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Health Management Information Systems (HMIS) using

ICT

Group 2:
Arul Murugan

1404001

Babu Venkatesh

1403003

Praveen R

1403019

Senthil Nathan Velu

1403024

Introduction
HMIS aims to consistently reduce the healthcare cost of institutions, country and private
companies trough an ICT based approach which involves the following stages in building a
robust health care system:

Increasing public expenditure on health

Reducing regional imbalance in health infrastructure

Pooling resources

Integration of organizational structures

Optimization of health manpower

Decentralization and District management of health programmers

Community participation and ownership of assets

Induction of management and financial personnel into District health systems

Operationalizing Community Health Centers into functional hospitals in each Block


across the country that meets international standards.

Deploying a HMIS increases the demand for data on population and health for use in both microlevel planning and programme implementation. At the same time, understanding the synergy
between availability of services, cost involved in provision of public health care. In response,
healthcare services expenditure and pattern of utilization among various sections of population,
including vulnerable sections of the society, are important aspects that influence decision
making. A continuous flow of good quality information on inputs, outputs and outcome
indicators facilitates monitoring of the objectives critical CSF of HMIS.
In the underdeveloped countries like Tanzania, Mali, Zambia and Uganda Health Management
Information Systems are being introduced in hospitals to assess health system performance
which is of high importance to the government, development agencies and multilateral
institutions. The international Institute for Communication and Development (IICD) has been
working with countries in Africa since 1998 by introducing Information Communication
Technology (ICT) to gather experiences and lessons learnt and identify challenges for
introducing and using information system (IS) in healthcare. During the same time in India due

to the telecommunication evolution HMIS was growing in a rapid phase. In this study we would
focus on the implementation of ICT in India and Tanzania in the health care sector.

Critical Success Factors for HMIS Implementation


Many CSF impact the implementation of healthcare service using ICT. Management\agencies
should focus on CSFs before any major implementation exercise is undertaken. The CSFs in
healthcare service falls under three major categories: User characteristics, System design
characteristics, organizational characteristics.

User
Characteristic
s

Cognitive
Style
Personali
ty
Demogra
phics
Situation
al
Variables
Attitude
Expectati
ons

System
Design
Characteris
tics

Hardw
are
and
softwa
re
perfor
mance
Learni
ng
Decisi
on
Makin
g
Suppo
rt
Ease
of use
Graphi
cal
user
interfa
ce

Organizationa
l
Characteristic
s

Organizat
ional
Structure
Hierarchy
of
Authority
Manage
ment
Support
Commitm
ent
Involvem
ent

Implementation Steps

User Characteristics

These are the study of people problems which should be extensively studied: example learning
style, behavior, user attitude. The recognition of the dysfunctional user behavior is a first step
toward successful implementation. User orientation, training, education, running awareness
programmes are some ways to minimize the behavioral problems.

System Design Characteristics


These characteristics play an important role in determining the HMIS acceptability: example
hardware software performance issues, user acceptance testing. For an HMIS to have a
seamless flow of data communication system requirements should be articulated during the
planning phase of HMIS. Some thoughts that should go into consideration of system design
characteristics are from nurses who interact with the patient and they would have historical
issues in the hospital management, incorporate favorable factors such as proper use of colours
and graphics to practice uniformity.

Organizational Characteristics
Organizational characteristics can also influence HMIS implementation success. Examples of
variables include organizational structure and power, organizational culture, and other
managerial factors, such as top management support, commitment, and involvement. Key
strategies to achieve successful HMIS implementation include a realistic situational assessment,
accurate identification of necessary resources, and development of an action plan. It is therefore
critical to encourage top management involvement in many areas, and there should be a disctrict
level authority, programme authorities, regional level authorities or another knowledgeable
senior member of the management team taking charge of HMIS implementation.

Data Sources & Data Flow

In the diagram shown above the straight lines represents upward flow of information and the
dotted lines represents downward flow of information (feedback report). Private facilities report
either at Block level or directly to the District Headquarter.

