Botswana, like many developing countries, is experiencing a health workforce crisis and has lacked a clear and complete picture of the national situation. A year ago, there was no centralized information system available for human resource managers and decision-makers to develop, regularly monitor, and review HRH policy and plans for the national or district level – different departments in the MOH used separate systems that did not link. As a result, the institutional capacity for analyzing information for HRH policy and planning has been weak. Although significant steps have been taken to develop an HR Policy and Strategic Plan, deployment is still not rigorously directed by evidence and in a sustainable manner. This has resulted in a mismatch between service requirements and training, both in numbers and skills, and inequity in the distribution of the available human resources.

To address this, the Capacity Project worked with the MOH to install a customized version of iHRIS Manage last year, for co-maintenance by the Department of Policy and Planning, Monitoring and Evaluation, and Ministry Management. This work transitioned to SA-HCD and approximately 60% of Botswana’s health workers have been entered into the system (from data collected via paper forms over the last year). While progress has been made in implementing the system, it is necessary to ensure it is fully integrated into MOH operations.

We have made several improvements to the iHRIS Manage software over the last year. Therefore, Carl worked with Kabelo Bitsang, the local iHRIS system administrator seconded by SA-HCD to the MOH, to upgrade the software to the newest 4.0.2 version. This version contains new features based on MOH user feedback and added to the core software, thereby highlighting one of the key advantages of Open Source software – improvements made for one country are available to all countries. 

In addition, version 4.0.2 will allow for decentralization of iHRIS Manage to the districts, which is a critical part of ensuring the sustainability of the system. As many of the routine HR functions happen at the district-level, data can be kept accurate. Moreover, it will increase the ownership of the system and the data it collects.

Carl reported that, “in order to ensure the MOH is on solid footing toward successful implementation of iHRIS Manage,” he spent time training Kabelo on administering the system, creating custom reports, and accessing technical documentation. Carl also trained the four data entrants (also seconded by SA-HCD to the MOH) on the 4.0.2 version and helped Kabelo create a report to track their individual progress.

above: data entrants at the MOH

During his trip, Carl worked closely with SA-HCD’s Regional HRIS Advisor, Godfrey Kyama. Together they met with departmental stakeholders in the MOH to make certain their needs are addressed by iHRIS Manage. They also met with key HRIS stakeholders outside the MOH. They visited the NMCB and assessed missing functionality of their current Health Professional Registration System. Carl advised the NMCB on necessary steps to develop their desired web-portal to increase registration compliance. He also demonstrated the iHRIS Qualify system and explained what would be required to import NMBC data into iHRIS Qualify.

above:data entrant at the NMCB

above: NMCB employees

On a broader scale, the pair met with representatives from the Center for Disease Control and discussed the need for harmonizing information systems at the MOH. They specifically discussed improving the interoperability of iHRIS Manage and District Health Information System 2.0 software (DHIS2), as there is a planned rollout of DHIS2 to the country’s districts. Carl and Godfrey also met with a professor from the University of Botswana’s Computer Science Department to discuss the best way to increase local capacity to customize and maintain the iHRIS Manage software.

Looking back on his trip, Carl believes, “the iHRIS Manage system has a firm foundation for sustainability beyond the SA-HCD project.” This is in part due to a recent decision made by the MOH to hire Kabelo and the data entrants as permanent MOH employees. Carl recommends a few additional activities that should be undertaken to help ensure sustainability. First, Kabelo should meet regularly with the various MOH departments to determine the system reports that would be most useful for decision-making.  These reports should then be posted on a web portal on the MOH site, similar to the Uganda KM portal. Also, data-driven decision-making workshops should be conducted for MOH employees along with training on iHRIS Manage. Finally, the MOH and Stakeholder Leadership Group should develop, in anticipation of the end of the SA-HCD project, an implementation plan for decentralized iHRIS Manage in the districts in collaboration with DHIS2 implementation.

While in the Southern Africa region, Carl also visited Lesotho. Look for a blog on his Lesotho trip soon.

Indeed, an HRIS contains valuable and confidential human resources information that if lost would be painstakingly difficult and time consuming to replace. Unfortunately, some historical health worker data could be lost forever, unable to be recaptured by a new data collection effort. Therefore, it is important to ensure a sustainable backup plan is in place.  One country, Namibia, recognizes the need for a reliable backup solution for their HR information management system (HRIMS), and recently took action to ensure they had a secure backup system in place.

The Namibia HIV Prevention, Care and Support Program, an IntraHealth-led Capacity Project Associate Award, is assisting the Ministry of Health and Social Services (MoHSS) with rolling out the central-level HRIMS to the 13 regions. The HRIMS tracks health professionals working in the public sector and captures data on their training, certification, licensing and deployment. All the HRIMS data lives on servers located in the Office of the Prime Minister (OPM); the MoHSS, and eventually all the regions, access the data via wide area networks. Therefore, the OPM is responsible for performing data backups.

