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Overview of the HISP Network
Angola
South Africa
Mozambique
India
Malawi
Norway
Tanzania
Cuba
Mongolia
Dominican Republic
Ethiopia
Ghana
Zambia
Nigeria
District Health Information Systems
MED-INF 5200April 2007
Topic 2: The health district and the district health system
Humberto Muquingue
Learning outcomes
• Provide a standardized definition of health district and district health system
• Explain the advantages presented by the concept of health district, with emphasis on information and the roles of the District Health Management Team (DHMT)
• Describe the tasks performed in a health district setting
• Explore the adequate characteristics of a health district
• Justify the current focus on district health systems
What is a health district ?
...It is the point of the national health system where people can get comprehensive health care
...It is a clearly defined geographical/administrative area
...It is the implementation spot for primary health care (Alma Ata, 1978)
...It is the optimal operation unit for the identification of the excluded from health care and for the implementation of health improving strategies (Harare, 1987)
HEALTH CARE LEVEL
HEALTH CARE LEVEL
PRIMARYPRIMARY
SECONDARYSECONDARY
OTHER SECTORS:-Environment-Civil Administration-Transport-Education
OTHER SECTORS:-Environment-Civil Administration-Transport-Education
Routine Health Information System
Routine Health Information System
Community LevelCommunity Level
TERTIARYTERTIARY
Patient/Client
contact
Patient/Client
contact
Referred patientsReferred patients
First level care unit
First level care unit
District HospitalDistrict Hospital
Referred patientsReferred patients
Regional HospitalRegional Hospital
Regional Health
Management Team
Regional Health
Management Team
Referred patientsReferred patients
National Hospital
University Hospital
National Hospital
University Hospital
Ministry of Health
Universities Other Health Institutions
Ministry of Health
Universities Other Health Institutions
INDIVIDUAL CARE
MANANAGEMENT
INDIVIDUAL CARE
MANANAGEMENT
HEALTH UNIT MANAGEMEE
T
HEALTH UNIT MANAGEMEE
T
SYSTEM MANAGEMEN
T
SYSTEM MANAGEMEN
T
DISTRICT LEVEL
DISTRICT LEVEL
REGIONAL LEVEL
REGIONAL LEVEL
NATIONAL LEVEL
NATIONAL LEVEL
HEALTH CARE SERVICESHEALTH CARE SERVICES
HEALTH SERVICES SYSTEMHEALTH SERVICES SYSTEM
HEALTH SYSTEMHEALTH SYSTEMN
ON
-RO
UTIN
E D
ATA
C
OLLEC
TIO
N M
ETH
OD
SN
ON
-RO
UTIN
E D
ATA
C
OLLEC
TIO
N M
ETH
OD
S
CATCHMENT AREA POPULATIONCATCHMENT AREA POPULATION
District Health
Management Team
District Health
Management Team
What are the characteristics of a health district ?
Population between 30,000 and 500,000 (most cases)
Clearly delineated geographical area
Identifiable form of local government
Managed by few officers
Balance between population size and availablity of technical specialised staff
What advantages presents the health district ? 1/2
...It is the most appropriate level for coordinating top-down and bottom-up planning
...It is close enough to the community to understand and act on its problems and constraints
...It has easier communication with the community to ensure its participation in planning and organization
What advantages presents the health district ? 2/2
...It presents large potential for effective collaboration with other sectors towards the health of the community
...It has the ability to handle decentralisation of resources and of decision-making
...It is the most suitable place to provide support to health workers in the health posts and health centres
What are the tasks of the health district ? 1/2
...Implementation of all community based health programmes
...Supervision and control of all community health workers in the district
...Organization and operation of district hospital services
...Management of all other public health facilities
...Coordination and supervision of all public, non-government and private health systems
What are the tasks of the health district ? 2/2
...Promotion of active links with local government entities
...Promotion of community participation in the local health service planning
...Preparation of annual health plan
...Raising additional local funds
...In-service training of health workers
...Collection, compilation and dissemination of routine health information
What is the experience of districts in your country ?
Exercise 1: YOU are asked to (individually):
- Fill up a table characterising your “district” in the country you originally came from. Please indicate, local name for “district”, geographic size, population, population density, approx ratios health professionals/inhabitant.
- Shortly describe your experience of living in a health district (their functions, responsibilities, involvement, etc) in your respective countries.
