Health information, research, evidence and knowledge
Data are crucial in improving health. The ultimate objective of collecting data is to inform health programme planning as well as policy-making and, ultimately, global health outcomes and equity. A well-functioning health information system empowers decision-makers to manage and lead more effectively by providing useful evidence at the lowest possible cost.
A health information system has been aptly described as "an integrated effort to collect, process, report and use health information and knowledge to influence policy-making, programme action and research". It consists of:
- inputs (resources)
- processes (selection of indicators and data sources; data collection and management)
- outputs (information products and information dissemination and use).
The role of a health information system is to generate, analyse and disseminate sound data for public health decision-making in a timely manner. Data have no value in themselves. The ultimate objective of a health information system is to inform action in the health sector. Performance of such a system should therefore be measured not only on the basis of the quality of the data produced, but also on evidence of the continued use of these data for improving health systems' operations and health status.
The availability and use of information enables:
- improved definition of a population
- recognition of problems
- setting of priorities in the research agenda
- identification of effective and efficient interventions
- determination of potential impact (prediction)
- planning and resource allocation
- monitoring of performance or progress
- evaluation of outcomes after interventions
- continuity in medical and health care
- healthy behaviour in individuals and groups.
It also empowers citizens by enabling their participation in health care, policy and decision processes; and empowers countries and international partners by enabling better transparency and accountability through use of objective and verifiable processes.
Health knowledge gaps are where essential answers on how to improve the health of the people in Lesotho are missing. This is an issue related to the acquisition or generation of health information and research evidence. The “know-do gap” is the failure to apply all existing knowledge to improve people’s health. This is related to the issue of sharing and translation of health information, research evidence, or knowledge. Although there are major structural constraints, the key to narrowing the knowledge gap and sustaining health and development gains is a long-term commitment to strengthen national health information systems.
This section on Health information, research, evidence and knowledge is structured as follows:
Evidence shows that access to the right information at the right time can often be the difference between life and death. UNICEF’s James Grant estimated that getting medical and health knowledge to those who need it and applying it, could have prevented 34 million deaths each year in the 1980s. This is because information is power.
With a vision to have a health information a system that will be comprehensive, efficient and effective in supporting the health sector and other relevant stakeholders in the delivery of health services by the year 2015, Swaziland has had a Health Information System (HIS) since 1978, and this HIS was initially based at the Central Statistical Office (CSO). From 1979 onwards, health information was collected, stored and analysed at the Ministry of Health (MOH). The process was then decentralized to the regional level in 1981. In 1985 the system was expanded to include specific components such as in-patient activity, out-patient activity, notification of selected communicable diseases and facility based information. Since then, a number of changes and improvements have been made towards realising a functional effective HIS that will provide timely and quality information to policy makers, planners, programme managers, service providers and the general public.
Health information in Swaziland includes information on population growth, births, marriages, mortality and morbidity, disease outbreaks, determinants of health (such as nutrition, environment, and socioeconomic status), access, coverage and quality of services, costs and expenditures, and equity. Various tools and data collection methods are available including vital registration and census systems, surveys (household, facility and regional), routine facility-based data collection systems, disease surveillance and research.
Major highlights include the development of the Health Information System Strategic Plan (HISSP) in 2010, as well as the development of the Health Information System Policy (HISP) in 2008, though the latter has not yet been endorsed by the country’s parliament. Both these documents are the backbone towards realizing a robust Health Management Information System (HMIS). Another major highlight was the improvement in ICT especially the connection of a wide area network from regional to national level. All these major highlights have been integral towards creating a condusive environment for the overall health information society. Strong linkages have been made between the National Health Sector Strategic Plan (NHSSP) and these two overarching documents forming the basis of the HIS in Swaziland. These linkages ensure that nothing is done outside or parallel to the overall health sector plan.
The government’s strong commitment together with the support from bilateral and multilateral agencies has also assisted towards ensuring availability of resources (human, financial, infrastructure) to realize improved HMIS. This would not have been possible without strong coordination efforts that the MoHSW has put in place to ensure effective management of partnerships and optimum use of resources.
Even though the MoSW has made some improvements in HIS, there are still pending challenges for strengthening. There is a major need for a cadre of trained staff, appropriate organisational structures and procedures, equipment and infrastructure, institutional arrangements, requisite funding and supportive planning and policy frameworks. The current HIS Policy framework seeks to address all these challenges to some extent.