To ensure a proper backup for the HRIMS data is in place, the Namibia HIV Prevention, Care and Support Program and MoHSS developed a Disaster Recovery Plan questionnaire to determine the level of HRIMS data security and whether additional steps and funds were required. The questionnaire was approved by Namibia’s Stakeholder Leadership Group and sent to the OPM to complete. It collected basic information on the system, including program language and the operating system; change management information, like recent changes, the number of people able to provide technical and user support, and the development timeline; backup information, such as frequency and medium; and the disaster recovery plan. After reviewing the completed questionnaire, the Program and MoHSS confirmed the OPM is doing a good job with the current backup solution and no additional steps need to be taken.

The questionnaire can be adapted and standardized and used by other countries/organizations to ensure their HRIS data is securely backed up. In addition, it is slated to be included in the next version of the HRIS Toolkit.

The guided demo can now be accessed on our website and clicked through with a mouse. It can also be downloaded and uploaded to a computer with a touch screen or to a computer with a regular monitor (again advancing using a mouse).

You can find the guided demo at the bottom of the iHRIS Manage page. There is also a link to download the demo.

As a Year One activity, the UCP is partnering with the World Health Organization (WHO) to expand Uganda’s iHRIS Manage to an additional ten districts. A team consisting of two representatives from UCP and one from the MOH is leading the rollout activity on the ground. Each is responsible for a set of districts.

I caught up with one of the team members, Martin Namutso, recently on the phone. Martin is an HRIS developer for UCP and was finishing up a long day of work in Hoima District, one of the four districts under his umbrella. When I asked him to tell me about the rollout project, right away he said, “UCP is taking an approach that emphasizes the iHRIS implementation is MOH-driven.” For example, he explained three technical staff members from the Human Resources Management (HRM) department are serving as point people for each of the districts, and will be receiving and analyzing district reports.

Martin advised the district selection process was strategic and participatory. First, 40 districts with less than 50% of their health worker posts filled were identified. Then, WHO and UCP met to narrow the selection to 15. Next, WHO and UCP, along with three commissioners from the MOH, agreed on the ten districts: Ibanda, Bushenyi, Mbarara, Mityana, Mubende, Kyenjojo, Hoima, Busia, Tororo, and Mbale.

This map shows the 9 initial districts supported by UCP and the 10 districts supported by both UCP and WHO.

Martin said the team on the ground visited each of the districts and conducted an ICT needs assessment to determine what equipment needed to be procured. He noted that none of the districts had computers designated specifically for managing HR data – all were being used for daily office work. Also, each district needed a printer for HR purposes.

WHO provided funding for the necessary computers and printers, along with network switches and cables. Martin installed all the computers with iHRIS Manage and other necessary software. He is now almost finished training HR managers and data entrants in his districts and expects to be done by mid-March.

Martin is also helping his districts to import or enter any existing electronic data into the iHRIS Manage software. The existing data are stored in different formats, and are not necessarily standardized. Martin said this is time consuming, “We have to clean all the districts’ data, and it is so tasking.” Throughout this process, he has found that if districts have data imported for them all at once, they don’t seem to embrace the system for day-to-day use, like entering a new employee or changing a current employee’s salary or position, which would help to ensure sustainability. So, now he is instead training users to enter  five to ten records a day. He said entering the historical data will not only familiarize them with using the system but will also encourage them to continue updating it and entering in new employees.

The needs assessment also prompted the UCP to change their game plan. Originally, the UCP planned for iHRIS Manage to reside on a computer in the office of the Principle Personnel Officer (PPO) in each of the districts, but they found the PPO office manages HR data for not only the districts’ health employees, but for those employed in water, education, works, veterinary, agriculture, etc., and the records officer’s attention was spread too thin. So, they decided to place the iHRIS Manage computer in the office of the District Health Officer (DHO), as those offices will not only be more likely to keep health worker information up to date, but will also benefit from it. Also the health workforce data is first handled in DHO office, and the PPO expect updated electronic data from the DHO office.

Martin said the districts will share their iHRIS Manage reports with the point person in the MOH HRM department. For now, well-connected districts will email reports (exported to Excel) to the HRM leads, and districts with less reliable internet will forward paper reports. Martin said he is looking forward to the districts eventually sharing data with the MOH electronically and in real time. He is also excited to soon include district data in the country’s biannual HR reports, which influence health policy and budgets.  

Read more about HRIS strengthening in Uganda here.