The levels of reporting in computerized HMIS can be Districts, Blocks, and Facilities. Each
level of reporting has its own benefits but it is always better to have facility-wise data entry and
reporting. Facility-wise data entry would help in:
Assessing performance of each facility with respect to other facilities in a District.
Identifying which facility has low or high coverage and this is very useful to identify
underserved population in a community.
Assessing how many facilities are reporting data on time (not possible in consolidated
reporting such as Block or District).
Probing further question related to data quality and services coverage: example - if a
District has reported full immunization=106%, facility-wise data helps in identification
of those facilities which have reported very high coverage and this can be due to
duplication or over reporting. Also, if the District has reported home deliveries=50%
facility-wise data will help find facilities that have highest burden of home delivery, so
that decisions can be made accordingly.
To ensure continuous and seamless data flow and reporting, these guidelines on data
reporting, entry and aggregation should be followed.

Data Reporting and Data Entry


As a team we have studied various HMIS models and we suggested to have facilities including
health sub-Centre (Hub and Spoke Model) which could report their data to Block in the format
prescribed for their facility. At the Block level, Block would consolidate these data to prepare the
Block Consolidated Report. Block Consolidated Report would be sent to the District
Programme Management Unit (DPMU). Then DPMU would consolidate all Block data and
include stock details of Districts to make the District Monthly Consolidated Report, which
would be then uploaded on Web Portal. If the State decides to have a functional State specific
HMIS application, facility-wise data could be entered at Block and at the District level. District
stock details would be entered in HMIS application at District level. Once data entry is complete,
Districts can generate District Monthly Consolidated Report to upload on Web Portal. Formats
required to generate a District Monthly Consolidated Report. The reports could be generated
quarterly, half yearly; the more frequent the data are reported the more approximate would be
precision of the data.

Information And Communication Technology (ICT) in HMIS


Globalisation is about the transformation of traditional systems, it is about innovations and
competition in a global market, at intensified pace, facilitated very significantly by or through the
use of Information and Communication Technologies (ICT). Effort to strengthen the HMIS in
developing countries goes back to only a decade ago. As a result of these efforts enormous
amount of data has been generated in many of these countries to the extent that in some of these
countries data has become a source of problem. This is because often managers are overwhelmed
with lots of data that they cannot analyse effectively and use it for decision-making. The
collection, compilation and analyses of data become an end rather than the means of improving
health care services.4 In addition, data produced continued to be of doubtful quality and
untimely, thus ending up being not adequately used for decision-making.5 This paper aims at
highlighting some of the opportunities and challenges offered by ICT in the strengthening HMIS
in the wake of globalisation.
Type of business\service Change in Indian
HMIS
Do New
Things
Degre
e Of
Explici
t-ness

Do Things
Better

Stop Doing
Things

Type of business\se
Do New Things

Do
Be

District HMIS
could intrun be
integrated with
the HMIS
operated by
WHO

Ro
an
sho
im
an
ne
tra
too
Be
ha
re
Be
en
im
ICT
all
to
go

Financial
Benefits

Quantifia
ble
Benefits

Measurab
le
Benefits

Rapid Real
time
monitoring of
HMIS
dashboards:
Could lead to
better handling
of inventory of
health care by
both private
organizations,
as well as by
government
agencies

Data
collected
from frontline
HMIS users
could be done
using PDA
devices: Field
data with very
accurate
metrics would
be available to
HMIS

Manual data
collection by
district HMIS
workers

New
application for
collating field
data: People
from rural
villages come to
district level care
centres to
attend to their
health needs
which could
capture and
mine the data to
give a
meaningful

information of
field data

Observab
le
Benefits

Usage of Cloud
computing for
duplex data
interaction
between the
application and
end HMIS users

Strategic Impact Grid India HMIS


Indian HMIS is a monopolistic service catered by Indian government through PPP, though the IT
strategic grid is done to understand the competitiveness of a companies IT strategy since HMIS
is a nationwide service offering the below mentioned grid shows the state of Indian HMIS which
was leaping towards improvement. The ICT based HMIS is currently in Support mode and is
moving towards Turnaround mode using the concept of functional IT.