The government of Swaziland is committed to develop a functional and effective Health Information System (HIS) that will enable the country to be accountable for all health inputs as well as to make evidence-based planning, resource allocation, policy implementation and monitoring performance of health sector investment plans and service delivery at all levels. The Ministry of Health and Social Welfare (MoHSW), with support from World Health Organization (WHO), has been involved in quite a number of different initiatives aimed at improving Health Management Information Systems (HMIS), and one major result has been the broad-based participatory development of the Health Management Information Policy (HMIP) in 2008.
The policy aims at providing a framework for strengthening the overall health data management and utilization at all levels, with considerations on human resources, financing, drugs and logistics, infrastructure and equipment necessary to effectively implement this policy. This policy also provides a framework for health information components such as vital registration, notifiable diseases, confidentiality, and the fundamental principles of official statistics. To operationalize the HMIP, the government has incorporated the implementation of this policy within the National Health Strategic Plan (2008-2013).
Furthermore, another milestone has been achieved through the development of the Health Information System Strategic Plan for 2010-2014 (HISSP) to enable the health sector to provide good quality data to inform evidence-based decision making.
The management of health information cannot be effectively carried out without the necessary financial resources. The government of Swaziland is committed to finance HMIS through a budget allocation. Even though information on health funding is available (i.e. budgets and expenditures), the financing system in place does not disaggregate the information by regional level. It also does not capture private health expenditures. Further, a National Health Accounts (NHA) exercise had been initiated but never completed. Financial resources from international bilateral and multilateral development partners also form an important component of the financing arrangements.
In order to strengthen institutional arrangements, the Health Information Systems Coordinating Committee (HISCC), was formed in 2007 with a mandate to coordinate and collaborate all HIS activities.
HMIS public partners include other government relevant ministries such as Ministry of Justice and Constitution, Ministry of Finance, Ministry of ICT and departments within the MOH especially the Strategic Information Development (SID), CSO. Health related Non-Governmental Organizations (NGOs) are also considered an integral part of the health service delivery system. The MoHSW also works closely with the Swaziland Business Council and Swaziland Federation of Employees to establish the Swaziland Business Forum on Health (SBFH). In order to coordinate these public-private partnerships, the MoHSW has established the National Health Sector Stakeholder Policy (NNHSSP) with the aim of promoting a sector wide approach with joint and cooperative actions aimed at maximizing the use of available resources.
One of the MoHSW’s strategic objectives is to strengthen its governance and management capacity to effectively and efficiently perform and discharge its core functions including sector wise leadership. One of its core activities to achieve this objective is to improve ICT coverage. The Ministry has since started implementing a programme to network all health facilities, hospitals and health centres. The hospitals and health centres are equipped with computers even though most of the clinics are not. The World Health Organization (WHO) and other development partners have been supporting Ministry Internet access efforts although this has not been sustainable. Through the National Emergency Response Council on HIV/AIDS (NERCHA), the Ministry submitted a proposal to support Internet connection to hospitals to facilitate communications. Impressive technological advances have been made by the MoHSW on its strategy towards strengthening HIS. The development of a nation-wide area networked HMIS from regional to national level, a system aimed at capturing out and inpatient programme data enables efficiency in the management and reporting of heath data.
Even though the country has wide area network coverage, a data warehouse is still not yet established; however there is work in progress to ensure that this is in place. Moreover, the country has also developed an Anti-Retroviral Treatment (ART) patient and drug management system, and a real-time entry ART database system. Further developments are being initiated to help Swaziland offer international standards health using the latest technologies; this would be realized through the full implementation of e-health and mobile health. India has already donated highly technological machinery that would be used to kick start implement the terms of the policy.
Cultural and linguistic diversity and cultural identity
One of the Kingdom of Swaziland’s characteristic is its unique culture and a mother language which is the identity of any Swazi and a tool for cultural expression. siSwati is the official mother language and the only mother language. English is widely used and is a formal second language in Swaziland. Both siSwati and English are key languages recognized in the country’s educational system. However, there are still challenges in strengthening the use of siSwati, which is mostly used for learning outcomes. Another major challenge is the fact that siSwati is not ICT compatible; hence this makes it difficult to translate health information publications for consumption down to the marginalized Swazi population. This necessitates the need for the development of siSwati to become ICT.
