IHIS Review and Assessment

IraqHealthInformationSystem
ReviewandAssessment
July,2011
By:
MinistryofHealth,MOHE,MOP/CSO,MOD,WHO
Coordinatedby:
MinistryofHealth,BabbALMoadham,Baghdad,Iraq
ContactAuthors:
1.
Dr.AhlamazizAli,DirectorofDonorAffaireSection,SeniorDeputyMinistersOffice,MOH
Email:donorsdy@yahoo.com
MobileNo.:+9647901940669
2.
Dr.ImadAbdulsalam,DirectorofHealth&VitalStatisticDepartment,PlanningDirectorate,MOH.
Email:the_dr_imad@yahoo.com
MobileNo.:+9647901925619
3.
Dr.AliMahmoodHasan,DirectorofHealthStatisticSection,DirectorateofPlanning,MOH.
Email:alimahmod77@yahoo.com
MobileNo.:+9647902649103
This report describes the current status of the National Health Information System (NHIS) in Iraq. The
assessment of theNHIS was carried out by the HIS Stakeholders WorkingGroup inBaghdad, Iraq from 810
March2011
Tableofcontents
ListofAcronyms..................................................................................................................................................3
Foreword............................................................................................................................................................5
Acknowledgement..............................................................................................................................................6
Executivesummary.............................................................................................................................................7
I.Background......................................................................................................................................................9
I.1.HistoricalbackgroundabouthealthadministrationinIraq.......................................................................9
I.2.OrganizationalchartoftheMinistryofHealth........................................................................................10
I.3.NationalHealthStatistics(NHS):.............................................................................................................11
I.3.1.HistoricalBackgroundonstatisticaldepartmentinMOH................................................................11
I.3.2.Health&VitalStatisticDepartment(HVSD).....................................................................................12
I.4.OrganizationoftheexistingHealthInformationSystemsanoverview.................................................13
I.4.1.ContextandResources....................................................................................................................13
I.4.2.PolicyandPlanning..........................................................................................................................13
I.4.3.HISinstitutions,humanresourcesandfinancing.............................................................................14
I.4.4.HISInfrastructure............................................................................................................................16
II.TheHISassessment.......................................................................................................................................16
II.1.Therationale..........................................................................................................................................16
II.2.Theobjectives........................................................................................................................................16
II.3.Themethodology...................................................................................................................................16
II.4.Theworkshops.......................................................................................................................................18
III.FindingsoftheHISassessment....................................................................................................................18
III.1.Resources..............................................................................................................................................18
III.2.EssentialHealthIndicator......................................................................................................................19
III.3.DataSources.........................................................................................................................................20
III.3.1.Populationcensus..........................................................................................................................22
III.3.2.CivilRegistrationandVitalStatisticsSystems................................................................................22
III.4.Datamanagement................................................................................................................................23
III.5.InformationProducts(HISdataquality)................................................................................................23
III.5.1MorbidityIndicators.......................................................................................................................26
III.5.2MortalityIndicators........................................................................................................................26
III.5.3HealthSystemIndicators................................................................................................................26
III.5.4Riskfactorsindicators.....................................................................................................................26
III.6.Disseminationanduse..........................................................................................................................26
III.OverallHIS...............................................................................................................................................28
IV.StrengthsandweaknessesoftheHIS...........................................................................................................29
IV.1.Strengths..............................................................................................................................................29
IV.2.Weaknesses..........................................................................................................................................29
V.Recommendations........................................................................................................................................30
AnnexI:HISAssessmentTool............................................................................................................................32
AnnexII:Listofthestakeholderswhoparticipatedtheworkshop.....................................................................33
AnnexIII:theassessmentresultsoftheCR&VSsystemsofIraq........................................................................34
IraqHealthInformationSystem:ReviewandAssessmentJuly20112
ListofAcronyms
Abbreviation
AIDS/HIV
AR
BHSP
CD
CDC
CR&VS/S
CSO
DOH
DPRD
GGHE
GIS/GPS
GP
HIS/NHIS
HMN
HRH
HVS/D/S
ICD/10
ICT
IMCI
IPSM
ITC
KIMADIA
KRG
LAN
MDG
MOD
MOH
MOHE
MOI
MOLSA
MOO
MOP
MOVEIT
MSSD
NGO
NHA
NHS
PHC/D
PRD
RA
SCTB
STC
SWISH
TB/DOTS
TOT
Description
AcquiredImmunodeficiencySyndromes/HumanImmunodeficiencyVirus
AnnualReport
BasicHealthServicesPackage
CompactDisk
CommunicableDiseasesControlcenter
CivilRegistrationandVitalStatistics/Systems
CenterStatisticalOffice
DirectorateOfHealthinGovernorates
DirectorateofPlanning&ResourceDevelopment
GeneralGovernmentHealthExpenditure
GeographicalInformationSystem/GlobalPositioningSystem
GeneralPractitioner
HealthInformationSystem/NationalHealthInformationSystem
HealthMetricsNetwork
HumanResourceforHealth
Health&VitalStatistics/Department/Section
InternationalClassificationofDiseases/10thversion
InformationandCommunicationTechnology
IntegratedManagementofChildhoodIllnesses
IraqPublicSectorModernizationproject
InformationTechnologyCenter
IraqiStateCompanyforImport.&DistributionofDrugs&MedicalAppliances
KurdistanRegion
LocalAreaNetwork
MillenniumDevelopmentGoals
MinistryofDefense
MinistryofHealth
MinistryofHigherEducation&ScientificResearch
MinistryOfInterior
MinistryofLabor&SocialAffairs
MinistryofOil
MinistryofPlanning
MonitoringofVitalEventsusingInformationTechnology
Medical&SpecializedServicesDirectorate
NonGovernmentalOrganization
NationalHealthAccount
NationalHealthStatistics
PrimaryHealthCare/Department
Planning&ResourceDevelopmentdepartment
RapidAssessment
SpecializedCenterofTuberculosis&ChestDiseases
StatisticalTechnicalCommittee(MOH&MOP/CenterofStatistics)
StateoftheWorld'sInformationSystemsforHealth
Tuberculosis/DirectlyObservedTreatmentShortcourse
TrainingOfTrainers
Abbreviation
UNDGITF
WHO
Description
UnitedNationsDevelopmentGroupIraqTrustFund
WorldHealthOrganization
Foreword
The Ministry of Health (MoH) is pleased to present the Iraq Health Information System (HIS) Review and
Assessment,whichwillcontributeinpavingthewayforthesuccessfulreformofthehealthcaresystemandin
achieving the MoH goal of transforming an inefficient, centrallyplanned and curative carebased health
service into a new system based on preventive and evidencebased, equitable, high quality and affordable
primaryhealthcare.
HIS is one of the Building Blocks of the Health system. It is the corner stone of health system planning,
implementation, management, monitoring & evaluation. Therefore, in the last few years, enormous
investmentshavebeenmadeintohealthinformationsystemsintermsofprovisionofhardware,softwareand
technical expertise; however, these efforts were lacking the required coherence. The frequent unplanned
efforts to put right the various components of health information systems have had little tangible effects,
particularlyintheareaofproducingqualityinformationthatcouldadequatelysupportevidencebasedhealth
careplanninganddecisionmaking,thisshortcomingattributedtolackofaclearHISvision,policyandstrategy.
Obviously, assessment of the existing situations was the first step toward HIS strategic planning. This
assessmentreportwillbeusedasthebasisforprioritizinginvestmentsinHIS,andcontributetoenablingIraq
tomeetMillenniumDevelopmentGoals(MDGs),andNationalDevelopmentStrategy(NDS).
I would like to extend my gratitude to the UNDG ITF for funding the process of developing the Health
Information System Review and Assessment. I would also like to acknowledge the support and technical
assistanceprovidedbytheWorldHealthOrganizationandthevariousdepartmentsofMoHwhichcontributed
tothefinalizationofthisreport.
Letuscommitourselvesandjoinourhandstogethertoachievethenoblecauseofestablishingaresponsive
andmodernhealthcaresystemthatmeetsneedsandaspirationsoftheIraqipeople.
Acknowledgement
ThisassessmentdocumentistheresultofacollaborativeeffortsfromseveralstakeholderstheMinistryof
Health(MOH),MinistryofHealthinKurdistanRegion,theMinistryofHigherEducation(MOHE),theMinistry
ofPlanning/CSO,andtheMinistryofDefense(MOD).
TheassessmenthasbeensupportedbyWHOtofurtherdevelopandenhanceHISinIraq.
TheassessmentoftheHISenjoyedthefullsupportatthehighestlevelsfromH.EDr.MajeedHammedAmeen,
MinisterofHealth,H.E.Dr.TaherAbdullahHawarami,MinisterofHealthinKurdistanRegion,H.E.Dr.Essam
NamiqAbdullah,SeniorDeputyMinsterandDr.HasanHadiBaqir,DirectorGeneralofthePlanning&Resource
DevelopmentDirectoratethattheStatisticdepartmentispartofhisDirectorate.
The aforementioned members encouraged the team to further the idea and that finally resulted in this
assessment.
Theassessmentwasbasedontheinputgivenbydistinguishedandqualifiedworkersinalldirectoratesofthe
Ministry in central level and other health directorates in the governorates and other related stakeholders
through a number of workshops. All participants of the workshops gave their time and efforts and have
contributed greatly to the findings of the assessment. Without their valuable contributions the assessment
wouldhavenotbeenpossible.
