Routine health management information system data in Ethiopia: consistency, trends, and challenges

Figures & data

Table 1. Thematic groups, selected indicators and data elements for analysis and source documents used in this study

Thematic group	Indicator or data element analysed	Source documents for analysis of indicator or data element
Maternal Health	First antenatal care visit Four antenatal care visits Skilled birth attendance Postnatal care	HMIS 2014–2018^b EDHS 2016
Neonatal Survival	Early neonatal death at community Early institutional neonatal death rate Total number of births in the same kebele	HMIS 2014–2018^a; EDHS 2016; Mini-EDHS 2019
Immunization	Pentavalent vaccine third dose Measles Fully immunized	HMIS 2014–2018^a; EDHS 2016; HCMIS 2014–2018^a
Child Nutrition	Vitamin A supplementation Deworming Severe acute malnutrition Growth monitoring promotion	HMIS 2012–2016^b; EDHS 2016
Malaria	Suspected malaria Positive malaria All malaria	HMIS 2014–2018^a; HCMIS 2014–2018^a; World Malaria Report (WHO) 2015–2018
Tuberculosis	New and relapse tuberculosis Treated tuberculosis	HMIS 2014–2018^a; HCMIS 2014–2018^a

^a2014–2018 is Gregorian calendar 8 July 2014 to 7 July 2018 = Ethiopian Fiscal Year 2007–2010

^b2012–2016 is Gregorian calendar 8 July 2012 to 7 July 2016 = Ethiopian Fiscal Year 2005–2008

EDHS = Ethiopian Demographic and Health Survey

HCMIS = Health Commodity Management Information System

HMIS = Health Management Information System

Kebele = the lowest administrative unit in Ethiopia, around 5000 persons

Penta = vaccine against Diphtheria, Tetanus, Pertussis, Hepatitis B, and Haemophilus Influenzae

WHO = World Health Organization

Table 2. Definitions of indicators and data elements in the routine Health Management Information System (HMIS) and the corresponding indicators in the Ethiopian Demographic and Health Survey (EDHS) 2016. HMIS indicator definitions from the Ministry of Health HMIS Indicators Reference Guide

Indicator used in this study	Definition of the numerator in the HMIS	Definition of the denominator in HMIS	Corresponding indicator in the EDHS 2016 All survey data in relation to relevant population estimates
Antenatal care 1	Number of pregnant women who received antenatal care first visit during the current pregnancy	Total number of expected pregnancies	First antenatal care visit
Antenatal care 4	Number of pregnant women that received four or more antenatal care visits	Total number of expected pregnancies	Four antenatal care visits
Skilled birth attendance	Number of births attended by skilled^a health personnel at a health facility^a	Total number of expected deliveries	Proportion of women with deliveries five years prior to survey receiving assistance^a during delivery Place of delivery^a is a separate indicator
Postnatal care	Number of women who received postnatal care at least once within two days of delivery	Total number of expected deliveries	Proportion of women with deliveries two years prior to survey receiving postnatal care within two days
Early neonatal death at community	Number of deaths in the first week (day 0–6) of life^b	Total number of live births^b in the same kebele	Neonatal mortality rate: the number of deaths in the first month of life^b regardless of place of death, for the five-year period preceding the survey
Early institutional neonatal death rate	Number of institutional neonatal deaths in the first week (day 0–6)^b of life	Total number of live births attended by skilled health attendants at health centers, clinics and hospitals	Not applicable (see neonatal mortality rate above)
Total births in the kebele^b	Not applicable	The data element Total number of births in the same kebele^b is the denominator in the indicator Early neonatal death in community above	Fertility rate for the 3-year period preceding the study.
Penta 3^c	Number of children below one year of age who have received the third dose of pentavalent vaccine	Estimated number of surviving^c infants	Coverage of third does of pentavalent vaccine “by appropriate age” (12 months)
Measles	Number of children under one year of age who have received the first dose of measles vaccine	Estimated number of surviving^c infants	Coverage of measles vaccination “by appropriate age” (12 months)
Fully immunized	Number of children who have received all routine vaccinations^c before their first birthday	Estimated number of surviving^c infants	Coverage of fully vaccinated children “all basic vaccinations”^c “by appropriate age”^c
Vitamin A Supplementation	Total number of children aged 6–59 months who received two doses of vitamin A supplementation	Estimated number of children aged 6–59 months	Proportion of children 6–59 months who received Vitamin A once in the preceding 6 months
Deworming	Total number of children aged 24–59 months dewormed twice per year	Estimated number of children aged 24–59 months	Proportion of children 6^d −59 months who received deworming once in the preceding six months
Severe acute malnutrition	Coverage^d of screening for severe acute malnutrition using mid-upper arm circumference or weight for height and number of children below five years of age classified to have severe acute malnutrition	Total number of children 0–60 months	Proportion of children with weight for height <-3 SD in the survey
Growth monitoring promotion	Number of children under two years of age weighed during growth monitoring promotion session	Estimated children under two years	None
Suspected malaria	Not an indicator in HMIS^e	Not an indicator in HMIS^e	None^e
Positive malaria	The data element Number of slides or RDTs positive for malaria is the numerator in the indicator Malaria positivity rate	Not applicable	None^e
All malaria	The data element All malaria is the numerator in the indicator Morbidity attributed to malaria	Not applicable^e	None^e
New and relapse tuberculosis^f	The data element Number of new and relapse cases is the numerator in the indicator Tuberculosis case detection rate	Not applicable^f	None^f
Treated tuberculosis^f	Not applicable^f	The data element Treated tuberculosis cases is the denominator of the indicator Treatment success of TB patients who received community-based treatment support	None^f