The existence of the country’s government website has been one major achievement in terms of availing information, including health related information to the general public. The World Health Organization (WHO) also has a communication strategy, whose aim is to ensure that global health information is available and accessible by all stakeholders at all levels, i.e. international level, regional level, as well as national level. Health information by WHO is accessible through WHO website for health information at all the highlighted levels of service delivery. Swaziland health related key documents may be accessed through the regional website. Journals have been accessible to the general public, and mainly by university research students through the GIFT website, unfortunately it is currently not accessible. The country’s WHO office has a library that has health information, and key partners in the Health sector response can easily access this information. In terms of specific HIV/AIDS related information, the country has an HIV/AIDS Information centre that is strategically and centrally located in the Manzini region so that it may be easily accessible to all who wish to get HIV/AIDS related information. This centre’s main objective is “to be a one-stop-shop for current and relevant HIV and AIDS Information to targeted audiences in Swaziland using multimedia information material.” Information end users can access both soft and hard copy materials, and has computer searching engines that are in-built within the centre’s website.
Despite having all these services, there country still has a great need to strengthen access of health information to the general public in a more coordinated and well managed approach. One major challenge is the availability of gray materials. These unpublished documents make it impossible to be disseminated and used, yet they contain valuable country-specific materials.
Following an assessment that has shown the country’s need to increase the number of health information management workers, SID as a developing body for HMIS has helped in the development of new cadres approved by the MoHSW towards strengthening information systems as well as the research unit. This development of a Human Resources Information System (HRIS) is aimed at streamlining human resources (HR) for the health information sector since there are significant skills gaps amongst Monitoring and Evaluation (M&E) and HMIS staff, with relatively large numbers of non-qualified data entry staff, and a shortage of graduate and post-graduate-qualified specialist staff. According to the country’s Service Availability Mapping (SAM-2010) report, currently there are 48 HIS personnel, and these are disaggregated accordingly as seen in the chart below. Further analysis showed that a majority of these staff are located in the Manzini (43%) and Hhohho region (33%), this in line with the distribution of health facilities in the four regions of Swaziland. Even though in-service training is ensured for continuing education for health professionals; however, there is lack of financial resources to sustain the project.
Production of quality information relies on the education and training systems aimed at developing health information systems and its management thereof. The country’s National Human Resources Health Policy (NHRHP) and its development plan emphasized the need for competent health workers to better deliver services.
Structural organization of health information
Organization and management
Coordination of the mainstream HIS in Swaziland is through the Health Information Systems Coordinating Committee (HISCC), which was formed in 2006. Coordination of HIV and AIDS information systems is through the National HIV and AIDS Monitoring and Evaluation Technical Working Group (M&E TWG), and through the Regional Multi-Sectoral HIV and AIDS Coordinating Committees (ReMSHACC). The M&E TWG meets on a quarterly basis and HISCC meetings are held every two months. A number of donors provide technical assistance to HIS and M&E activities; although the advisors involved have met informally to coordinate their activities, there is no formal structure in place to ensure this coordination.
The Government of Swaziland provides the basic infrastructure for the HIS, including staff, transport and office supplies. However, the resources provided are sorely stretched, and several key partners provide vital additional support for the collection and analysis of health data in the country. The Global Fund is providing support for Health Systems Strengthening (HSS) that has a component on HIS. Other major international agencies that provide additional support to health information systems strengthening are PEPFAR through the Enhancing Strategic Information (ESI), ICAP, EGPAF and URC. Skillshare International has provided the MOH’s SID with an M&E Advisor, whilst UNICEF is supporting data collection for the Expanded Programme on Immunization (EPI). MSH and WHO supports the collection of ART patient data, and the surveillance of communicable diseases. MSH is supporting the roll-out of drug-management software to ART clinics. UNDP provided funds to network the four regional HIS offices to the Health Statistical Unit in Mbabane. JICA has supported M&E training workshops and related M&E systems strengthening support to the SID. The Italian Cooperation has provided equipment, including computers and office fittings.
Overview of the flows of information
Data collection, processing, dissemination and use follow the different levels of the health service delivery system (community, facility, region and national levels). Figure 2 illustrates the framework for routine data flow in HMIS. This flow shows that all routine data comes from the community level through major health facilities in the communities, then to the regional level, where the data is compiled electronically then sent to the national level to SID via a wide area network, and at the national level, the data is received through the central server, then it is analyzed and used to inform health programmes.