TremendouseffortsweremadebythestaffofHealthStatisticDepartmentinMinistryofHealthtostudythe
assessmenttoolandguideparticipantsthroughit.Theresultsofthelastassessmentworkshopwereinstantly
presentedanddiscussedmakingmostuseoftheparticipantscontributions.Theyhavealsogiventheirtime
andeffortstousetheformaldocumentsthatrelatedtotheMinistryslegislations.

Executivesummary
Iraqhasembarkeduponimprovingandmodernizingitshealthcaredeliverysystem.Undertheadministration
oftheMinistryofHealth(MOH)inIraq,thereare229hospitals(generalandspecialized)including61teaching
hospitals. The number of primary health centers, headed by medical doctors, is 1185 and the number of
primaryhealthcenters,headedbymidlevelhealthworkers,is1146.
Although,theMOHisasthemainhealthcareproviderinIraq,therearecurrently92privatehospitalsandthe
privatehealthcaresystemisexpandingrapidly,lately.
The MOH is also the main player in managing health information system in Iraq. Other stakeholders of HIS
includetheMOP/CSOandMOI.DespitetheHealthandVitalStatisticsSections(HVSS)beingresponsiblefor
managing information at DOH level, usually they do not get information on all health events in their areas,
especiallyfromtheprivatesectorandsomeverticalprogrammes.
In the last few years, enormous investment has gone into health information systems in terms of both
hardware and software, but in a fragmented manner. Due to lack of a clear vision, policy and strategy, the
resultsoftheseeffortshavenotbeensofruitful.
InOctober2010,WHOconvenedaworkshopinAmman,Jordan,invitingalltheHISstakeholdersfromvarious
levelsoftherelevantministriestoconductstakeholderanalysisandtodiscusswayshowtostrengthenHISin
Iraq. The October 2010 workshops agreement on conducting the Iraqi HIS assessment, using the Health
Metrics Network (HMN) framework for assessment, as well as the subsequent training and preparatory
workshopsinIraq,resultedinthe810March2011assessmentworkshopinBaghdad.
Theassessmentresults,assummarizedinthebelowtable,puttheNHISinIraqisintheAdequate(62%)range.
Thisisinterpretedasweakwithmostoftheelementsfunctionpoorly.
Categories
Scores
Maximum
Percentage
Assessed
(%)
1. Resources
75
33.5
Presentbutnotadequate
(45%)
2. EssentialHealthIndicators
15
10.0
Adequate(67%)
228
135.5
Adequate(60%)
15
8.0
Adequate(53%)
5. Informationproducts
207
151.0
Adequate(73%)
6. Disseminationanduse
30
15.0
Adequate(50%)
570
353.0
Adequate(62%)
3. Datasources
4. Datamanagement
OverallHIS
Table(1)
Thebelowchartpresenttheaboveresultsgraphically.ItclearlyindicatesthatallcomponentsoftheHISneed
interventionsforimprovements.
OverallHISPerformanceinIraq
Resources
45%
Indicators
67%
Data sources
60%
Data management
53%
Information products
73%
Dissemination & use
50%
Overall HIS
62%
0%
25%
50%
75%
100%
Chart(1)
At present, the HIS does not produce quality information that is required in a timely manner to enhance
efficiencyinmanaginghealthprograms.Lackofeffectivecoordinationamongvariousdepartmentswithinthe
MOH and also among different concerned ministries and statistical institutions, have contributed to the
weaknessofthesystemintermsofdataincompletenessaswellastheirmanagementatalllevels.
Althoughthesurveysandspecialstudiesaregeneratingvaluableinformation,theyarenotoptimallyutilizedin
enhancingefficiencyinmanagingthehealthsystem.Informationdissemination&useisthesecondweakest
componentaccordingtotheassessmentfindings.
Iraq is lacking clear HIS legislation and policies. Available legislations are also not fully enforced. Thus, the
currentHISindeedhasamultitudeofproblems.Inthiscontext,theresultsofthisassessmentwouldhavethe
followingpolicyimplications:
1. EnactmentandenforcementofHISlawsandregulations,
2. Enforcement of a mechanism for coordinating of data collection activities, required for management of
healthsystem,
3. Provisionofharmonizeddatacollection,processinganddisseminationoftoolsandsupportingguidelines,
4. Establishmentofhealthandrelateddatarepositoriesatnationalandgovernoratelevels,
5. Provision of preservice and continuous inservice or on the job training in data management and
informationuse,
6. Provisionandenforcementofacomprehensivenationalhealthinformationstrategy,and
7. Provisionandendorsementofstandardoperatingproceduresfordatamanagement&use.
Theassessmenthasidentifiedanumberofissues,problemsandgapsintheexistingHIS.Eachofthoseneeds
tobeminutelyscrutinizedfromvariousperspectiveswithanaimofproducingqualityinformationinatimely
mannerandensuringtheiradequateusebyallrelevantstakeholders.AclearlydevelopedHISstrategicplan
wouldprovideasolidfoundationfordevelopmentofaresponsivehealthinformationsystem.
The next step in the process of establishing a robust national health information system would be the
developmentofanationalHISstrategicplanthatfullyembracesnationalhealthpolicyguidelinesandcritical
findingsofthisassessment.
I.Backgrou
und
TheRepub
blicofIraqislo
ocatedintheN
NorthoftheArrabianPeninsu
ula,borderedb
byTurkeyfrom
mtheNorth,Iraan
fromEast,KuwaitandSaaudiArabiafromSouth,Jordaan&Syriafrom
mWest.
ThepopulaationofIraqis32.326.011distributedin188governoratess(figure1).
Figgure(1)
ofIraqandthe
ereisanotherM
MinistryofHeaalthinKurdistaan
MinistryoffHealthislocaatedinBaghdad,thecapitalo
RegionlocatedinErbil.
I.1.Historicalbackgrroundabouth
healthadminisstrationinIraq
q
-
Th
hefirstHealthUnitinIraq,headedbyaphyysicianandah
healthinspecto
or,wasestablisshedin1905,
In
n1914,PublicH
HealthManage
ementwasesttablishedandittbelongedtoB
BritishArmyuntil1921,
In
n1921,thePub
blicHealthManagementwassrenamedasP
PublicHealthD
Directorate,
OnSeptember 12,1921,afterthefirstWorrldWar,thefirstIraqiGovernment(RepublicofIraq)was
esstablishedandthePublicHeaalthDirectorattewasconverttedintoMinistryofHealth,
In
n1922,theMin
nistryofHealth
hwasalliedtotheMinistryo
ofInternalAffairs,
In
n1936,itwasrrelatedtotheM
MinistryofSoccialAffairs,
IraqHealthInformationSystem:RReviewandAAssessmentJuly20119
In
n1952,theMin
nistryofHealth
hestablishedaasanindepend
dentMinistry.Sincethenitissresponsiblefor
deeliveringpreveentiveandcuraativehealthservicestoIraqipopulation.
There is also privatee sector, delivering health services througgh private hospitals, clinics, pharmacies an
nd
mainlycurative
ehealthservices.
mediccallaboratoriess,yetitisweakkandprovidem
ConceerningHuman ResourceforH
Health(HRH),tthereisnosep
parationbetweeenpublicandprivatesectorrs;
thesamepersonnelworkinbothssectors.
I.2.OrrganizationalcchartoftheMiinistryofHealtth
TheAd
dministrativeSStructureofthecentralMinisstryconsistsoffmanydirecto
orates

Figgure(2)
IraqHealthhInformationnSystem:RevviewandAsssessmentJuuly201110
Eachoneofthe(18)governorateshasaDirectorateofHealth(DOH),exceptforBaghdad,whichhasthree
HealthDirectorates.EveryDOHsupervisesmanyhealthfacilitiesthatincludeshospitalsandseveralmain
&subprimaryhealthcenters.ThenumberofthesefacilitiesisshowninTable1.
Generalandspecializedpublichospitals
168
Teachinghospitals(General&specialized)
61
Privatehospital
92
Primaryhealthcenters,headedbymedicaldoctors
1185
Primaryhealthcenters,headedbyhealthworkers
1146
TotalNumberofIraqifacilities
2,652
Table1:HealthcarefacilitiesinRepublicofIraq,2010
TotalhospitalsinIraqwithKRGare(229),ofthese(150)generalhospitals&(79)specializedhospitals.
In2004,theMinistryofHealthbeganaprocesstodeterminethemajorissuesinthedevelopmentofthe
nationalhealthsystem.Thisprocessresultedinanumberofkeypolicyinitiatives,includingtheNational
HealthStrategy20042008,andtheupdatedone(20092013)thatincludes26goals.Thesestrategiesand
otherissueswerereflectedinaconferenceofnationalhealthsysteminBaghdadin2008,settingpriorities
andthedevelopmentofthefollowinginterventions:
1.
Basic Health Services Package (BHSP), supported technically by WHO and funded by UNDGITF,
EuropeanFund.ThepackageapprovedinFeb.2010.
2.
IraqiPublicSystemModernization(IPSM)thatbeguninApril,2010.
3.
NationalHealthAccount(NHA)whoseresultswill bereleasedinNationalConference inSeptember

2011.
4.