Dykki Settle, HRIS team lead, will join Paul Jones of the University of North Carolina and Ed Hammond of Duke University for a panel discussion about the contributions open source systems have made to health systems in the developing world.

Visit the TGHC’s site for more details. You can also follow the discussion on Twitter, at #triangleglobhlth.

The HRIS Advisor will serve as the liaison between the project, the PMO-RALG, the Ministry of Health and Social Welfare, and other HRH stakeholders. The new hire will support the district-level deployment and provide on-going mentoring to establish results-oriented operational plans and ensure HRIS skills are transferred and concrete results are achieved. The project is in the process of signing a memorandum of understanding with the PMO-RALG to outline and agree upon expectations of the new HRIS Advisor. This official collaboration between the project and the PMO-RALG will promote harmonization of data collection tools and software as well as build capacity to effectively collect, process, store, retrieve, and use HRH information.

Phesto Peter Namayala was selected for the post and officially started today.  He brings with him a wealth of experience in information technology (IT). He earned a bachelor’s and master’s degree in computer science from University of Dar-es-Salaam and University of Hertfordshire, respectively. He has previously served as an IT lecturer, at the Tumaini University, Mzumbe University, and the Institute of Transport Management, and as a programmer and database administrator for SoftTech. Phesto also has experience in IT management, software implementation and programming work on both proprietary and Open Source software, as well as in database design, installation, configuration and support.

Read more about HRIS strengthening in Tanzania here.

Although some work still needs to be completed before the iHRIS Qualify system is fully implemented, progress made in Pakistan thus far is monumental as it is the first time the Open Source iHRIS software has been customized and implemented with only virtual support from the HRIS team in Chapel Hill. The HRIS team, through the Capacity Project and follow-on CapacityPlus, has been supporting this work as a pilot effort to understand the needs, advantages, and challenges of a country when implementing the iHRIS software with only minimal support. Virtual learning and communication was made possible using the online tools Skype and, especially, Elluminate. Elluminate access was provided by AKU.

As part of an official launching ceremony held in November, PNC representatives gave a presentation about the iHRIS Qualify software and discussed future plans for expansion. A packet of materials—including information about iHRIS—was distributed to all participants. Representatives from USAID/Pakistan, Pakistan’s other professional health councils; ministries of health, education, and information sciences; and local nurses attended. Dr. Rafat Jan, associate professor of the AKU School of Nursing and consultant for the PNC implementation, said the PNC took advantage of the event to introduce stakeholders to the system and encourage other councils to also adopt it.

The Current Registration Process

The PNC registers nurses, midwives, lady health visitors, and nursing auxiliaries to practice in Pakistan. These health workers are required to renew their registrations every five years. In 2006, the PNC began using a simple electronic database for registration, called the Nursing Management Information System (NMIS). As the PNC previously relied on a paper registry, it benefits from the NMIS and now has the ability to issue computerized registration cards and generate limited reports. However, the registration process requires data from many stakeholders and the procedure for sharing and gathering this data using the NMIS is still largely paper-based. To illustrate, NMIS registration involves the following steps:

1. Individuals send hard copy registration applications to the PNC office.
2. The country’s four Nursing Examination Boards (NEB) each send examination results to the PNC via hard copy spreadsheets.
3. Individual training institutions send new student enrollment information and yearly examination forms to NEB. These individual institutions also send this same information to the PNC. 
4. The PNC uses the above information to verify new registration applications. Once information is verified, the registration and exam information is entered into the NMIS and registration cards are issued to individuals.

As you can imagine, the paper applications, spreadsheets and forms result in surmounting stacks of paper at the PNC. In addition to storage issues, the processing of the paper documents is labor- and time-intensive, requiring many PNC staff members’ attention, and involving duplication of effort. Further, illegible hand writing often present on paper forms increase rates of errors by data entrants, causing longer processing times for registration verification.

The Decision to Implement and Customize iHRIS Qualify

To address NMIS challenges, the PNC decided to adopt a more efficient and effective registration system, and to introduce online registration to NEBs, schools and health professionals. USAID, through TACMIL, sponsored a workshop with stakeholders to discuss system requirements. In June 2009, the PNC decided to implement iHRIS Qualify.

As all countries’ policies and procedures for registering health workers are different, the iHRIS Qualify software required modification to meet the PNC’s needs. For example, the PNC requires a current photo with all registration applications, so they needed the ability to upload photos to health professionals’ records. Also, various fees are associated with registration and renewal, and a Challan (bank draft) must be submitted with applications. Therefore, the PNC required a finance module that would record the type of fee, refund or balance, and Challan details.