Swaziland has established the ‘SwaziInfo’ (DevInfo) system, which identifies and compiles core development indicators across sectors. These include the health-related Millennium Development Goals (MDGs) indicators. An area of weakness was that reporting against health indicators was inconsistent and incomplete. Although the health related indicators were clearly defined, the actual reporting is not sufficient due to the absence of an effective mechanism for enforcement. For purposes of health sector planning, programme management and performance tracking, the indicators in the SwaziInfo are however regarded insufficient. A number of critical diseases and interventions were not included. Similarly, indicators for most support systems (e.g. infrastructure, equipment, pharmaceuticals and logistics, and financing) were not included. The current HMIS policy aims to implement the inclusion and capture of these set of indicators into the national core indicators on health information.
Specific regulatory framework
The Health Information Policy provides a basis for a structured planning framework for health information. The Health Information System Strategic Plan for 2010-2014 (HISSP) has been developed and provides a roadmap and strategic direction on key priorities in line with the Health Sector Strategic Plan and articulates the agreed vision, mission, mandate and core values of HIS. It also sets strategic objectives, strategies, activities, time frame, resource requirements and assigned responsibilities for achieving expected outputs in the next five years.
In terms of legislation, the country has no up-to-date legislation to provide a framework for health information components such as vital registration, notifiable diseases, confidentiality, and the fundamental principles of official statistics. The formation of a coordination and collaboration body for health information in 2006, (HISCC) was one great achievement towards strengthening institutional capacity. Since its formation, the effectiveness of the body has since been visible; however efforts are still required towards its overall strengthening.
Data sources and generation
The data that informs HMIS and SID comes from the census, vital statistics, population based surveys, health and disease records, research, health service records as well as from administration records of the health programmes. All these data sources are summarized as follows.
The census provides health information on mortality estimates. The custodian for the census information is the CSO. The most current census data is the 1997 document which provides the only reliable and robust estimates on mortality. Although the CSO produces annual population projections by age and sex for sub-national areas, they are not disseminated or published, and are therefore not readily available for HIS purposes. Similarly, the census projections are rarely used for the estimation of coverage and for planning of health services delivery.
Civil registration and vital statistics systems
These provide health information on births, marriages and deaths (BMD). The collection, processing, analysis and management of vital registration data (births, marriages and deaths), which is an important component of the health information system, presently remains the sole responsibility of the Births, Marriages & Deaths (BMD) Registry, a unit of the Ministry of Home Affairs (MOHA). All regions have officers who register births and deaths; however, challenges remain around analytical capacity as well as the compilation reporting of vital statistics. Reliable vital statistics are an essential component of many health indicators.
Population-based surveys conducted included 1) the 2000 Maternal Audit and Sexual Reproductive Health Needs Assessment Survey, 2), the 2002 Community Health Survey, 3) the 2002 Risk Factor Survey, and 3) the 2006-07 Demographic and Health Survey. The surveys conducted in recent years meet international standards for consent, confidentiality and access to personal data. In terms of health facility assessments, the country collects health and disease records (including disease surveillance systems).
Surveillances are carried out to gather data on cases reported on key epidemic-prone diseases and diseases targeted for eradication in Swaziland. The country has adequate capacity to diagnose and record cases of notifiable diseases, and to analyse this data for outbreak responses. Plans also exist for extending the coverage of disease surveillance to all other conditions of public health importance. However, only a small number of public health risks are properly mapped. Similarly, surveillance data is not being disseminated and fed back regularly through published weekly, monthly or quarterly bulletins. Instead, reporting is done on ad hoc basis and often with overlaps due to separate notification reports required by different public health programmes. The different surveillances carried out in Swaziland are; Sentinel Surveillance, ...
The country’s MoHSW recognises the importance of health research as a critical tool to gain evidence needed to support policy and decision making. Health research is limited in Swaziland and is conducted mostly on an ad-hoc basis by individual departments and units. The MOH has a research coordinating body (the Scientific and Ethics Committee) established in 2005 and its purpose is to approve research proposals and assess whether proposals meet ethics standards.
Some research and periodic reviews in the Health sector has been conducted, even though these efforts have been incoherent and limited. This limited research has focused largely on public health topics, rather than curative or rehabilitative research. The MoHSW has since created a research unit in the SID and the establishment of the research coordinator’s post, with this, the MOH intends to galvanise the conduct of health research and to strengthen oversight functions.
There are two types of health information collected in country, these being routine data, vital statistics and other episodic data. Routine health data collection is conducted through a network of health facilities distributed throughout the country. The HMIS unit is responsible for collecting routine public and private health facility-based data on the operations of the health sector i.e. disease profiles, utilization of services, maternal health and family planning, hospital beds and bed occupancy, human resources, and epidemic-prone diseases. Data collection tools are available at all public health facilities for monthly reporting of morbidity data. Routine health data is collected at health facilities and entered into the HMIS database at the regional level. This has been made possible through the establishment of networking infrastructure in all four regions and in some major facilities. The major challenge in terms of health data is its quality. There are still challenges with regards to data quality which emanates from different reasons, such as poor design of data collection tools, incompleteness and untimely reporting of data.