Applyfamilymedicinesysteminselectedmainprimaryhealthcentersineverygovernorate
5.
Applyreferralsystem.
Planning, monitoring and evaluation are key functions of the ministry to effectively fulfill its
responsibilities. A focus on health outcomes and a resultsbased culture can only be achieved when
relevant, accurate, and accessible evidence and information on performance of the health system are
available.Effectivenessofpolicies,strategiesandprogramimplementationcannotbeevaluatedwithout
soundevidence.TheMOHfulfilstheseresponsibilitiesinanumberofways,includinglookingatpoliciesin
health, priorities and resource generation and their implications, information needs, and generating
appropriatedatafordecisionmaking.
I.3.NationalHealthStatistics(NHS):
I.3.1.HistoricalBackgroundonstatisticaldepartmentinMOH
-
In1949,thestatisticssectionwasestablishedinthePublicHealthDirectorateintheMinistryof
SocialAffairs;
In1952,thesectionwasupgradedtoaDepartmentlevel;
In 1958, the statistics department became a Directorate named Health & Vital Statistics in
MOH;
In1972,thestatisticsdirectoratewaslinkedtotheMinistersOfficeintheMOH;
In1973,thestatisticsdirectoratewasattachedtothePublicMedicalServicesDirectorate;
In 1983, the statistics directorate was turned in to a Department of Health & Vital Statistics
(HVSD),linkedtotheplanning&monitoringdirectorate;
In1985,thestatisticsdepartmentwaslinkedwiththePlanning&HealthEducationDirectorate,
which was renamed into the Planning & Resource Development (PRD) Directorate as it is
currentlynamed;
On16May2000,inordertoenhancethestatisticssystems,twostatisticsunitswereestablished;
studies&statisticalplanningunitandstatisticalstudiesunit;
In2009,thetwounitsjoinedandbecameStatisticalPlanning,StudiesandSystemsSection,which
is responsible for receiving the statistical researches & studies from DOHs as well as receiving
monthlyperformanceevaluationreportsfromHealth&VitalStatisticsSections(HVSS)inDOHs.
I.3.2.Health&VitalStatisticDepartment(HVSD)
The National Health Statistics (NHS) is represented by HVSD in the Directorate of Planning and
Resource Development (PRD), Ministry of Health. The HVSD is represented in all Directorates of
HealthintheGovernorates(DOH)byaHealth&VitalStatisticsSection.Thesesectionsreceivehealth
and health related data from health facilities, arranging them in special designed Statistical tables,
sendingthemonfixeddatetotheHVSD,electricallyinCDsandmanuallyintypedstatisticaltables.
Moreover, there are births & deaths registration offices located in the districts in all Iraqi
Governorates, responsible for registering birth & death events in their surrounding areas. As
mentioned earlier in this report, there is also private health sector, which delivers health services
through private hospitals,clinics,pharmacies and medical laboratories.Yet it isweakand providing
mainlycurativehealthservices.TheMOHdoesn'thaveanylawforregulatingtocapturehealthdata
fromtheprivatesector,exceptforthenumbersofinpatientsandtheircausesofadmission,whichthe
private hospitals report to the HVSD. Concerning the registration of birth & death events that took
place in private sectors, they ought to be recorded in the same birth & death certificate which are
usedinpublichealthfacilities,andthenendorsedinthebirth&deathofficesofMOH.
HVSDismainlyconcernedwithcolletingstatisticaldata,analyzingthemandproducingAnnualReport
(AR),amatterthatmakeshealthinformationavailable.
In order to obtain accurate, reliable, relevant, uptodate and timely health and health related
informationandmakeitavailableandaccessibleforhealthmanagersatdifferentlevelsofthehealth
system,HVSDdeveloped&distributedthefollowingguidelinestoallstatisticalsectionsinDOHtobe
usedinfillingthestatisticalreports:
1.
Guidanceforregistrationofbirths,stillbirthsanddeaths,2009;
2.
Guidancefortheuseofworkersinmedicalrecordsofhealthfacilitiesintheministry,published
byWHO,2005.
Theavailableinformationshouldbeableto:
-
Supportdecisionmakingatdifferentlevelsofhealthmanagement;
Permittheformulationofhealthpolicies,plansandstrategies;
Permitmonitoringandevaluationofimplementationsofhealthplans;
Permithealthservicesmanagementatmacrolevels;
Allowmeasuringhealthstatusofthepopulationandmonitoringtrendsandchanges;
Allowtoidentifyhealthandhealthrelatedproblemsandtheirprioritization;
Permitidentificationofhealthcareandmedicalneeds
Permittheevaluationofeffectivenessofthehealthsystemperformance
Permittheevaluationofhealthstatusandhealthsystemperformanceincomparisonwithother
relevantandneighboringcountries.
Although, the NHS in Iraq has made progresses over the years; still there are deficiencies in data
disseminationanduse.Thereareanumberofgapsandweakareas,whichneedtobeidentifiedand
addressed. The development of statistical skills of the statisticians & IT staff at the central and
governorateslevelsisregardedasoneoftheprioritiesthattheMOHneedstotackle.
Intheupdatedhealthstrategy,thedecisionmakersconfirmthatdevelopinganevidencebasedHISis
oneofthestrategicgoalsthatmustbeachievedinthecomingfiveyears.
ThisreviewandassessmentofHISclarifytherealityofcurrentsituationinordertocreatestrategic
planthatcontributestoenhanceHIS,toenableustoplanandmonitorhealthsystemwithqualityand
timelydataandinformation.
I.4.OrganizationoftheexistingHealthInformationSystemsanoverview
I.4.1.ContextandResources
Before2003,Iraqwascompletelyisolatedfromtheworld.Allpublic&privatesectorsweresuffering
due to deficiency in the communication and development systems & programs.Health information
systems were completely paperbased and manually processed because of the lack of computers,
network systems and personnel capacity. Since 2004, MOH realized the importance of information
technology (IT) in collecting & processing health information. So, the MOH initiated the use of
moderntechnologyinitshealthfacilitiesatthecentralandprovinciallevels.
In Phase I of Strengthening Primary Health Care Project, many statistical & Information Technology
(IT)staffworkinginMOHhasbeentrainedonhowtousecomputersanddesignspecialprogramsthat
wouldcontributetostrengtheningtheHIS.Also,numerouscomputersandserverswereprovidedto
DOHs in Baghdad andother governorates. The Information Technology Center(ITC) designedmany
computerprogramsforenteringdatafromspecialhealthprograms(HealthVisitor,FamilyMedicine),
linkingelectronicallyPrimaryHealthCenters(PHCs)withDOHs.Thissystemiscurrentlyusedinabout
300PHCsinIraqandnotablyreflectedinMaysanDOH.
Certain public hospitals developed Patient Management Programs that follow patients from their
entry to the hospital record system until receiving medicine from the pharmacy. Ibn ALRushed
MentalHospitalinBaghdad,ALRusafaDOH,isoneofthehealthfacilitieshavingsuchasystem.
There are fragmented software programs that deal with some healthrelated data management
including management and maintenance of medical devices in three hospitals in different
governorates.YettheseprogramsneedtobeoptimizedandbecomepartoftheMOH.
The MOH planned to carry out assessment of the current situation of HIS in Iraq, identify priority
areasforinterventionwithinthesixHIScomponentsandfillthegaps.Thisprocessisalsointendedto
leadtodevelopmentofaHISstrategicplanforIraqtostrengthenHISthatwilleventuallyresultinto
improvedandevidencebaseddecisionmakingsystem.OneofthegoalsoftheStrategicplanistolink
allhealthfacilitiesinthecountrythroughanetworkinordertocaptureaccurateandtimelyhealth
information.
I.4.2.PolicyandPlanning
Asmentionedabove,theNHSisrunbyMOH,thereforeobjectives,strategiesandproceduresforall
components of HIS that are laid out and documented, are applicable only to MOH health facilities.
Thereareanumberofoperationalandpolicydocumentsandfunctioningcommitteesthatregulate
andcontrolthefunctionsandmechanismsoftheNHS.Theseinclude:
-
HealthLaws,RegulationsandGuidelines2009,thecompletecollectionsofhealthlegislation;
BirthsandDeathsRegistrationlawNo.148.1971;
GuidanceforRegistrationofBirths,Stillbirths,andDeaths,2009;
PublicHealthLaw,2009
Guidance for the workers in Medical Records applied in the Health Facilities in the Ministry,
publishedbyWHO,2005;and
AnnualReport(AR),2009
I.4.3.HISinstitutions,humanresourcesandfinancing
The HIS is the responsibility of HVSD within the Directorate of Planning & Resource Development
(PRD)ofMOH(refertofig.2organizationalchartoftheMOH).TheHVSDisaseparatebodywithin
the PRD in MOH. It is fully equipped with computers, printers, scanners, CD writers and
communication facilities including telephone lines, and internet accessibility. The HVSD has units in
theplanningdepartmentsofallDirectoratesofHealth(DOH)atgovernoratelevel,calledHealthand
VitalStatisticsSection(HVSS).
ThefollowingtableshowsthestaffingpatternofHISorhealth&vitalstatisticsrelatedstaffinIraq.