Low to
high
need for
reliable
informat
ion
technolo
gy

Defensive
Factory Mode

Offensive
Strategic Mode

Support Mode

Turnaround Mode

* With the advent of mobile


technology Indian HMIS saw
enormous growth in the past 10
years
* As a overall ICT growth, there
were new internet kiosks, web
based reporting
* E-governance/Government
plans were introduced to widen
the scope of HMIS
*Parts of rural India are still not
have robust supply of electricity

Low to high need for new information technology

Strategic Impact Grid Tanzania HMIS


Compared to India; Tanzania lacked the very level of resources required to run an ICT based
HMIS across the country. Compared to India; Tanzania had high PPP to implement the
programme. The ICT based HMIS is currently in Support mode and is slowly moving towards
mode and is moving towards Turnaround mode using the concept of functional IT.

Defensive
Factory Mode

Offensive
Strategic Mode

Support Mode

Turnaround Mode

* Web based centralized


database system enhancing data
mining, telemedicine
Low to
high
need for
reliable
informat
ion
technolo
gy

*Open source applications were


initially used and then later on
moved to a more customized
suite for customized data
warehousing purposes

Low to high need for new information technology

ICT - HMIS in India

India has been witnessing ICT in HMIS since November 2009 were 543 million phone
subscribers (landline and mobile) in India, and the overall telephone density was 46 percent. The
growth in mobile phone ownership is also reflected in large-scale national and state-specific
health surveys. The increased penetration and use of ICTs presents unprecedented opportunities
to communicate with rural audiences, and may soon be the largest communication media in rural
India. . By November 2009, 57,599 rural internet kiosks (common service centers - CSC) were
established in India.

The development of an integrated, national web-based reporting system for the Ministry of
Health and Family Welfare (MoHFW), commonly referred as the NRHM HMIS, has been a
significant step in recent years. In order to make the NRHM HMIS a single point of reference for
all health-related information, the system is being expanded to include sub-district level
information, and integrated with an advanced Geographical Information System (GIS) and other
national health programs. Data collection by frontline health workers have demonstrated faster
data transfer and communication though the use of ICTs. Some ICT projects also report better
data quality as compared to paper-based data collection systems. In all the projects reviewed, the
pace of data transfer was directly associated with the quality of service delivery monitoring in
realtime for supervision and follow-up with field workers. For example, Rapid SMS, an SMS

based data collection tool that uses any mobile phone, was used for supply chain management in
were field reports and alerts could be sent through SMS to a web portal, thus reducing the time
taken for reporting and allowing for quicker response from the management.
The review identified projects that used ICTs to collect beneficiary data in rural communities in
India including the Community Accessible and Sustainable Health System (Ca:Sh) project being
implemented in Ballabhgarh; the mCARE project being pilot tested with healthworkers at 120
sub-centers in Tirur (Kerala); the Beneficiary Tracking System (BTS) being implemented in 206
sub-centers in Gujarat; and the Catholic Relief Services program on maternal and neo-natal
health monitoring being implemented in UP. Results show that in the Ca:SH project the use of
mobile devices resulted in greater accuracy in data collection, a reduction in data entry time for
ANMs and use of data. Community feedback is relevant for both public and private sector health
service providers, but is particularly important for the provision of public sector services as these
are largely outside the monitoring influence of market forces. A review of projects in India shows
that with the rapid growth of telephones (landlines and mobiles) and the internet, ICTs have the
potential to develop an effective community feedback system. For example, Lokvani, an egovernance initiative in Sitapur district, UP, was launched in 2004 by the district administration
and the National Informatics Centre.
Lokvani has a website in Hindi and includes an online public grievance redressal service. As part
of the project, existing computer training institutes and cyber cafes have been designated as
Lokvani centers. As of June 2008, 115 Lokvani kiosks were operational in Sitapur district.
According to project documents, in June 2008 a total of 117,179 complaints were registered on
the Lokvani website, of which 97 % were addressed. Among the services provided through the
internet kiosks that are part of this initiative, online public grievance redressal services emerged
as the most popular. Another example is the Jhansi Jan Suvidha Kendra (JJSK); through these
centers, citizens can approach the concerned government officials and register their grievances
using a mobile phone (including SMS), landline phone or the internet. This free-of-cost service is
easily accessible for registering complaints, ensures the effective tracking of complaints through
follow-up with concerned officers and intimates citizens of the status of their complaints. As of
January 2010, a total 7,379
grievances were registered with JJSK, of which 7,007 (95 %) were attended. The provision of
diagnosis and treatment support through ICTs, including telemedicine, has been accepted by