Vital Statistics data collection
Reliable vital statistics are an essential component of many health indicators. The collection, processing, analysis and management of vital registration data (births, marriages and deaths), which is an important component of the health information system, presently remains the sole responsibility of the Births, Marriages & Deaths (BMD) Registry, a unit of the Ministry of Home Affairs (MOHA). All regions have officers who register births and deaths; however, challenges remain around analytical capacity as well as the compilation reporting of vital statistics.
Data compilation, storage, management
Data compilation and storage: Routine data is compiled in computer systems at regional level by trained data clerks and then sent electronically to the national level and stored in the central server. However, there is currently no data warehouse to store all health information, and the SID is currently working towards ensuring that this is in place.
Data management is regarded as the weakest link in the country’s HIS. There is an absence of written procedures to guide the various aspects of data management – data collection, storage, validation, quality control, analysis and presentation. Similarly, the MOH does not have a ‘data warehouse’ for consolidation of (routine and survey-based) data collected by its various units and programmes; and no ‘data dictionary’ to provide clear definitions for data items and consistent construction of indicators.
The coordination of routine health information in Swaziland is at present the principal responsibility of the Health Management Information System (HMIS) unit in the Strategic Information Department (SID) within the MOH. The unit is responsible for collecting and analysing routine public and private health facility-based data on the operations of the health sector i.e. disease profiles, utilization of services, maternal health and family planning, hospital beds and bed occupancy, human resources, and epidemic-prone diseases. The HMIS unit is also ensuring harmonization and integration of data collection through a harmonization and integration framework. This is mainly done to address issues such as duplication and gaps in data collection, reporting, use and management thereof.
Data sharing and access
A 2007 assessment found the analysis of data and use of information to be ‘present but not adequate’ at all levels, and that demand for quality and timely health information is generally weak. Information is usually demanded on an ad-hoc basis, and even where requests are made, the knowledge and skills required to properly interpret the provided information do often inhibit effect use. Policy- and decision-makers do occasionally use health information to evaluate performance and set health policies, but usually with clear reservations about the quality and validity of data. Decisions on national resource allocations and those advocating equity aspects do not seem to have benefited much from HIS.
In terms of strengthening health information sharing as well as ensuring easy access of health information, the MOH aims to realize quality dashboard reports, scores cards, periodic reports customized for various stakeholders and annual comprehensive health statistics that are published in the predefined format. Through the implementation of the HISSP 2010, the MOH also aims at ensuring that quality information reaches on time to each primary stakeholder and all resource allocation and prioritization related decisions are evidence based. In this note, the MOH acknowledges that, if not disseminated and/or shared, health data outputs will not increase the existing stock of knowledge or contribute towards improved service delivery. One health information product that is widely shared with stakeholders is the Quarterly Service Coverage report produced by NERCHA in collaboration with MoHSW. The QSCR constitutes information on HIV and AIDS related indicators collected through SID and HMIS units, and is disseminated to relevant stakeholders on a quarterly basis. Major information products by HIS are;.......
Data quality and analysis
Data quality still remains a challenge that calls for accelerated solutions. With this in mind, the MOH has since partnered with Enhance Strategic Information (ESI) to provide support towards improving the quality of health data. A holistic Data Quality Improvement Strategy (DQIS) has been developed with the aim of improving the quality of health data. Through this approach, data quality issues have been identified at all levels. This has been made possible through the integration of a Data Quality (DQ) software solution to the HMIS and ART databases. An institutionalised routine data quality assessment and data quality auditing initiative is implemented to sustain the quality of health data. Following a a data quality assessment in 2010, the SID is now in a better position after being informed with the current situation in terms of data quality and having in mind the desired picture of the quality of health data. This data quality baseline has provided a basis for a root cause analysis needed for data corrections and appropriate measures that will help prevent future data errors.