The PHC Approach
• …is a conceptual model for health care planning and health systems development
1. respect the needs and lifestyles of the target population,
2. be an integral part of the national health system,
3. include other health related sectors,
4. involve the communities in planning, decision making and realization,
5. rely on local resources and be cost-effective,
6. integrate and coordinate preventive, curative, rehabilitative and promotive measures,
7. take place near the targeted level.
Primary Health Care (PHC) should (Alma-Ata, 1978)....
Why size matters ?
....greater number of health districts, then...
more management structures and systems
cohesion and co-ordination more difficult at a national or provincial level
it will cost more and fail to capture economies of scale
If the health districts are too small...1/2
district hospitals will be managed as separate entities from the rest of primary level health care
could create a further dislocation between primary level services and district hospital services (many health districts without a district hospital)
If the health districts are too small...2/2
district-level management can become unwieldy and bureaucratic
the DHS loses its “service delivery" functions
The DHS becomes too remote from the community.
If the health districts are too large...
Community involvement
Comprehensive services
Population size
Geographic size
The required balance
Technical autonomy
...more or less self-contained segment of the national health system
...it comprises first and foremost a well-defined population
...within a clearly delineated administrative and geographical area
...it includes all the relevant health care activities in the area, whether governmental or otherwise.
What is a DHS ? (WHO, 1987) 1/3
What is a DHS? (WHO, 1987) 2/3
...it will be most effective if coordinated by an appropriately trained health officer ...to ensure as comprehensive a range as possible of promotive, preventive, curative and rehabilitative health activities
...ideally contains a network of primary health units and a district hospital for referral of cases
What is a DHS ? (WHO, 1987) 3/3
...it is the point and level at which different health service activities are integrated into a comprehensive and holistic approach to health care
...it is able to accept the transfer of responsibility, resources, authority and seniority from central levels of management to the periphery
... too much emphasis on curative services
... little attention to preventive and promotive areas
... weak assessment of the health status of the population
... data gathering is low priority, unreliable and routinely performed, it strongly affects the information circulation in the health system
... frail coordination with other sectors: water, sanitation, agriculture, housing, roads and transportation
... lack of skills
... growing pressure for health reform and decentralisation
Why the focus on DHS ? 1/3
...the many responsibilities of the district health team
...the need to carefully allocate the scarce resources
...the necessity of sound health management
obvious need for adequate information BUT
Why the focus on DHS ? 2/3
the main constraint for implementing the primary health care approach in practically all countries:
...inadequate information for the managerial processes !
The district information system has yet to make available...
• ... the right information and the right knowledge
• ... to the right persons and institutions
• ... in the right form
• ... at the right time
• ... in the right place
Why the focus on DHS ? 3/3
The DHS can only be a functioning entity if the following assumptions are met.
The implications of a DHS 1/3
DHS is a means to an end, rather than an end in itself
... the "means" to achieve the "end" of an equitable, efficient and effective health system based on the principles of the Primary Health Care (PHC) approach
DHS is more than just a structure or form of organisation
...it is also the manifestation of a set of activities:
community involvement, integrated and holistic health care delivery, inter-sectoral collaboration and a strong "bottom-up" approach to planning, policy development and management
The implications of a DHS 2/3
the PHC approach and the DHS model apply to the whole of the health system and at all levels of health care delivery
... the health district and its management structure should be the core building block of the entire heath system,
... DHS should be the underlying framework for the organisation of health care as a whole
the essence of the DHS is the organisation of health care according to geographic sub-divisions of a country which are managed through a decentralised management structure
The implications of a DHS 3/3
the theory of the DHS is straightforward
...but its implementation is much more complex
...there are different interpretations of what is adequate:
size
roles and relationship
Health district - local government
National - provincial - district levels
District hospital
Theory vs practice
Health District versus District Health System
• Health District
= geographical/administrative area
• District Health System
= a segment of the national health system with a complex set of actors interacting in a health district
David McCoy, Beth Engelbrecht, Establishing the district health system, in Health Systems Trust (eds) South African Health Review 1999
Additional Literature
WHO (1987). "Eighth General Programme of Work Covering the Period 1990-1995". "Health for All" Series 10. Geneva: World Health Organization
Uwe Washer (1991) Construction of an Adapted Health Information System, http://www.wahser.de/uwe/DIPLOM/dip12.htm
WHO (1988) The challenge of implementation: district health systems for primary health care, WHO/SHS/88.1/rev.1