doctors and has resulted in increased efficiency in diagnosis. In some cases, telemedicine has
been shown to be cost-effective among populations with poor access to health care. In rural UP,
Tamil Nadu and Madhya Pradesh, pilot projects provide telemedicine-based health services at the
village level.
The key challenges in this application is the need to have a dedicated pool of qualified health
practitioners who provide advice based on information received through a telemedicine center,
the possibility of misuse of potential applications such as portable ultrasonography by frontline
health workers, and operating the technology under conditions with erratic supply of electricity.
Technology in telemedicine includes sophisticated and highly priced equipment such as
satellites, video-conferencing and medical devices. However, the emergence of mobile networks
and retrofitting digital data capturing interfaced to simple diagnostic tools like a hematogram
analyzer, pulse and blood pressure unit, digital camera and weighing machine can provide data
for early diagnosis for a large number beneficiaries. Frontline health workers and trained
medical practitioners use various job-aids, flow-charts and checklists to adhere to protocols
during counseling, diagnosis and treatment provision. ICTs automate job-aids, flow-charts and
checklists using algorithms, known as decision support systems (DSS). DSS projects have shown
improved counseling, increased adherence to protocols, diagnosis and treatment provision among
frontline health workers and trained medical practitioners. These were found to have an indirect
effect on BCC strategies by providing managers with data for informed decision-making and
improving the productivity of frontline health workers, as well as the quality and timeliness of
their interaction.

Education and skill development of health care


providers/frontline health workers
Intervention studies reveal that e-learning, including m-learning, is effective in imparting
knowledge and skills. E-learning was found to be as effective as classroom learning in some
studies. Further, e-learning is consistently associated with increased motivation, independent
learning and control over learning and recall, particularly when supplemented with direct or
classroom interaction. Successful e-learning initiatives in low resource settings indicate that

e-learning can be used to train frontline health workers at Primary Health Care Centres (PHCs) \
Community Health Care Centres (CHCs) on fixed days and at fixed times. This approach could
also be used to train village health committee members.
As some PHCs\CHCs are located in remote villages hands-on training needs to be provided:
example - If the system crashes, a redundancy needs to be in place to access the data seamlessly
to restore recent backup of data from the central database. A system crash may affect the entire
reporting process if it is not rectified immediately which makes the importance for training the
field staff. Also, staff should be trained in the software application and the usabilitys.

Changing the behavior of end-users


The review identified two types of communication for end-users using SMS, telephony and the
web or email in terms of how they were designed: single interaction systems or multiple
interaction systems between the sender and each receiver. For rural and low literacy audiences,
voice calls and voice SMS have been piloted and found to be successful. Single interaction
systems: Bulk SMS services where the same message is sent to many recipients enrolled with a
provider is an example of a single interaction system. Various web-based yellow pages, customer
care services and helplines send such SMS to their subscribers. Project reports reviewed suggest
that such a system is effective in increasing awareness on a topic or issue, addressing the specific
queries of individuals interested in undertaking an action, usually regarding the location of a
service delivery point (referral) and as a reminder. In this context, in January 2010, the
Mangalore Deputy Commissioner announced a scheme for the mobile operator BSNL, by which
all its customers would be sent an SMS two days prior to the polio immunization day.