Access to existing global health information, evidence and knowledge
Availability and use of indexes of local, non-English, and unpublished
The country has a Legal Depository Act, though it is now outdated. The Swaziland National Bibliography produced by the University of Swaziland’s library together with the Swaziland National Library Services (SNLS),( these two being the legal depositories of research in Swaziland), provide an index of locally available health information. The SNLS uses the Dewey Decimal Classification (DDC) and Relative Index scheme to index all their materials including health material indexing. The SNLS is also a subscriber to SAbinet, South African National Libraries, and this subscription enables the country to access more materials as well as to add more country specific materials from time to time. The major challenge with this subscription are the cost implications, especially considering the current economic situation in the country, this facility’s continuity may be threatened. The HIV/AIDS information centre has specialized indexing for local information materials, which makes it easier for information users to easily locate the information materials they need in a more effective manner. One major challenge faced by most health libraries is the increase in gray literature. These unpublished documents are at a rise, yet they pose difficulty for information disseminators because they are not published and hence are not for public consumption. Swaziland is no exception, what with an increase in the number of unpublished documents with valuable information, especially government documents.
Availability and use of search engines, networking platforms
The establishment of the government web site, which has enhanced accessibility to electronic health information for the general public, and the National Emergency Response Council’s support of online information on HIV/AIDS are described as important initiatives to promote access to electronic health content.
At regional and international levels, WHO has websites that have built-in search engines for browsing health-related information. This information is available free of charge for journals related to health. At local level, the HIV/AIDS information centre has internet access and a website that has built-in search engines for accessing country documents on the multisectoral HIV/AIDS, and all these journals are accessible free of charge. The centre has an electronic database developed by UNESCO (Computerised Documentation System/CDS) and health information is free of charge. The SNLS now has installed internet access in all its main libraries, including its branches. This facility is available at very minimal costs when comparing with internet rates across other service providers. However, there still remains a challenge for local health libraries in terms of updating health information. This is mainly due to the uncoordinated efforts in terms of health research.
Availability and use of open access journals
Open access journals are available through WHO website, as well as through local health libraries. Journals are accessed through the internet, which is mostly provided free of charge in local health information centres, as well as in hard copy especially for walk-ins. Hard copies are normally provided at a small fee to cover photocopying costs. These journals are mostly used by university students as well as university students in health institutions outside the country, and these are mainly used for research purposes. Local health libraries also attend to “walk-ins” other health information is e-mailed though this is done as per request.
Access to copyrighted publications
Health libraries in Swaziland do have access to copyrighted materials. One main information depository is HINARI, where copyrighted information is accessed by the country’s information users. However, local health libraries such as the National HIV and AIDS Information and Training Centre face limitations with some journals which are mostly on demand. This is mainly to the fact that such materials are not easily accessible with HINARI and if they are, they are accessible at a fee. This necessitates the need for country-specific information depository systems that will serve the Swazi population. Moreover, the SNLS distributes some health information through its 16 libraries throughout the country. These materials are copyrighted published materials, and they are made available free of charge. SNLS has set up libraries in 38% of all Swazi schools, both at primary level and at high school level, and ensures that health materials are available. Processes are being made to establish libraries in all the remaining schools to avail information including health related materials. The main challenge faced with SNLS in this endeavor, are the limitations in financial resources to buy books, currently the institution relies heavily on donated materials.
Regulatory frameworks on intellectual property
The SNLS’Ss vision is to provide an effective library, documentation and information service throughout Swaziland. To do this, the SNLS has since developed a Swaziland National Library Documentation and Information Policy (SNLDIP). This policy was developed to provide and to progress improvement on library facilities and services in order to contribute effectively to national development. The country has a National Library Service Act of 2002, in which all libraries are to align themselves to. This very Act of 2002, provides for three legal deposit institutions which are; the SNLS, the Swaziland National Archives (SNA) and the University of Swaziland Library (USL).
Storage and diffusion of information, evidence and knowledge
Availability and use of health libraries and information centres
The country has very limited health-specific libraries and information centres. The SNLS also has some information related to health subjects in all its 16 branches, which include the main libraries. These libraries are strategically located in different geographic areas of Swaziland for ease of accessibility and usage by the general public. Within each of the SNLS libraries, there is an HIV/AIDS corner with specific and up to date information on HIV and AIDS. As a decentralization strategy, the SNLS is currently in the process of setting up libraries at all Tinkhundla centres of Swaziland. The vision is to bring library services closer to the people whislt improving the culture of reading and to increase knowledge to the Swazi people in all aspects, including health issues. There is also a specific health related centres, such as the National HIV/AIDS Information and Training Centre, which is a one-stop centre for all HIV/AIDS related materials. Currently the HIV/AIDS information centre has approximately 1200 health related materials. Information from health libraries and health information centres serves key health stakeholders, university students, researchers as well as the general public. The local WHO office also has a health library which can be accessed on request, and this library is very rich especially on global health materials as well as local health-related materials.
