The utility and effectiveness of routine health information systems (RHIS) in improving health system performance in developing countries has been questioned. This paper argues that the health system needs internal mechanisms to develop performance targets, track progress, and create and manage knowledge for continuous improvement. Based on documented RHIS weaknesses, we have developed the Performance of Routine Information System Management (PRISM) framework, an innovative approach to design, strengthen and evaluate RHIS. The PRISM framework offers a paradigm shift by putting emphasis on RHIS performance and incorporating the organizational, technical and behavioural determinants of performance. By describing causal pathways of these determinants, the PRISM framework encourages and guides the development of interventions for strengthening or reforming RHIS. Furthermore, it conceptualizes and proposes a methodology for measuring the impact of RHIS on health system performance. Ultimately, the PRISM framework, in spite of its challenges and competing paradigms, proposes a new agenda for building and sustaining information systems, for the promotion of an information culture, and for encouraging accountability in health systems.

Evidence to support that antenatal screenings and interventions are effective in reducing maternal mortality has been scanty and studies have presented contradictory findings. In addition, antenatal care utilization is poorly characterized in studies. As an exposure under investigation, antenatal care should be well defined. However, measures typically only account for the frequency and timing of visits and not for care content. We introduce a new measure for antenatal care utilization, comprised of 20 input components covering care content and visit frequency. Weights for each component reflect its relative importance to better maternal and child health, and were derived from a survey of international researchers. This composite measure for antenatal care utilization was studied in a probability sample of 300 low to middle income women who had given birth within the last three years in Varanasi, Uttar Pradesh, India. Results showed that demarcating women's antenatal care status based on a simple indicator--two or more visits versus less--masked a large amount of variation in care received. Logistic regression analyses were conducted to examine the effect of antenatal care utilization on the likelihood of using safe delivery care, a factor known to decrease maternal mortality. After controlling for relevant socio-demographic and maternity history factors, women with a relatively high level of care (at the 75th percentile of the score) had an estimated odds of using trained assistance at delivery that was almost four times higher than women with a low level of care (at the 25th percentile of the score) (OR = 3.97, 95% CI = 1.96, 8.10). Similar results were obtained for women delivering in a health facility versus at home. This strong positive association between level of care obtained during pregnancy and the use of safe delivery care may help explain why antenatal care could also be associated with reduced maternal mortality.

BackgroundSound policy, resource allocation and day-to-day management decisions in the health sector require timely information from routine health information systems (RHIS). In most low- and middle-income countries, the RHIS is viewed as being inadequate in providing quality data and continuous information that can be used to help improve health system performance. In addition, there is limited evidence on the effectiveness of RHIS strengthening interventions in improving data quality and use. The purpose of this study is to evaluate the usefulness of the newly developed Performance of Routine Information System Management (PRISM) framework, which consists of a conceptual framework and associated data collection and analysis tools to assess, design, strengthen and evaluate RHIS. The specific objectives of the study are: a) to assess the reliability and validity of the PRISM instruments and b) to assess the validity of the PRISM conceptual framework.MethodsFacility- and worker-level data were collected from 110 health care facilities in twelve districts in Uganda in 2004 and 2007 using records reviews, structured interviews and self-administered questionnaires. The analysis procedures include Cronbach's alpha to assess internal consistency of selected instruments, test-retest analysis to assess the reliability and sensitivity of the instruments, and bivariate and multivariate statistical techniques to assess validity of the PRISM instruments and conceptual framework.ResultsCronbach's alpha analysis suggests high reliability (0.7 or greater) for the indices measuring a promotion of a culture of information, RHIS tasks self-efficacy and motivation. The study results also suggest that a promotion of a culture of information influences RHIS tasks self-efficacy, RHIS tasks competence and motivation, and that self-efficacy and the presence of RHIS staff have a direct influence on the use of RHIS information, a key aspect of RHIS performance.ConclusionsThe study results provide some empirical support for the reliability and validity of the PRISM instruments and the validity of the PRISM conceptual framework, suggesting that the PRISM approach can be effectively used by RHIS policy makers and practitioners to assess the RHIS and evaluate RHIS strengthening interventions. However, additional studies with larger sample sizes are needed to further investigate the value of the PRISM instruments in exploring the linkages between RHIS data quality and use, and health systems performance.

Substantial progress has been made to strengthen health information systems, with most efforts focusing on digitization, improving data quality and analysis, and identifying problems. But the ultimate goal is using information to solve problems, which requires building an information use culture over time. How? Human-centered design, role modeling by senior managers in use of data, and incentive-based systems hold considerable promise.

No abstract