Location
Numberofstaff
HVSDatthecentrallevel
48
HVSSatGovernoratelevel
1520
Healthcareatdistrictlevel
23
Hospitalstatisticsunits
1520
Healthstatisticsrelatedstaffathealthcenterlevel
12
Birthanddeathsregistrationoffices
68
Table(3)
ThebelowtableshowsthecurrentactualnumberofHIS/statisticsrelatedstaffinIraq.
Registrationofbirthsanddeathsatthegovernorates
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
KarkhOfficeofHealth
RusafaHealthOffices
BasraHealthoffices
NinevehHealthoffices
MaysanHealthOffice
Diwaniyaoffices
Diyalaoffices
Anbar,offices
BabelOffice
Karbalaoffices
KirkukOffice
WasitOffice
DhiQarOffice
Muthannaoffices
SalahalDinoffices
Najafoffices
Currentnumberofstaff
13
22
7
30
13
6
18
18
15
7
11
14
19
8
9
8
AllOffices(total)
218
Table(4)
Communications among HVSD and HVSSs are established via telephone and fax. There is no Wide
AreaNetwork(WAN);however,dataexchangestakeplacethroughmanualreports,exchangeofCDs
andoccasionallythroughemails.
Datacollectedfromvarious healthfacilitiesatthefieldlevelissenttotherespectiveDOH/HVSSat
the governorate level. The HVSS compiles and arrange these data in specially designed statistical
tablesandthensenditonfixeddates,electricallyinCDsandalsohardcopiesofthestatisticaltables
forfurtheraggregationandanalysistotheHVSDatnationallevel.
PrivatehospitalsandhealthcareprovidersotherthantheMOH,although,havestatisticalunits,but
these units are not well established as those in the MOH. Communication between the non
government health care providers and the MOH is very limited. More coordination is required to
furtherenhancecommunicationsanddataexchange.
InadditiontoHVSDandHVSSs,otherunitswithinMOHalsocapturesomehealthandhealthrelated
data.Thesearemainlyspecializedunitsincertainhealthdomainse.g.sectionofnoncommunicable
diseases, which hosts diabetes, hypertension & cardiovascular diseases; Cancer Registering Council
that hosts cancer registry; Communicable Diseases Control center (CDC) that hosts communicable
diseasesurveillance;SpecializedCenterforTuberculosisandChestdiseasesthathostthetuberculosis
registry; National AIDS center that hosts HIV registry; Medical & Specialized Services Directorate
(MSSD) and Emergency Medicine Department, which host data sets for occupational injuries,
poisoningregistry,androadtrafficaccidentsdata.
Othersourcesofhealthrelatedinformationcomefromorganizationsotherthanhealthorganizations
e.g. Medical Affairs Directorate in Ministry of Defense (MOD), Ministry of Labor & Social Affairs
(MOLSA),MinistryofOil(MoO),MinistryofInterior(MOI).
Insummary,therearemultiplesourcesofhealthinformation,withinandoutsidetheMOH,making
the health informationsystem partially fragmented.Although there are links among such units and
HVSDhostingtheNationalHealthStatistics(NHS),morecoordinationisrequired.Coordinationshould
helptomakedatatimelyandaccuratelyavailabletoHVSDandtoreduceburdenofdatamanagement
fornonstatisticalunits.
Statistical units in the country, comprising the NHS, are run by physicians, statisticians, IT
programmers,inadditiontoadministrativestaff.Theyaretrainedonhowtodealwithhealthrelated
data through on job training and training courses in collaboration with nongovernmental
organizations, donors, local specialized institutions in Baghdad and ALMustanseriya Universities,
MinistryofHigherEducation&ScientificResearch.
In 2008, the International Classification of Diseases (ICD) has been applied in filling the statistical
tables in MOH. In 2007, 2009 and 2010, in collaboration with WHO, several international training
coursesonICD10wereconductedinAmmanandIstanbulasTrainingofTrainers(TOT).Inaddition,
manynationaltrainingcoursesonICDwereconductedthatcomprise25%oftheworkersintheHVSD
&HVSSsinallIraqiprovincesincludingKurdistanRegion.
There are no epidemiologists assigned in the statistical services of the MOH. Physicians who are
specialized in community medicine and General Practitioners (GP) work mainly as directors of the
department.Theuseofdataandinformationismainlyatthediscretionofthosedirectors.Thereisa
need to further strengthen the coordination among the directors and other staff who work in the
statisticalunits.
Coordination should be established andbrought to all stepsof capturing, processing, analyzing and
reporting health data and not merely for directors to use the outputs. More strong coordination
amongHVSDandITCisrequiredandisconsideredacrucialelementforfurtherdevelopmentofHIS.
HVSD supervising the HVSSs does not have an independent budget but financed through the
recurrentbudgetofMOH.Allequipments,humanresourcesandsoftwarerequirementsareplanned
andincurredthroughMOHprocurementmechanisms.
I.4.4.HISInfrastructure
Asmentionedearlier,HVSD&HVSSsarefullyequippedwithcomputers,printers,scanner,CDwriters
andothercommunicationfacilitiesincludingtelephonelines,andinsomecasesinternetaccessibility.
The HVSD is housed in the MOH main building. The MOH main building has a Local Area Network
(LAN). This LAN is being used for certain programs that are designed by ITC staff e.g. Electronic
ArchivingSystemthatcurrentlyworksintheAdministrativeDirectorateofHospitalRecordingSystem.
Moreover,certainMOHDirectoratese.g.theStateCompanyofMarketingDrugs&MedicalSupplies
(KIMADIA)hasanelectroniclinkbetweenMOH&someofDrugStoresandappliedinventorysystem.
II.TheHISassessment
II.1.Therationale
Inthelastfewyears,enormousinvestmentshavebeenmadeintohealthinformationsystemsintermsof
provisionofhardware,softwareandtechnicalexpertise,butinaratherfragmentedmanner.Thefrequent
adhoceffortstorevampthevariouscomponentsofhealthinformationsystemshavehadlittletangible
effects,particularlyintheareaofproducingqualityinformationthatcouldadequatelysupportevidence
basedhealthcareplanninganddecisionmaking.Thisdrawbackisattributed,toalargeextent,tolackofa
clearHISvision,policyandstrategy.
ThecallforanenhancedHISwasfurthernecessitatedbytheneedtoprioritizeandstreamlinetheinflow
of resources into the healthcare system for bringing about quality and measureable outputs and
outcomes. Obviously, assessment of the existing situations was the first step toward HIS strategic
planning.ThisassessmentreportwillbeusedasthebasisforprioritizinginvestmentsinHIS.
II.2.Theobjectives
ThemainobjectiveoftheHISassessmentwastocreateunderstanding,enhanceavailabilityandquality,
and foster use of health information for improvement of the healthcare system in Iraq. The specific
objectivesoftheexercisewereto:
Establish an objective baseline for subsequent followup evaluations assessment findings should
thereforebecomparableovertime;
InformstakeholdersofaspectsoftheHISwithwhichtheymaynotbefamiliar;
Build stakeholder consensus and understanding around the priority needs for health information
systemstrengthening;and
Mobilizejointtechnicalandfinancialsupportforthedevelopmentandimplementationofanational
HISstrategicplan.
II.3.Themethodology
The assessment of HIS in Iraq was carried out in collaboration with other stakeholders. The process of
assessment was first discussed with the stakeholders through a workshop in Amman in Oct. 2010.
Following the workshop, two committees (HIS Steering Committee and Assessment Implementation
Committee), headed by H.E the Minister of Health, were established. The assessment Implementing
CommitteeheldseveralmeetingsonthesubjectandpresentedtheirreportstotheSteeringCommittee.
Duringthediscussions,consensuswasreachedonthekeyrolesofthestakeholdersintheHISassessment,
astheyaretheparticipantsofthoseactivitiestobeassessedintheprocess.
Assessment of the HIS took place over a period of 6 months; through a series of workshops and
consultation meetings. The last consultation took place in Erbil in Feb. 2011 where the assessment
implementationcommitteereviewedandfinalizedtheassessmentplan.Thefinalassessmenttookplace
throughastakeholdersworkshopinBaghdadinMarch2011.
Technical support from WHO consultant Mr. Khan Aseel was provided in the form of training of the
assessmentimplementingcommitteemembersonhowtodividethestakeholdersintogroupsaccording
to themes for the assessment exercise as well as on the methodology for review and scoring the
assessmentquestions,providedintheHealthMetricsNetwork(HMN)assessmenttoolforHIS(AnnexI:
TheHMN/HISAssessmentTool).
HISassessmenttool,whichisbasedontheHMNHISFrameworkandStandardsforCountryHealth
InformationSystems,isaquestionnairewith197questionsdividedonthesixHIScomponentsasthe
following:
HIScomponent
Input
Includes:
PolicyandPlanning
HISinstitutions,humanresources
andfinancing
HISInfrastructure
1.Resources
Tocoverthreedomains:
1.determinantsofhealth;
2.healthsystem;
3.healthstatus
Populationbased
1.Censuses
2.Civilregistration
3.Populationsurveys
Institutionbased
4.Individualrecords
5.Servicerecords
6.Resourcerecords
Comprises:
datacollection,
storage,
analysis
process&compilation
2.Indicators
Process
3.DataSources
4.DataManagement
Output
No.of
questions
25
83
5.Informationproducts
Thesequalitiestobeassessed:
Datacollectionmethod
Timeliness
Periodicity
Consistency
Representativeness
Disaggregation
Adjustmentmethod
69
6.DisseminationandUse
10
Total
197
Table(5)
Foreachquestionfour(4)mutuallyexclusivescenariosareproposedwithscoresfrom3,2,1,0asshownin
thebelowchart.