It is worth highlighting though, that there is still a great need to sensitise the general public on the value of using information as well as to enrich their knowledge on key health related issues. Generally, the culture of reading is still low, especially if not prompted by research needs or scholastic outputs.
Availability and use of publications in appropriate formats and languages
Even though Swaziland is not a multi-lingual country, dissemination of information that is repackaged and tailor made to suit the different audiences at the grassroots level is seen as vital. The local resource centres currently have no capacity or resources to re-package health information into vernacular language. This is one area of weakness which can be strengthened with the availability of resources. The SNLS policy stipulates the importance of providing appropriate materials, that is to provide library resources in various formats to all citizens including people with disabilities, so that they may access any information at a user-conducive format.
Consolidating and publishing existing evidence for policy and decision
Health Libraries and information centres face a challenge in collecting and diffusing health related information. This is mainly due to the fact that most health information producers have not yet fully realized the value of information flow, hence health libraries/centres end up not having up-to date information. This challenge has continual effects towards documenting best practices because of non-coordinated information. Despite these challenges, information centres, such as the HIV/AIDS information centre are in the process of setting up a system that will enable structured consolidation and publishing of existing evidence for policy and decision. Even the HIS has no data warehouse where all health related information may be stored and further consolidated for evidence-based planning.
Indexing of local publications in international indexes
The Swaziland National Bibliography produced by the University of Swaziland’s library together with the Swaziland National Library Services (SNLS),( these two being the legal depositories of research in Swaziland), provide an index of locally available health information. However, the HIV/AIDS information centre has a specialized indexing system developed by SAFAIDS, this was mainly because international indexing systems such as HINARI are not allowing access to some HIV/AIDS health related materials, hence the need for developing a special index system for Swaziland.
Health research has not been adequately institutionalized in the sector. However, the Ministry with the assistance of health partners established a secretariat to record and coordinate health research activities in the country. While the country moves towards institutionalization of health research, it has set up an independent scientific and ethics committee with the aim screening and approving all health research activities in the country. While the scientific and ethics committee screen the research protocol, it also ensures that the rights of the patients or community are protected. Although accurate estimates of amount spend on research are not available it could mentioned that expenditures of health research are increasing. Currently, the country is conducting research over the first ever, HIV/AIDS incidence in the country.
The government of Swaziland, through the National Health Sector Strategic Plan, 2008-2013 (NHSSP) has shown her commitment towards strengthening health research by including health research in the budget plans, see figure below.
Creating and sustaining resources
The Ministry of ICT is charged with the responsibilities of overseeing the National Research Council, which is responsible for coordinating and commissioning all research in the country, including health research. The MoHSW has a research coordinating body (the Scientific and Ethics Committee) established in 2005. Its purpose is to approve research proposals and assess whether proposals meet ethics standards. The committee meets once in two months. With the creation of the research unit in the SID and the establishment of the research coordinator’s post, the MOH intends to galvanise the conduct of health research and to strengthen oversight functions. Among other things, the research coordinator is expected to spearhead the development of a national health research agenda and implement activities aimed at building research capacity in Swaziland.
The following key health related research has been produced in Swaziland; however the list is not comprehensive;
i. The Swaziland Demographic Health Survey: This is one major research output in the HIS in the country. The SDHS is a nationwide survey commissioned by the MoHSW and implemented by the Central Statistics Office (CSO), aimed at generating estimates at the country level, regional level and for urban and rural areas. The last SDHS was carried out between 2006 and 2007. The objective of the DHS is to provide up-to-date information to policy makers, planners, researchers and program managers working in the health programmes in Swaziland. The SDHS specifically collected information on fertility levels, marriage, sexual activity, fertility preferences, awareness and behavior regarding HIV/AIDS use of family planning methods. The survey also collected information on malaria prevention and treatment.
ii. MIX report
iii. BSS report
iv. ANC Sentinel Surveillance report
v. Modes of Transmission Analysis report
vi. Community-level Service Availability Mapping (SAM)
vii. MESS report
However, based on a national assessment in 2007 on HMIS, a good proportion of the health research work done in Swaziland remains unpublished and inadequately disseminated. Consequently, key stakeholders are not adequately informed about research processes and outcomes. Poor dissemination and packaging of research outcomes also results in poor linkages between research, policy and programme development.