Multiple interaction systems


This system requires the beneficiaries enroll to receive ongoing messages from a service
provider and interact with this system by providing information pertaining to their health status
or behavior, asking questions and getting answers. Messages sent to recipients are customized,
based on the input they provide, and the system supports the
recipient through the behavior change process. This system has an extensive body of evidence
showing its effectiveness in improving health status, behavior modification and increased
adherence. Reviews show that behaviors related to smoking cessation, weight management,

physical activity, HIV/AIDS prevention, adherence to medication (including tuberculosis),


diabetes management and asthma management have been modified. For example, in a
andomized controlled trial, the effectiveness of SMS and multimedia message services (MMS)
for weight loss among overweight adults was evaluated. Participants in the intervention group
received customized SMS and MMS messages, 2-5 times a day, printed materials and brief
monthly phone calls from a health counselor. SMS were generated automatically from a database
using predetermined algorithms and user profiles participants plans and actions. Responses to
these questions were used to customize future SMS.
BabyCenter is an interactive network targeting pregnant and newly-delivered mothers. It
provides personalized, stage-based email and SMS messages (tied to gestation / babys age)
addressing a wide range of topics relevant to pregnant women and new mothers. In India, the
website had 3.5 million users in December 2009 and received 2,000 discussion posts a day. The
site provides expert-vetted content and parent-to-parent advice. BabyCenter India has launched a
phone-based platform, combining daily SMS messages and pre-recorded voice content, accessed
through an Interactive Voice Response system. Users receive customized emails from pregnancy
till the child is 3 years of age. Messages focus on maternal and child health issues such as
nutrition, iron folic acid tablets and danger signs during pregnancy. The BabyCenter seeks to
adapt this platform in the long term to reach a significant proportion of the Indian market,
including rural, low literacy women, poorly trained frontline health workers, and consumers
seeking reliable information on health.

ICT - HMIS in Tanzania

Since independence in 1964 Tanzania has struggled to improve its health services. During the
late 70s the service level in health was relatively high. Economic problems and structural
adjustment devastated the health sector, causing falling numbers of health workers, decrease of
available materials, and a breakdown of the referral system. Also the rural- urban inequality
increased sharply. The ICT (Information Communication Technology) structure in Tanzania was
developed to a level where it is realistic to computerize some of the routine processes in hospitals
to support management in dealing with these issues. The Tanzanian government decided to
implement a HMIS to supply each level of the health sector with the necessary information in a
timely and accurate manner. Provision of support to sector performance monitoring system was
identified as a priority for health development. An array of information sub systems already
existed to generate a set of input, output, outcome, and process indicators for gauging key
sectoral performance and contribution to development. Included in this are the health
Management Information Systems (HMIS), Demographic Surveillance Systems (DSS) and
Health Systems Research under the MoHSW (Ministry of Health and Social Welfare), the
Demographic and Health Surveys (DHS), Population Census and Housing and the Household
Surveys are coordinated by the National Bureau of Statistics (NBS) in collaboration with the
MoHSW. Robhust
ICT programme in Tanzania required resources, including training and skill upgrading needs,
will be a more natural part of the planning process. Contrary to India which is a developing
country with booming scale of ICT, most of the health facilities in Tanzania are located in remote
areas where there is inadequate access to reliable electricity, telephone lines and poor
infrastructures as a whole. This has contributed to major problems in the provision of health
services to the population.
All the village health posts are staffed by village health workers primarily providing first aid
services. Dispensaries provide basic curative and Maternal and Child Health (MCH) care. They
are usually headed by a rural medical aide who is responsible for curative services, and who is
supported by a MCH aide and other less trained nursing staff, that is, staff with less training than
nurses and/or without formal training for health care services. In addition to the basic curative