Highlyadequate
Adequate
Presentbutnot
adequate
1
Notadequateatall
0
Chart(2)
Themethodforscoringissothatoneoftheparticipantsreadaquestionoutloadwiththefourproposed
scenarios for that specific question. The participants discuss the question and refer to the relevant
documents,ifany,andreachtoconsensusonascore.Theconcernedscoreisthenrecorded.Thismethod
isrepeatedforeveryquestion.
Ifaquestionisnotrelevantornoneoftheparticipantsknowstheanswer,thenthatquestionisescaped
and not scored, which means the situation related to that specific question was not assessed and
therefore no score will be added to the total scores.The same question will also be excluded from the
denominatorforcalculatingaveragescoreforasection.
DuringtheMarch2011assessment,outofthetotal197questions,only7questions,whichwererelated
topopulationcensus,werenotassessed.
Also, this needs to be mentioned here that the assessment of the National Civil Registration and Vital
Statistics Systems in Iraq were assessed in the same sitting, using the WHO Framework for Rapid
AssessmentofNationalCivilRegistrationandVitalStatisticsSystems.
II.4.Theworkshops
The assessment workshop had targeted different users and producers of health information as well as
differentlevelsofdecisionmakers.TheHealthMetricsNetwork(HMN)assessmenttoolwasusedwithout
modification.
Oneassessmentworkshopwasperformedfrom810March2011withtheparticipationof38participants
fromdifferentstakeholders,usingtheHMNassessmenttooltoassesstheHISasawhole,butthelastday
oftheworkshopwasdevotedtoassesstheCivilRegistrationandVitalStatisticsSystemsspecifically.
Infact,thelargeteamof38peoplewasformedoutoftheeightdifferentgroups,asrecommendedbythe
HMN GroupBuilding tool for answering different parts of the HMN assessment questionnaire. The
assessment team was leadby the Director ofDonors Affairs Section of the MOH.The TeamSecretaries
includedtwopersonsfromtheHealth&VitalStatisticDepartmentoftheMinistryofHealth.(AnnexII:list
oftheworkshopsparticipatingstakeholders.)
III.FindingsoftheHISassessment
Forthesakeofconsistency,theresultsfromthe810March2011HISassessmentworkshopinBaghdad,are
presentedhereintheorderofthesixcomponentsaspresentedintheHISassessmenttool.
III.1.Resources
AccordingtotheHISframework,componentofresourcesisfurtherdividedintothreegroupsincluding:
A. PolicyandPlanning
B.
HISinstitutions,humanresourcesandfinancing
C.
HISInfrastructure
There are 25 questions for covering assessing the three groups related to resources. All the questions
werescoredduringtheassessment.
Scores
Maximum
Assessed
Categories
A.PolicyandPlanning
21
9.0
B.HISinstitutions,humanresources
andfinancing
39
14.0
C.HISInfrastructure
15
10.5
Total
75
33.5
Percent(%)
(43%)
(36%)
Adequate
(70%)
(45%)
Table(6)
As indicated in the summary table above, the combined average score of the three groups related to
resourcescomponentfallsinthepresentbutnotadequate(45%)status.Thetwomostimportgroupsof
theresourcescomponentincludingpolicyandplanningandinstitutions,human&financeresources,
whichcomprisethebackboneofanationalhealthinformationsystem,areveryweak.
However, the HIS infrastructure group, which includes data recording and reporting materials,
information processing and communication equipment and technologies, is comparatively good with
adequate(70%)scoring.Seethebelowchartforgraphicpresentationofthesummaryfindings.
1.Resources
45%
Overall
43%
Policy and planning
36%
Institutions, HR and financing
70%
Infrastructure
0%
25%
50%
75%
100%
Chart(3)
III.2.EssentialHealthIndicator
Coreindicatorsareneededtoassesschangeinthreemajordomains:
Determinants of health these include socioeconomic, environmental, behavioral, demographic and
genetic determinants or risk factors. Such indicators characterize the contextual environments in which
the health system operates. Much of the information is generated through other sectors, such as
agriculture,environmentandlabor.
Health system indicators include inputs to a health system and related processes such as policy,
organization,humanresources,financialresources,healthinfrastructure,equipmentandsupplies.There
arealsooutputindicatorssuchashealthserviceavailabilityandquality,aswellasinformationavailability
andquality.Finallythereareimmediatehealthsystemoutcomeindicatorssuchasservicecoverageand
utilization.
Health status indicators include levels of mortality, morbidity, disability and wellbeing. Health status
variables depend upon the efficacy and coverage of interventions and determinants of health that may
influence health outcomesindependently ofhealth servicecoverage.Health status indicatorsshould be
available stratified or disaggregated by variables such as sex, socioeconomic status, ethnic group and
geographicallocationinordertocapturethepatternsofhealthinthepopulation.
Scores
Categories
Percent
Maximum
Assessed
15
10.0
EssentialHealthIndicators
(%)
Adequate
(67%)
Table(7)
Forassessingtheindicatorscomponent,therearefivequestions,whichallthefivewerescoredduring
the assessment. The assessment score as presented in the above table puts the current status of
indicatorsinadequate(67%)status.
2.Indicators
Indicators
67%
0%
25%
50%
75%
100%
Chart(4)
Despitetheassessmentfindingsofindicatorsasadequate,theparticipantsoftheassessmentworkshop
were of the opinion that additional indicators for measuring changes in fields such as economy,
environmentalhealth,occupationalhazardsandMDG,wouldneedtobedefined.
III.3.DataSources
There are different sources of data for an HIS. According to the HMN framework, these sources are
classifiedintothefollowingtwomaincategories:
Populationbased
1.Censuses
2.Civilregistration(vitalstatistics)
3.Populationsurveys
Institutionbased
4.Individualrecords(healthanddiseasesrecordincludingsurveillance)
5.Healthservicerecords
6.Resourcerecords
Theassessmentofthesixdatasourceslookedintowhether;
a.
Contentofthedatabeingcollectedwererelevantandalsosufficienttotheneeds,
b.
Thecountryhasadequatecapacityandpracticesinhandlingdatafromsources,
c.
Informationandreportsgeneratedfromthesourcesaredisseminatedandontimelybasis,
d.
Variouspiecesofdata/informationintegratedandutilized.

Duringtheassessment,76outofthetotal83questionsrelatedtodatasourcescomponentoftheNHIS
Iraq were assessed and scored. The seven questions that were skipped during the assessment were
relatedtopopulationcensusandvitalregistrationandwerenotrelevanttothesituations.
DataSource
1.Census
2.Vitalstatistics
3.Populationbased
surveys
4.Healthanddisease
records(incl.
surveillance)
Contents
Notassessed
Highly
adequate
100%(9.0/9)
Highly
adequate
100%(9.0/9)
Adequate
67%(6.0/9)
5.Healthservice
records
Notadequate
atall
0%(0.0/6)
6.Resourcerecords
Adequate
60%(14.5/24)
Total
Capacity&
Practices
Dissemination Integrationand
use
Total
Presentbutnot
Presentbutnot
Adequate
Notassessed
adequate
adequate
50%(3.0/6)
33%(4.0/12)
(42%)
Highly
Highly
Highly
Adequate
adequate
adequate
adequate
60%(9.0/15)
100%(3.0/3) 100%(3.0/3)
(90%)
Highly
Highly
Highly
Highly
adequate
adequate
adequate
adequate
100%(12.0/12) 100%(6.0/6) 100%(6.0/6)
(100%)
Highly
Presentbutnot
Highly
Adequate
adequate
adequate
adequate
(65%)
79%(16.5/21) 33%(1.0/3)
83%(5.0/6)
Presentbutnot
Presentbutnot
Adequate
Adequate
adequate
adequate
50%(3.0/6)
56%(5.0/9)
29%(3.5/12)
(34%)
Presentbutnot Notadequate Presentbutnot Presentbutnot
adequate
atall
adequate
adequate
42%(14.0/33)
0%(0.0/6)
25%(3.0/12)
(32%)
Adequate
(60%)
Table(8)
The summary assessment results,as shown inthe above table, suggestthat generally the data sources
areadequate(60%),butweak.Thesametableshowsthatpopulationsurveysandvitalstatisticsare
thetwowellfunctioningdatasources,whiletheresourcerecordsandhealthservicerecordsarethe
mostinadequateandrarelyusedsourcesofdataforthenationalHISinIraq.
The vital statistics functions were assessed as highly adequate (90%). The reason is, most probably,
that;birthanddeathregistrationlawno.148,1971isobligatory,whichshouldbestrictlyfollowedbyall
relatedIraqiinstitutionswhetherpublicorprivate.
However,theabsencesofdetaileddataaboutbirthsanddeathsthattakeplaceoutsidehealthfacilities
representanimportantobstacle,thoughitrepresentsabout10%ofearlyneonataldeathsandstillbirths.
TheHVSDregularlyproducesspecialstatisticalreportscomprisesbirth,stillbirthanddeath.
BelowgraphdepictstheHISassessmentfindingsforthedatasources.