Use of information, evidence and knowledge
The 2007 assessment on HIS system in Swaziland found the analysis of data and use of information to be present but not adequate’ at all levels. Demand for quality and timely health information is generally weak. Information is usually demanded on an ad-hoc basis, and even where requests are made, the knowledge and skills required to properly interpret the provided information do often inhibit effect use.
Formatting and packaging of evidence for policy and decision making
Data that are reported up from the facility level are not processed and translated into information that is useable at facility level for decision making. The SID unit produced a Quarterly Service Coverage report, which is a standard report that gives information on all core health indicators related to HIV and AIDS. The MoHSW through the SID unit also produces an annual report.
Sharing and reapplying information and experiential knowledge
The SID unit shares its reports with NERCHA and with all relevant stakeholders. Staff in the regional offices and health facilities occasionally use the information in the planning process but hardly analyse their respective health statistics comparative to the national benchmarks. There is lack of clear information dissemination guidelines. Moreover, key stakeholders are not adequately informed about research processes and outcomes. Poor dissemination and packaging of research outcomes also results in poor linkages between research, policy and programme development.
Policy and decision makers' articulation of their need for evidence
Policy and decision-makers do occasionally use health information to evaluate performance and set health policies, but usually with clear reservations about the quality and validity of data. Decisions on national resource allocations and those advocating equity aspects do not seem to have benefited much from HIS.
Leverage information and communication technologies
Level of access to IT infrastructure
As an initiative in health ICT, The Ministry of Health and Social Welfare has a programme to network all health facilities, hospitals and health centres. The hospitals and health centers are equipped with computers while the clinics are not. The World Health Organization (WHO) and other development partners have been supporting Ministry Internet access efforts although this has not been sustainable. Through the National Emergency Response Council on HIV/AIDS (NERCHA), the Ministry submitted a proposal to support Internet connection to hospitals to facilitate communications. The SNLS has since shifted from undertaking its operations manually, and has now evolved into a system that incorporates ICT. With the establishment of internet services within the country’s national libraries, a new window to information and technology and knowledge sharing platform has been opened. This initiative will go a long way towards facilitating the move by the nation towards realizing the vision of “anytime access to the best and latest of human thought and culture, overcoming all geographical barriers, so that no individual is isolated from knowledge resources..”. (source, year)
Availability of IT solutions
To populate all pharmaceutical data, the MoHSW uses RX solutions for populating all clinical data from facilities, the RX system is supported by Management Sciences for Health (MSH), and this system is available in all health centers and referral centers, with a scale up in some clinics. The goal is to have RX solutions installed in all health facilities in the country. RX system is also used to manage drug information at central level. To collect non-clinical data on HIV/AIDS, NERCHA through Swaziland’s HIV and AIDS Programme Monitoring System (SHAPMOS) populates data on District health Information Systems (DHIS).
Extent of integration of the HIS
To integrate health information, the MoHSW has a data collection process from community level up to national level. Data is collected at health facilities and entered into the HMIS database at the regional level. This has been made possible through the establishment of networking infrastructure in all the four regions of Swaziland. Built in HIS systems such as RX solutions have been installed into the HIS system and this enables a standard way of reporting across all heath sites up to the central level.
Endnotes: References, sources, methods, abbreviations, etc.
AIDS : Acquired Immune-Deficiency Syndrome
BMD : Births Marriages and Deaths
CHW : Community Health Worker
CMS : Central Medical Store
CR : Civil Registration
CSO : Central Statistical Office
DQIS : Data Quality Improvement Strategy
ESI : Enhanced Strategic Information
GF : Global Fund
HFC : Health Facility Census
HIS : Health Information System
HISSP : Health Information System Strategic Plan
HIV : Human Immuno-deficiency Virus
HMIS : Health Management Information System
HMN : Health Metrics Network
HRD : Human Resource Department
HRIS : Human Resource Information System
M&E : Monitoring and Evaluation
MDG : Millennium Development Goals
MoHSW : Ministry of Health and Social Welfare
MOHA : Ministry of Home Affairs
MOEPD : Ministry of Economic Planning and Development
NHSP : National Health Strategic Plan
RHM : Rural Health Motivator
RHMT : Regional Health Management Team
SDHS : Swaziland Demographic and Health Survey
SID : Strategic Information Department
SNA : Swazilad National Archives
SNAP : Swaziland National Aids Program
SNLS : Swaziland National Library Services
TB : Tuberculosis
WHO : World Health Organization