and maternal and child services, health centers offer inpatient and obstetric services. They are
physically large institutions than dispensaries and are served by a large staffing complement. The
health facilities collect data, which are then collected and aggregated at the district level where
the reports for the particular district are being generated. This is being done manually, that is,
using paper-based forms. Data from the districts are sent to the regional level, where the reports
for a particular region are being generated and sent to the national level. At the regional levels
reports generation is being done using a computer system. The HMIS includes all data collected
at all the health units in all levels.

The before implementing the ICT based HMIS the manual way of collecting data has led to
various weaknesses in HMIS systems which are as follows:

Data quality and accuracy are not sufficiently assured through simple validation or
verification procedures.

Information is generally not sufficiently used for local decision-making.

Data presentation, analysis, and feedback are generally very weak.

Late reporting of health information from one level to another.

HMIS-related activities result in higher workloads, especially for health staff at the
dispensary and health center level where data are being collected.

I n 2005, as a result of the Round Table District Health Management system (D-HMIS) was set
up in 2006. The specific objectives of the D-HMIS using ICT was to:

Train HMIS users in 14 hospitals


Raising awareness to other stakeholders and government personnel
Capacity building for project headquarters
Installing internet connectivity at the regional and district offices
Exchange date and improve the performance

Software package and modules


In 1997 the already prevailing DOS based HMIS system was decided to be enhanced further by
MoHSW. The Project was first initiated in six hospitals, but only one continued to use it after a
few years. This experience showed that there is interest, because people indicated it helped them
in their work and they have since asked for a better version of the system. But it also clearly
showed the problems that inhibit the effective use of such a system. Most problems related to:

The integration of ICT in the workflow, processes and responsibilities


The robustness, effectiveness and user friendliness of the system
The computer skills of the hospital staff
The technical support structure

The project team compared many alternatives which were either too expensive, of poor quality
or without affordable long term support. After a careful review of available solutions with a

broad collection of stakeholders from amongst others the Ministry of Health and the University
of Dar es Salaam Computer Centre (UCC), Evangelical Lutheran Church in Tanzania (ELCT)
decided to develop a generic Tanzanian version of Care2X, an open source HMIS that is used in
several countries over the world. ELCT programmers cooperated with UCC, COSTECH and a
German software company to adapt the software to the government health registration system
Mfumo wa Taarifa za Huduma za Afya (MTUHA) , and to specific hospital requirements.
Drafting of requirements was done with hospital managers. Experiences and lessons learned
from the hospitals were continuously translated into requirements for further development of the
Care2X software which took two years.
Care2X a client/server software, which is scalable from a single computer to a big hospital
network. It is modular and health facilities can choose which modules they need or are able to
use. Modules used in this project are patient registration, billing, laboratory, pharmacy, radiology,
diagnosis and treatment, appointments, in-patient, outpatient, eye-clinic and nursing.

Strengthening the MOHSW HMIS unit and building the


integrated district and national data warehouses
The software teams main tasks are to develop the national and district data warehouses and to
customize DHIS and additional software tools as according to the needs of the MOHSW,
Furthermore, to integrate the data warehouse with other data sources by extracting the needed
data. GIS functionality will be developed as part of the collaboration with WHO on the HMIS
project. The software team will work with, and be part of, the global network of DHIS
developers and work closely with the WHO and HMN on the developing of appropriate Open
Source tools. Capacity building MOHSW; data management, DHIS data warehouse and open
source technologies