3.Datasources
Overall
60%
Census
42%
Vital statistics
90%
Population-based surveys
100%
Health & diseases records
65%
Health service records
34%
Resource records
32%
0%
25%
50%
75%
100%
Chart(5)
Thereareothersourcesofinformationthatareconsideredimportantandarebeingregularlyusedbutdo
notconstitutepartoftheinformationreportedbyHIS.Theseinclude:
Recordsfromotherministries,e.g.MinistryofSocialAffairs,MinistryofHigherEducation&Scientific
Researchandothers
RecordsfromMinistryofEnvironment,MinistryofMunicipality(waterandsanitationreports)
Healthresearchesandstudiespublishedinpeerandnonpeerjournals
III.3.1.Populationcensus
ThelastcensusinIraqwasconductedin1997,morethan10yearsago.However,thenextroundof
census,whichwasoriginallyplannedforOctober2009,hasbeenrescheduledseveraltimes,withthe
latesttoundefineddatein2011.
III.3.2.CivilRegistrationandVitalStatisticsSystems
ItisworthmentioningherethatbecauseoftheimportanceofCivilRegistrationandVitalStatistics
(CR&VS) Systems as well as a global special focus on strengthening CR&VS systems as part of the
Monitoring of Vital Events using Information Technology (MOVEIT) initiative to assess progress
towards the MDG, the last day of the (810 Mar, 2011) assessment workshop was allocated for
assessing the CR&VS Systems, using the WHO framework Rapid Assessment of National Civil
RegistrationandVitalStatisticsSystems.
TheCR&VSrapidassessmenttoolhas25questionsin11differentareasrelatedtothesubject.The
assessing method is the same as the HMN/HIS assessment tool where there are four scenarios for
eachquestionandthescoringorderis3(highest),2,1and0(lowest).
Through the assessment, the scores gained were 54 out of 75 or 72%. According to the WHO
frameworkforCR&VSrapidassessment,scoresbetween65%and84%indicatethatCR&VSSfunction
butwithsomeelementsthatfunctionpoorly.(AnnexIII:theassessmentresultsoftheCR&VSsystems
ofIraq).
III.4.Datamanagement
Datamanagement,accordingtotheHMNframework,coversallaspectsofdatahandlingfromcollection,
storage, qualityassurance and flow, to processing, compilation and analysis. Specific requirements for
periodicityandtimelinessaredefinedwherecriticalasinthecaseofdiseasesurveillance.
Forassessingthedatamanagement,therearefivequestionsintheassessmenttoolwithmaximumtotal
scoresof15.
Scores
Categories
Datamanagement
Maximum
Assessed
15
8.0
Percent(%)
Adequate
(53%)
Table(9)
The assessment results for data management, as shown in the above table, are in the lower range of
adequate(53%).Thisscoreindicatesthatseveralelementsofthedatamanagementareweakandneed
tobestrengthened.
ThebelowchartisthegraphicpresentationofdatamanagementinHISIraq.
4.Datamanagement
Data management
53%
0%
25%
50%
75%
100%
Chart(6)
Thecurrentdatamanagementpracticesinclude:
1.
At the level of health facilities (PHCs, hospitals) a record of all services & activities are collected
monthly,throughfillingspecialstatisticaltablesandthensenttoHVSSsinDOHs.
2.
HVSSsinDOHscollectthedatathatcomesfromallhealthfacilities,unifythemandthensendthem
toHVSDashardcopiesofthestatisticaltables&CDsonregularbasis.
3.
HVSDalsoreceiveshealthdatafromspecializedhealthfacilitiesandfromotherministriesandprivate
sectors,analyzesthosedata,discussesthecurrentsituationofhealthandproduceannualreport.
4.
Concerning notifiable diseases data, they are reported by the health facility as soon as the event
occursbyanycommunicationmeans;telephone,email,orwrittenreporttoDOHandMOHandthey
inturnaresupposedtotakeappropriatemeasurestorespondtotheproblem.
Although,healthworkersinallhealthfacilities,HVSSsandHVSDareactivelyinvolvedincollectingdata,
analyzingthemandprovidereportstodecisionmakers,the53%assessmentscoreimpliesthatthereisa
needtofurtherstrengthenthedatamanagementcomponentofHISinIraq.
III.5.InformationProducts(HISdataquality)
The assessment questionnaire has 69 questions under the information products (HIS data quality)
component. Those questions cover quality assessment related to the following information products
(indicators):
a)
Under5mortality(allcauses)
b) Maternalmortality
c)
HIVprevalence
d) Measlesvaccinationcoverageby12monthsofage
e) Deliveriesattendedbyskilledhealthprofessionals
f)
Tuberculosis(TB)treatmentsuccessrateunderDOTS
g)
Generalgovernmenthealthexpenditure(GGHE)percapita(ministryofhealth,otherministries
andsocialsecurity,regionalandlocalgovernments,extrabudgetaryentities)
h) Privateexpenditureonhealthpercapita(households'outofpocket,privatehealthinsurance,
NGOs,firmsandcorporations)
i)
Densityofhealthworkforce(totalandbyprofessionalcategory)by1,000population
j)
Smokingprevalence(15yearsandolder)
Thefollowingqualityattributeswereincludedintheassessmentoftheaboveindicators:
Datacollectionmethod,
Timeliness,
Periodicity,
Consistency,
Representativeness,
Disaggregation,and
Adjustmentmethod)
The assessment summary results for the information products (HIS data quality) are presented in the
followingcrosstable.
Data
collection
method
Timeliness
Periodicity
Consistency
Representati
veness
Disaggregati
on
Adjustment
method
Overall
a) <5mortality(allcauses)
100%
67%
100%
100%
100%
100%
100%
95%
b) Maternalmortality
100%
67%
100%
100%
100%
100%
100%
95%
c) HIVprevalence
33%
100%
100%
100%
67%
100%
NA
83%
d) Measlesvacc.coverage
67%
0%
100%
33%
100%
100%
NA
67%
e) Deliveriesbyskilledh.prof.
100%
100%
100%
100%
100%
100%
NA
100%
f) TBtreat.DOTSsuccessrate
100%
100%
100%
100%
100%
100%
NA
100%
g) GGHE)percapita
33%
0%
0%
33%
0%
17%
67%
21%
h) Privateh.expend.percapita
33%
33%
33%
33%
67%
50%
67%
45%
i) H.workforce/1,000popul.
33%
100%
100%
100%
NA
83%
NA
83%
j) Smokingpreval.(>15years)
0%
67%
100%
67%
100%
100%
NA
72%
56%
63%
81%
74%
79%
83%
78%
73%
Qualityattribute
Indicator(Info.Product)
Allindicators
Note: While the color scheme in the table follows the same trend as before, a blank cell means that
assessingtheindicatoragainstthespecificqualitywasnotapplicable.
Table(10)
5.HISdataquality(byinformationproduct/indicator)
A. <5 mortality
95%
B. Maternal mortality
95%
C. HIV prevalence
83%
D. Measles vacc. coverage
67%
E. Deliveries by skilled h. prof.
100%
F. TB treatment success rate under DOTS
100%
G. GGHE per capita
21%
H. Private expenditure per capita
45%
I. Health workforce 1,000 population
83%
J. Smoking prevalence (15 years and older)
72%
All indicators
73%
0%
25%
50%
75%
100%
Chart(7)
Results of the summary crosstable (above) and the chart below indicate that except for the health
expenditureindicators(g.Generalgovernmenthealthexpenditure(GGHE)andh.Privateexpenditureon
health),therestoftheinformationproductsarewellmaintainedandregularlycheckedfortheperceived
qualityattributes.
5.HISdataquality(byqualityattribute)
Data-collection method
56%
Timeliness
63%
Periodicity
81%
Consistency
74%
Representativeness
79%
Adjustment
method
Disaggregation
83%
Estimation method
78%
Overall
73%
0%
25%
50%
75%
100%
Chart(8)
The above chart indicates that in comparison to the other attributes, Data collection method and
TimelinessarethetworelativelyweakqualitiesoftheinformationproductsintheNHISinIraq.
III.5.1MorbidityIndicators
Morbidityindicatorsarecalculatedfromdifferentsourceshealthanddiseasesrecordscollectedon
monthly basis (part of routine health information system) and from health surveys. Health and
diseases records of MOH facilities constitute the main source of morbidity from routine health
informationsystem.RecordsofhealthcareprovidersotherthanMOHarenoteasilyaccessibletobe
obtainedastheydonothavestronginformationorstatisticalunits.
ThehealthservicesinIraqisprovidedfreeofchargetoallcitizens.Thisisinfavorofhighcoveragefor
morbidity,ifcapturedfromhealthcarefacilities.Theroutinehealthinformationsystemensuresthe
availability of morbidity statistics (with its limited coverage) on monthly basis. In addition, data are
validatedandcheckedregularlyforcompletenessandaccuracy.
III.5.2MortalityIndicators
Mortalityindicatorsareproducedusingdatafromdifferentsourcesthehealthanddiseasesrecords
whichprovidedataoninpatient(hospitaldeaths),casesthatarebroughtdeadanddeathshappening
inaccidentandemergencydepartments.Italsoprovidescausespecificdeaths,e.g.deathsbecauseof
acute respiratory diseases, protein energy malnutrition, tuberculosis and HIV. Mortality data are
availableonmonthlybasisfromMOHfacilities.Healthanddiseasesrecordsforcareprovidersother
thanMOHarealsoobtainedonregularbasisfordeaths,butonlyonannualbasis.
