at the bureau the trainees where divided into groups of two to three people, each group had access to one computer with DHIS installed. At the first day of the training I planned to use a projector to demonstrate the basic use cases. The HMIS unit head said that they preferred to experiment with the software themselves, so that is what we did. The groups tried to perform the basic use cases while we answered questions and guided them when necessary.
The next week Kalkedan and I continued the work on the reports. In connection with this I showed Kalkedan how to make reports, so he could design report for the bureau when I had left. Our visits to the different departments reveled some tension between the departments. I didn’t obtain enough knowledge about the inner workings of the bureau to say anything for certain about the reason for the tension. The leader of the Decease prevention and control (DPC) department said that effort had been made to unify the reporting, but without success. DPC did plainly not trust HMIS for information. DPC thought HMIS used too long time to process the report from the districts. DPC have reason to want information quick in order to detect decease outbreaks. They had a number of weekly reports. DPC had need for weekly surveillance data while DHIS version 1.3 was designed for monthly/quarterly routine data.
After I had finished almost all the reports I was presented with a pile of new reports. This reports were recently approved for use in Tigray. I had only a couple of days left in Tigray so I left the work to include this in DHIS to Kalkedan. On Saturday 23th of October I left for Addis Ababa. After a week in Addis Ababa doing nothing of relevance for the project I took an aeroplane back to Norway.