EDHS = Ethiopian Demographic and Health Survey

HMIS = Health Management Information System

Penta = vaccine against Diphtheria, Tetanus, Pertussis, Hepatitis B, and Haemophilus Influenzae

^aIn the HMIS, a skilled attendant is defined as a health professional (such as a midwife, nurse, health officer or doctor) who has been trained in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period. HMIS also requires that the delivery takes place at a facility. HMIS does not include health extension workers (HEW) or traditional birth attendants (TBA) among skilled attendants. In the EDHS, a skilled attendant is defined as a doctor, nurse, midwife, health officer, or HEW. It does not include TBA.

^bEarly neonatal death at community (ECND) and early institutional neonatal death rate (EIND) are reported separately so that ECND and EIND together make up the total early neonatal death. There is no indicator for deaths in day 0–28 in HMIS. In the EDHS, the deaths within day 0–6 can be disaggregated from the total neonatal deaths in day 0–28. Births are registered in another system, the Vital events registration, by the local administration in the kebele (lowest administrative level) that collects data on births and deaths from health facilities and community. The total number of births in the same kebele is the denominator of ECND.

^cHMIS considers a child as having full immunization coverage if he or she received the following vaccines that are in the current Expanded Program of Immunization in Ethiopia: BCG (tuberculosis), 3 doses of Penta, 3 doses of oral polio-vaccine, 3 doses of PCV-vaccine (pneumococcal conjugate), 2 doses of rota-vaccine, 1 dose of IPV-vaccine (inactivated polio vaccine) and 1 dose of measles-vaccine before the age of 1 year. In the EDHS, ‘all basic vaccinations’ is defined as one dose of BCG, three doses of Penta, three doses of polio vaccine and one dose of measles vaccine, whereas ‘all age-appropriate vaccinations’ also include the newer vaccinations: 3 doses of PCV and 2 doses of rota, but not IPV. The denominator ‘estimated number of surviving infants’ refers to the population estimate and is used for denominators as stated in the table (MOH, personal communication). In contrast, the guideline states that the denominator ‘total number of surviving infants’, meaning infants who survive to their first birthday, to be used for measles and fully immunized, but not for Penta 3 where the estimated number of infants is in the guideline.

^dIn EDHS, the reported deworming among children 6–24 months for the younger ages may represent treatments rather than prophylaxis. In HMIS, the indicator severe acute malnutrition (SAM) is the proportion of children screened for SAM (coverage) and findings are further classified into prevalence of SAM, using the definitions Middle Upper Arm Circumference (MUAC) <11 cm or weight for height <70% of the median, or <-3 Z score (used in health centers and hospitals) and/or bilateral pitting edema (used in all health facilities). The growth monitoring promotion (GMP) is a preventive activity that includes measuring, analyzing and counseling on nutrition and is therefore not the same as the SAM-screening.

^eThe ORCA malaria group studied the suspected, confirmed, and all malaria (=”total malaria”) as reported in the HMIS-framework. These measurements are data elements and ‘All malaria’ is the numerator of the corresponding burden-of-disease HMIS-indicator ‘Morbidity attributed to malaria’, and the estimated total population is the denominator. ‘All malaria’ is ‘positive malaria’ with the addition of ‘Clinical diagnosis of malaria’ (=presumed treatment) (Supplementary Figure S1). In the EDHS, only the use of anti-malarial drugs is surveyed.