Vitalregistrationsystemandnotificationsofdeathsisanotherimportantsource.
III.5.3HealthSystemIndicators
Theroutineinformationsystemcapturesdataregularlyonmonthlybasisthatdescribehealthsystem
resources,utilizationandoutputs.Dataareregularlyvalidatedandcheckedforappropriatenessand
consistency.TheseappliedinallMOHhealthfacilities.
III.5.4Riskfactorsindicators
Health surveys and studies are the main source of information on indicators that describe
determinantsofhealth.Asdescribedearlierinthereport,alargescale,multipleindicatorsurveyis
executedevery45yearsinadditiontootherindividualstudies.Effortsaremadesuchthathealth
surveysareexecutedwithproperandrepresentativesamplesthatwouldensuretheresultscanbe
generalizedtothetargetpopulation.
III.6.Disseminationanduse
Under the dissemination and use component, there are 10 questions in the assessment questionnaire,
coveringfiverelatedareas.Theseinclude:
a) Analysisanduseofinformation,
Demandfromseniormanagersandpolicymakersforcomplete,timely,accurate,relevant
andvalidatedHISinformation,
Wideruseofuptodateandclearlyunderstoodgraphsfordisplayinginformationatsub
nationalhealthadministrativeofficesandhealthfacilities,
Wideruseofuptodateandclearlyunderstoodmapsfordisplayinginformationatsub
nationalhealthadministrativeofficesandhealthfacilities.
b) Informationuseforpolicyandadvocacy,
RegulardistributionofintegratedHISsummaryreportsincludinginformationona
minimumsetofcoreindicators(includingthoseusedtomeasureprogresstowardsachieving
theMDGsandthoseusedbyGlobalHealthPartnerships,ifapplicable)toallrelevantparties.
c) Informationuseforplanningandprioritysetting,
Demonstrableuseofhealthinformation(populationhealthstatus,healthsystem,risk
factors)intheplanningandintheresourceallocationprocesses(e.g.forannualintegrated
developmentplans,mediumtermexpenditureframeworks,longtermstrategicplans,and
annualhealthsectorreviews).
d) Informationuseforresourceallocation,
WideruseofHISinformationisbydistrictandsubnationalmanagementteamsforsetting
resourceallocationsintheannualbudgetprocesses,
UseofHISinformationinadvocatingforequityandincreasedresourcestodisadvantaged
groupsandcommunities(e.g.,bydocumentingtheirdiseaseburdenandpooraccessto
services).
e) Informationuseforimplementationandaction.
Useofhealthinformationbymanagersathealthadministrativeofficesatalllevels(national,
regional/provincial,district)forhealthservicedeliverymanagement,continuousmonitoring
andperiodicevaluation,
Useofhealthinformationbycareprovidersatalllevels(national,regional/provincial,
districthospitalsandhealthcenters)forhealthservicedeliverymanagement,continuous
monitoringandperiodicevaluation,
Systematicuseofinformationonhealthriskfactorsinadvocacyfortheadoptionoflower
riskbehaviorsbythegeneralpublicandbytargetedvulnerablegroups.
Duringtheassessment,allthe10questionswereanswered,scoringatotalof15.0outof30oradequate
(50%).ThisisjusttheborderlinebetweenAdequateandNotAdequate.
Scores
Maximum Assessed
Categories
Percent
(%)
a. Analysisanduseofinformation
6.0
Adequate(67%)
b. Informationuseforpolicyandadvocacy
2.0
Adequate(67%)
c. Informationuseforplanningandprioritysetting
2.0
Adequate(67%)
d. Informationuseforresourceallocation
2.0
e. Informationuseforimplementationandaction
3.0
30
15.0
Total
Presentbutnot
adequate(33%)
Presentbutnot
adequate(33%)
Adequate(50%)
Table(11)
Results in the above table reveal that uses of information in the two areas of Information use for
resourceallocationandInformationuseforimplementationandaction,inparticularly,areveryweak.
Thisaffectstheachievementofgoalsofthenationalhealthstrategyand,therefore,morefocusneedto
concentrateonenhancinginformationintheseareas.
6.Disseminationanduse
Analysis and use of information
67%
Information use for policy and advocacy
67%
Information use for planning and priority setting
67%
Information use for resource allocation
33%
Information use for implementation and action
33%
50%
TOTAL
0%
25%
50%
75%
100%
Chart(9)
III.OverallHIS
Summary of the assessment findings for the six HIS components, which were elaborated under their
individualheadingsinthecurrentsection(Sec.III),arepresentedinthebelowtable.
Categories
Scores
Maximum
Percentage
Assessed
(%)
1. Resources
75
33.5
(45%)
2. EssentialHealthIndicators
15
10.0
Adequate(67%)
228
135.5
Adequate(60%)
15
8.0
Adequate(53%)
5. Informationproducts
207
151.0
Adequate(73%)
6. Disseminationanduse
30
15.0
Adequate(50%)
570
353.0
Adequate(62%)
3. Datasources
4. Datamanagement
OverallHIS
Table(12)
Aspertheresultsofthesummarytable,resourcescomponent,whichisaninputtothewholeHISprocess,
istheweakestlinkintheIraqiNHIScycle.Similarly,thedissemination&usecomponent,astheoutputof
theHISprocess,hasalsobeenassessedveryweak.
Thefollowingchartrepresentssummarystatusofthesixcomponentsandaswellastheoverallstatusof
NHISinIraqgraphically.
OverallHIS
Resources
45%
Indicators
67%
Data sources
60%
Data management
53%
Information products
73%
Dissemination & use
50%
Overall HIS
62%
0%
25%
50%
75%
100%
Table(10)
Insummary,thestatusofoverallNHISinIraq,accordingtothe810March2011assessment,beinginthe
adequate(62%)range,isconsideredtobeweakwithmostofitscomprisingcomponentsfunctionspoorly.
Itis,therefore,concludedthatsystematiceffortsareneededtoimproveandenhancetheHISstomeet
the information needs of the Iraqi health system for evidencebased decision making in all aspects of
health.
IV.StrengthsandweaknessesoftheHIS
TherehavebeensomeachievementsinimprovingthefunctionsofnationalhealthinformationsysteminIraq
in the past few years. However, the 810 March 2011 assessment, which thoroughly reviewed the various
componentsofthenationalHIS,haslistedanumberofstrengthsandweaknesses.Theexistingstrengthsand
weaknesseshavetobetakenintoaccountwhenembarkingupontheHISreformprocess.
IV.1.Strengths
1.
Presence of a political will and support for strengthening the HIS for its use in evidencebased
decisionmaking;
2.
Relatively strong routine health information system within MOH that reviews almost all relevant
administrativeandhealthanddiseasesrecordsinMOHinstitutionsonmonthlybasis;
3.
RelativelywellestablishedHISinfrastructure,whichwillbesufficienttomeetthesystemsimmediate
andthenearfutureneeds;
4.
WellfunctioningVitalRegistrationsystemforbirthsanddeathsregistration;
5.
Welldocumentedandregularannualreportingonhealthsystem,morbidityandmortalityindicators.
IV.2.Weaknesses
1.
Despite the presence of political will and support, the statistical law and strategy does not show
enough supportto HIS.Thiscould affect data collection and compilation fromdifferent healthcare
providersandthusaffectsrepresentativenessoftheinformation;
2.
TheMinistry of Health hasmade tremendous efforts to develop HVSD.Other healthcare providers

are notsimilarly developed in statisticalservices. Thismakes it difficulttocompilethe health data
thatwillportraythenationalpicture;
3.
RelativelyweakcoordinationamongstatisticiansinHVSSattheDOHlevelanditsrelatedunitsinthe
districts,PHCs,andhospitals.
4.
The HVSD and Information Technology Center (ITC) are two separate bodies. Currently, the
coordinationamongthesetwobodiesisinadequate;
5.
Although major health surveys and studies are listed and their findings are available, these surveys
andstudiesneed tobe electronicallydocumented for easy dissemination, and for easy information
extraction;
6.
Physicians and relevant health workers lack proper training in recording cause of death, coding
morbidityandtheoptimumuseofinformation;
7.
ThereislackofstatisticianswithinMOHtoruntheHIS;and
8.
Therearenospecialinstitutionsformedical/healthrecordingtraining;
9.
WeaknessesofmorbidityandmortalitycodingaccordingtoICD10byphysicians;
10. Poorfeedbackfromprivatehealthsectorsbecauseofpoorcoordinationandcollaborationbetween
publicandprivatesectorsandtheabsenceoftheregulationsthatcontroltheseissues.
V.Recommendations
Inlightoftheassessmentfindings,thefollowingarerecommended:
1.
EstablishNationalHIScommittee,includingFederalMoH,KRGMoH,lineministries,privatesectorsand
otherHISstakeholders;
2.
ThecoordinationmechanismsbetweentheHISstakeholdersshouldbe improved,especiallybetween
theMOP/CSOandtheMOH;
3.
Legislationscoveringprivatesectordatashouldbemadeand/orenforced;
4.
The MOH staff capacity should be developed in core health information sciences (epidemiology,
demography,statistics,informationandICT);
5.