Capacity building MOHSW; data management, DHIS data


warehouse and open source technologies
Capacity will be developed in the MOHSW through the activities of the software team
described above but also through the building of a solid base for managing the overall
HMIS. All staff in the HMIS and ICT units will be part of this effort. As the building of the
National data warehouse and the National HMIS will take place in the HMIS unit, capacity
building will be part of every step of the process. In order to achieve capacity development in the
MOHSW, the project needs to recruit additional regular MOHSW staff, train existing staff,
allocate skilled project staff to the HIR section and engage them fully in the development of
the system and its rollout. Training of regional and zonal HMIS staff will also be part of this
effort. Both Topdown and bottom up approach were used for capacity building and application
work packages (WP). Integration with other computer based application such as Electronic
Patient Record systems in hospitals and other facilities was handled through a standardized data
interchange platform. This, of course, was depending on the use of open standards also by other
computer applications, which will be ensured through the strategic planning process. and other
computerised data sources; establishing web-based data warehouse, electronic reporting etc.
The basic principle underlying the various software applications involved in this work package is
that first a first customised, stable and useful application is implemented, and thereafter it is

continuously further developed and integrated with the patient record systems such as the
Care2X, OpenHealth and other systems in place.

Capacity building scheme was carried out in stages; starting with the regional and national
levels, and about 3 months later, also with the district level staff in the test region(s) The first
objective and stage for this work package is to establish a training program for the training
of trainers; regional and national staff.
Three staff from each region, including the HMIS focal person, totaling 63, and about 12
from national and zonal level, totaling about 75. Four training sessions of 2 weeks was
conducted over 2 years. The topics of the training will address HMIS and management,
analysis and use of information for health management and health services delivery.
Assignments were given to the staffs to be completed between the training sessions which
included the use HMIS and other information for situation analysis, planning and target setting,
as well as the organisation of data use workshops at district and regional (i.e. for all districts in
the region) levels. The training was conducted using the zonal training centres where appropriate.

The second objective is to devolve an adapted part of this training program to the district level,
starting in the test region(s). Three times one week training over about 1.5-2 years will be carried
out at the regional level for 3-4 staff from each district. With about 25 persons per training
session, some regions may be combined. The training included the same issues as for the
regional staff, but with an additional emphasis on facility supervision and the training of facility
level staff. Assignments to be completed between training sessions will include, as for the
regional level staff; use HMIS and other information for situation analysis, planning and target
setting, as well as the organisation of data use workshops at district level for district and facility
staff. Regional level staff would be responsible for conducting the training, but with support
from national level, in particular during the first session. The third objective was to devolve the
training scheme to the facility level. The test region(s) would be used to develop cost effective
methods to train facility level staff (data use workshops may be the primary methodology, linked
to supervision an additional one). Details will be developed later. For long term HMIS
sustainability, an HMIS module will be designed and integrated into pre-service training. In
addition, a diploma in Health Informatics programme will be established for HMIS cadre. The
training materials were prepared as a joint effort between MOHSW, Ifakara, UDSM and
University of Oslo.

Conclusion
Increasing penetration of computer and information communication technology to the lower
level is of primary importance if poor countries are to bridge the internal digital divide in their
countries. Participation of the private sector has been of crucial importance in the establishment,
investment and development of ICT when compared to other stakeholders. With the current
economic situation the private sector will continue to play major role in the efforts to spread ICT
technology. But currently, most investors shy away from investing in rural areas due to
unfavorable conditions such as low purchasing power and high investment costs in areas with
lack or erratic supply of electricity and shortage of telephone lines. ICT revolution will continue
to ignore and marginalize poor countries and its people. The profit motive in the private sector
cannot work unless deliberate efforts are taken to create conducive environment for investing
through the establishment of favorable Government policies and infrastructure. There is therefore
a need for poor countries to exercise strong commitment and political will to bring

in favorable conditions for investment in the rural areas by encouraging the development of low
cost access technologies that address the need of the rural majority by reducing taxation for
solar-power equipment that can be used to run computers in remote areas where there is no
electricity an through various other schemes. Certainly in countries like India and Tanzania were
larger sector of population are still left out without electricity and telecommunication; the future
for HMIS looks bright as technology becomes affordable to all class of general public.