The PNC and HRIS teams, along with local developers, began meeting virtually in July to discuss the implementation plan and required customizations. Photo upload capability was already slated for the 4.0.2 release of the software, so the iHRIS developers focused on that while local developers concentrated on the finance module. The local developers also migrated existing NMIS data to the new iHRIS Qualify system; developed a small database to electronically link NEBs with the iHRIS Qualify system in the PNC office to quickly share information for verification; and trained users.

The PNC recognizes the need to eventually electronically link all the stakeholders and sites i.e., from the PNC to the NEBs and schools, and vice versa. This would help with information sharing and pave the way for online registration. In response to this need, the PNC initiated an online registration pilot, and installed iHRIS Qualify in one NEB and one school, with the hope of eventually rolling the system out to all of the country’s 200 nursing training institutions and all four NEBs.

The TACMIL project, along with implementation funding, ended in December. There is remaining work to complete development, switch to the new system and ensure sustainability. The PNC is dedicated to using the new system and is currently working with the iHRIS developers to refine the software code and write essential reports that can be generated easily by PNC staff.

Look for updates about the PNC implementation on our blog. We’ll soon be posting a write up specifically about the PNC’s vision for online registration!

*All photos are from the PNC presentation given at the launch ceremony in November.

IMA, and particularly Scott, have been instrumental to our HRIS strengthening work in Tanzania Mainland, first under the global Capacity Project and now under the IntraHealth-led Tanzania Human Resource Capacity Project Associate Award. As Health Management Information Systems and Geographic Information Systems program manager for IMA, Scott has an impressive background working with health information systems in the FBO community and is using this experience to support the implementation of iHRIS Manage at Christian Social Services Commission (CSSC), Tanzania’s largest FBO. 

In Tanzania, it’s estimated that FBO’s manage 40% of health facilities in the country, and provide 50% of all health services.   So, it’s crucial to ensure that data is collected (in iHRIS Manage or another HR management system) on health workers employed by the FBO sector. Unfortunately, data is often only collected on health workers working in the public sector. Scott is dedicated to bridging this gap.  “The faith-based and public sectors should be more integrated,” he said in a meeting last week, “because countries need to incorporate the faith-based sector.” 

A priority under the new global CapacityPlus is to expand and further decentralize iHRIS development.  As IMA is ideally situated to work with the FBO’s in Tanzania and beyond, it can take a leadership role in disseminating training, best practices, and providing support for iHRIS deployments in these communities.  To this end, Scott’s visit to Chapel Hill was focused on improving the capacity of IMA to provide technical assistance on a global level for iHRIS Manage. 

During his visit, Scott primarily worked with the iHRIS developers. The first day he was oriented on the iHRIS database structure, including modules and form relationships. He was then led through the process of customizing the software, walking through recent CSSC customizations as examples. On day two he installed Ubuntu and iHRIS Manage and provided helpful feedback on improving the process with additional documentation and Ubuntu shortcuts. He was also trained on various tools used by the iHRIS developers to encourage and foster a wider development community, including the wiki, Launchpad and IRC. As he is supporting zonal deployment of iHRIS Manage at CSSC, he discussed implementation strategies and best practices for large scale rollout with our IT department.  On his final day, he met with the larger HRIS team and provided advice on enhancing iHRIS documentation and improving existing tools and resources. Scott sees the need to bridge the gap between technical and non-technical people, so HR managers, for example, can more easily understand the benefits and functions of iHRIS Manage. To do this, he suggested creating more graphics, a topical mind map, and an overview video, and encouraging standards such as job codes and classifications.  

Scott provided excellent insight and ideas for moving the iHRIS software forward. As he has a geography background, he is interested in helping to integrate GIS into iHRIS. For example, IMA already has about 900 CSSC health facilities geo coded. The iHRIS developers said that in the future, we should add fields to iHRIS Manage to store this sort of GIS information, like facility location data. He also discussed promoting interoperability between iHRIS Manage and District Health Information System software (DHIS). This is high on his agenda as he is also supporting DHIS implementation in DR Congo and S. Sudan and is traveling to both countries later this month. 

Dykki Settle, HRIS team lead, said he is hoping with what he’s learned, Scott will now be our ‘FBO expert,’ and provide support for FBO’s interested in implementing iHRIS. He encouraged Scott to share any FBO-specific needs for the iHRIS software back to the team. The HRIS team is looking forward to continuing to work with him. In the next few weeks he will be providing additional feedback on iHRIS resources, work plans, budget templates and project deliverables.

A few weeks ago we added an overview of custom reporting. This article includes information on creating relationships between data forms, developing a new report, and creating different report views. You can read the article here.

This week we added an article about regional rollout. It covers developing a policy, designating who has the ability to edit data, and standardizing lists and dropdown menus. You can read the article here.

In the next few months we plan to focus on adding more documentation and improving what is already available.