^fThe ORCA tuberculosis group studied the new and relapse cases and treated cases of tuberculosis as reported in the HMIS (Supplementary Figure S2). Number of new and relapse cases is the numerator of ‘Tuberculosis case detection rate’ where the annual WHO-estimate is the denominator. The treated tuberculosis is the denominator of the indicator ‘Treatment success of TB patients who received community-based treatment’ which aims at determining the proportion of all forms of new TB cases successfully treated (cured plus completed treatment) among those who received treatment adherence support at community for at least full course of the continuation phase treatment. Tuberculosis is not investigated in the EDHS.

Table 3a. Total number of women coming for postnatal care within two days of birth by region and month in the routine Health Management Information System, July 2017-June 2018. Internal consistency. Outliers within 2–3 standard definitions from the mean value per region or city administration are underlined and extreme outlier >3 standard deviation from the mean shown in bold

	Month
Area	1	2	3	4	5	6	7	8	9	10	11	12
Addis Ababa (city)	7931	8593	7968	7831	6634	7885	7574	7751	8200	8067	10,476	9411
Afar region	2035	2166	2257	2412	2352	2366	2090	2417	2122	2220	1986	2025
Amhara region	41,038	46,691	43,515	43,274	45,177	46,155	47,399	46,338	45,133	44,393	49,375	40,134
Benishangul-Gumuz region	2658	2584	2737	2713	2591	3040	3069	2185	2190	2426	2235	1886
Dire Dawa (city)	765	854	847	819	664	1887	858	969	1153	833	887	816
Gambela region	376	339	493	453	440	378	363	412	330	301	448	408
Harari region	371	368	367	417	511	420	450	664	352	463	598	526
Oromia region	86,731	91,638	87,213	86,251	81,345	82,934	73,409	81,902	82,561	78,682	79,480	80,085
Somali region	8725	7388	7158	7225	6769	9793	9780	9005	9350	5511	6191	5518
SNNP region	44,133	48,510	-	-	0	48,117	48,501	50,728	50,710	52,918	54,677	50,198
Tigray region	9532	10,455	10,853	10,928	10,357	11,849	11,581	10,884	11,205	11,050	11,644	10,377

- No value

SNNP = Southern Nations, Nationalities, and Peoples

Table 3b. Total number of early neonatal death at community by region and month in the routine Health Management Information System, July 2014-June 2015. Internal consistency. Outliers within 2–3 standard definitions from the mean value per region or city administration are underlined

	Month
Area	1	2	3	4	5	6	7	8	9	10	11	12
Addis Ababa (city)	-	-	-	-	-	-	-	-	-	-	-	-
Afar region	2	0	0	2	5	2	4	3	4	0	1	0
Amhara region	8	4	34	19	10	13	14	17	10	13	8	42
Benishangul-Gumuz region	3	1	16	6	5	4	5	6	20	1	11	25
Dire Dawa (city)	0	0	0	0	0	0	0	0	0	0	0	0
Gambela region	0	0	0	6	0	1	0	0	0	1	0	3
Harari region	0	0	0	0	0	0	0	0	0	0	0	1
Oromia region	58	43	44	82	22	59	28	21	14	28	16	24
Somali region	-	-	-	0	-	-	0	0	0	1	0	0
SNNP region	1041	43	1701	2008	20	9	160	13	17	24	145	4
Tigray region	19	5	8	3	5	8	7	4	7	5	5	2

- No value

SNNP = Southern Nations, Nationalities, and Peoples

Figure 1. Number of regions and city administrations (n = 11) with internal consistency over time per routine Health Management Information System indicator or data element (n = 19)

Kebele = lowest administrative level

Figure 2. Number of routine Health Management Information System indicators (n = 19) that showed internal consistency over time per region or city administration (n = 11)

SNNP = Southern Nations, Nationalities, and Peoples

Figure 3. External consistency comparing the routine Health Management Information System (HMIS) data 2014/15 or 2015/16 (Ethiopian fiscal year 2007 or 2008) with the Ethiopian Demographic and Health Survey (EDHS) 2016 for (a) coverage of four antenatal care visits, (b) coverage of vaccinations against measles, (c) fully vaccinated 1-year old children and, (d) coverage of deworming of children