A LACK OF MONITORING AND ADEQUATE INFORMATION SYSTEM and
CONFLICT BETWEEN HIGH VERSUS APPROPRIATE TECHNOLOGY
Ackoff goes on to identify five assumptions commonly made by designers of management information systems (MIS). The Ackoff Assumptions are that:
(1) the deficiency under which most managers operated is the lack of relevant information;
(2) the manager needs the information he wants;
(3) if a manager has the information he needs his decision making will improve,
(4) better communication between managers improves organizational performance; and
(5) a manager does not have to understand how his information system works, only how to use it.
Ackoff argues that these assumptions are in most cases not justified cases, and often lead to major deficiencies in the resulting systems, i.e. "Management Misinformation Systems." To overcome these assumptions and the deficiencies which result from them, Ackoff recommends that management information system should be imbedded in a management control system, i.e. integrated with other support systems. In Ackoff's words, "No MIS should ever been installed unless the managers for whom it is intended are trained to evaluate, and hence control it, rather than be controlled by it."
Despite the best of intentions, intensive training and quantifiable objectives, statistical reporting somehow inevitably becomes over-complicated, under-utilized and rarely understood. For a health information system to be useful it must permit and encourage data analysis by the person collecting the information rather than waiting for feedback from a higher level. This is especially true at the level of the health center nurse who usually is the person most burdened with monthly reporting responsibilities. The information system should help nurses in setting program objectives, identifying what information to collect, analyzing the collected data and applying corrective feedback.
While several countries, including Malawi, Niger, Cameroon and even Haiti, have made impressive strides in the development of health information systems, these efforts seem to often result in a top- down development that reinforces centralized control rather than encouraging decentralized planning and management. The case of the VACS project in Haiti (see Box 8) is simply one of several which could be cited which needs to limit the health information system to a bare minimum of indicators on which all programs would report, and encourage flexibility and innovation at the local level to develop additional local indicators.
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Box 8 FLEXIBILITY IN INFORMATION SYSTEM STRENGTHENING IN HAITI The stated purpose of the Voluntary Agencies for Child Survival (VACS) project in Haiti is to (1) to develop the institutional capacity of private and non-governmental organizations (PVOs/NGOs) in Haiti to provide child survival outreach services; and (2) to increase the access of the rural population to child survival services. The project, which began in 1987, includes a health information system component. VACS was originally designed to provide complementary inputs through the public and private sectors. With the disruption of the overall AID/Haiti program in November 1987, support through the public sector was stopped and VACS' support to PVOs became USAID's principle vehicle for providing health assistance to the population of Haiti. The 1993 mid-term evaluation found that the Health Information Systems (HIS) of VACS grantees were divided into computerized and manual systems which were generally efficient and working well. Most systems have the minimal necessary elements to satisfy the reporting requirements of their institution and donors agencies. Grantees also include variables used only for their internal project management. The Health Information Systems of VACS grantees show diversity. Most of the VACS direct grantees received technical assistance from the national level to build their HIS. But they have brought modifications to the original version to fit their particular needs. More than one PVO is in process of creating computerized databases with individual level information on health status indicators and program outputs. An excellent one page reporting form is being used by the program at Mirebalais both for quarterly and yearly reporting. The form includes a column for each three months of activity and provides cumulative totals as the year progresses. The adoption of this kind of form as the minimum standard for VACS reporting would greatly simplify and facilitate data collection and analysis, while allowing for local flexibility to add additional variables tailored to the needs of the local program. USAID was considering the pros and cons of buying the production and distribution rights for one of the existing computerized HIS systems, and standardizing its use across all project-assisted PVOs. However, the evaluation recommended that VACS should not attempt to standardize PVO health information systems (HIS), but should disseminate information about good systems already in use. The fact that there is no standardized HIS program that all VACS grantees use is not a problem. Better to have different systems that grantees develop and use effectively, than a project driven standardized system that grantees feel is imposed from above. |