Revise the indicators list to include all categories (determinants of health, health system inputs,
outputs,outcomesandhealthstatus)aswellasformeasuringhealthrelatedMDGs;
6.
AllocationofadequateresourcesforstrengtheningHISactivitiesatvariouslevelsoftheMOH;
7.
DesignationoffulltimeHISOfficersattheHVSofficesatnationalandgovernoratelevels;
8.
AddresstheproblemoffrequentturnoveroftheHISandstatisticalstaff;
9.
ProvisionofcomputersandotherICTinfrastructure(telephone,internet,andemails)todifferentlevels
oftheMOH;
10. Population census needs to be done periodically every 10 years and data be processed in time and
relevantdatamadeavailabletotheMOH;
11. Capacitybuilding of district and health facility levels in timely reporting of notifiable diseases and
surveillancereportandintegrationofthefragmentedandverticalreportingsystemsintoasingleand
unifiedNHIS;
12. DevelopmentofstrongGISsystemandmappingservicestomapallhealthservicesandavailabilityof
GPStoallhealthfacilities;
13. Developmetadatadictionary;
14. The HVSD at national level and the HVSSs at the subnational level should have an integrated data
warehouse,containingdatafromallpopulationbasedandinstitutionbasedsourcesincludingthekey
health programs with a user friendly reporting utility accessible to all relevant users and linking,
electronically,oftheHVSD&HVSSsdatabases;
15. Regularpublishingofinformationbulletinonsurveillanceofepidemicpronediseases;
16. Information should be widely used for resource allocations and also for advocacy for equity and
increased resources to disadvantaged groups and communities (e.g. by documenting their disease
burdenandpooraccesstoservices)
17. Health care providers and managers at all levels (national, regional/provincial, district, hospitals and
health centers) should use health information for health service delivery management, continuous
monitoringandperiodicevaluation.
Toconclude:
The NHIS in Iraq was assessed adequate (62%). This score is interpreted as weak NHIS. To serve its
perceivedobjectives,thesystemneedstobereformedandstrengthened.Therefore,itisrecommended
thatthecurrentassessmentexerciseshouldleadtodevelopingaHISStrategicPlanforIraq,assoonas
possible.TheStrategicPlanshouldreflectthefindingsofthisreportandtheaboverecommendations.
AnnexI:HISAssessmentTool
AnnexII:Listofthestakeholderswhoparticipatedtheworkshop
Theparticipantsofthe810March2011workshopinBaghdad,Iraq
S.N
Participatingstakeholderdepartmentandagency
Numberof
persons
1.
DirectorofHVSD,PlanningDirectorate,MOH
2.
DirectorofHumanPowerDepartment,PlanningDirectorate,MOH
3.
DirectorofPolicy&PlanningDepartment,PlanningDirectorate,MOH
4.
DirectorofInformationTechnologyCenter(ITC),MOH
5.
DirectorofVitalStatisticSection,PlanningDirectorate,MOH
6.
SeniorStatisticianinCensus,CenterofStatistics,MinistryofPlanning
7.
DirectorofHealthStatisticinCenterofStatistics,MinistryofPlanning
8.
ArepresentativeofMedicalAffairsDirectorate,MinistryofDefense
9.
ArepresentativeofstatisticalandinformationdepartmentintheMinistryofHigher
Education&ScientificResearch
10. DirectorofPlanningDepartment,KirkukDOH
11. DirectorofPrimaryHealthCareDepartment,PublicHealthDirectorate/MOH
12. AssistantDirectorofemergencyDepartment,MOH
13. ResponsibleforHISPrograminMaysanDOH
14. ResponsibleforHISPrograminKarbalaDOH
15. DirectorofStatisticalDepartmentinErbilDOH,KurdistanRegion
16. AssistantDirectorofLegalDepartment,AdministrativeDirectorate,MOH
17. DirectorofLegalDepartment,KIMADIA,MOH
18. ProgrammersfromStatisticsDepartment,PlanningDirectorate,MOH
19. DirectorofPHCSection,PublicHealthDirectorate,MOH
20. DirectorofIMCISection,PublicHealthDirectorate,MOH
21. AssistantDirectorofSpecializedCenterforTuberculosis&ChestDiseasesPublicHealth
Directorate(TB),MOH
22. DonorsAffairsSectionStaff
23. AssistantDirectorofFinancialPlanning,PlanningDirectorate
24. ResponsibleforHISPrograminProject&EngineeringServicesDirectorate,MOH
25. RepresentativesofHISCommitteewithITechcompany,SeniorDeputyMinistersOffice
26. DirectorofPerformanceEvaluationSection,PlanningDirectorate,MOH
27. DirectorofCurativeServicesDepartment,TechnicalAffairsDirectorate
28. DirectorofPharmaceuticalServicesDepartment,TechnicalAffairsDirectorate
29. RepresentativeofWHOIraq,BaghdadSuboffice
AnnexIII:theassessmentresultsoftheCR&VSsystemsofIraq
RapidAssessmentof
TheCivilRegistrationandVitalStatistics(CR&VS)Systems
InIraq,usingtheWHOFrameworkMarch2011
No.
Question
Score
Legalframework
Doesthecountryhavelegislationthatstatesthatbirthanddeathregistrationiscompulsory?
a Yesthecountryhasadequateandenforcedlegislationoncivilregistrationstatingthat
registrationofbirthsanddeathsiscompulsory;
b Yesthecountryhaslegislationoncivilregistrationstatingthatregistrationofbirthsanddeaths
iscompulsory,butitisinneedofamendment;
c Legislationexistsbutisnotenforced;or
d Nothereisnolawthatmakesitobligatorytoregisterbirthsanddeaths.
Doesthecountryhaveregulationsthatobligemedicalestablishmentstoreportallvitaleventstothe
vitalstatisticssystemwithinagiventime?
a Yesallmedicalestablishments(public,private,socialinsuranceandothers)reporttheseevents
tothevitalstatisticssysteminatimelymanner;
b Regulationsexistbutnotallmedicalestablishmentsreporttheevents;
c Regulationsonlycoverpublicmedicalestablishments;
d Noregulationsexist.
Doesthecountryhavelegislationthatstatesthatdeathhastobecertifiedbycause,andspecifiesthose
whocancertifythecauseofdeath?
a YescauseofdeathmustbeindicatedonthedeathcertificateaccordingtoICDrulesand
proceduresandcanonlybecertifiedbyamedicaldoctor;
b Causeofdeathmustbestatedonthedeathcertificatebutitisnotspecifiedwhocancertifythe
cause;
c Causeofdeathmustbeindicatedbutonlybroadcategoriesarenecessaryandthe(nonmedical)
registraroranotherlocalofficialisusuallythecertifier;
d Noitisnotnecessarytoindicatethecauseofdeathonthedeathcertificateoratanystageof
theregistrationofdeath.
Registrationinfrastructureandresources
4
Arethereadequatenumbersofcivilregistrationoffices/pointstocoverthewholecountry?
a Yesthecountryisadequatelycoveredwithplaceswherecitizenscanregisterbirthsanddeaths;
b Theurbanareasarewellcoveredwithpartialcoverageofruralareas
c Onlytheurbanareasarewellcovered
d Noonlythecapitalcityhasregistrationoffices.
Docivilregistrationofficeshaveadequateequipmenttocarryouttheirfunctions(forexample,forms,
telephones,photocopiersandcomputers)?
a Yesnecessarysuppliessuchasforms,paper,andpensareadequateandtechnicalequipment
suchastelephones,photocopiersandcomputersiswidelyavailable;
b Suppliessuchasforms,paper,andpensaregenerallyavailableeverywherebutthereare
widespreadshortagesoftelephones,photocopiersandcomputers;
c Inperipheralofficessuppliesareoftenshortandonlythecentral/provincialofficeshave
telephones,photocopiersandcomputers;
d Bothavailabilityofbothsuppliesandtechnicalequipmentisaprobleminallcivilregistration
offices.
Annexes
No.
6
Question
Score
Haveregistrarsreceivedtrainingtocarryouttheirfunctions?
a Yesallregistrarshavereceivedadequatetraining;
b Allregistrarsreceivesometrainingbutitisinsufficientandskillsandknowledgearelargely
acquiredonthejob;
c Mostregistrars(particularlyinsmalleroffices)receiveonlyonthejobtraining;
d Nolackoftrainingisaseriousproblemandhasanegativeimpactonthefunctioningofcivil
registration.
Organizationandfunctioningofthevitalstatisticssystem
7
Howwelldothedifferentgovernmentagenciesanddepartmentsresponsibleforcivilregistrationand
vitalstatisticssystemscollaborate(includesministriesofhealth,justice,interior,localgovernment,
statisticsoffices,etc.)?
a Theinvolvedagenciescollaborateverywellandaninteragencycommitteeexistsandensures
thattheinterfacebetweenthecivilregistrationandvitalstatisticssystemsisseamless;
b Althoughthereisnoformalinteragencycommittee,theagenciesinvolvedhaveregularmeetings
toidentifyandresolveproblemsastheyarise;
c Nointeragencycommitteeexistsandproblemsaresolvedinanadhocfashionwhichdelays
effortstoresolveproblemsandcanleadtoseriousbottlenecksindatatransfer;
d Thereislittleinteragencycollaboration,withthevariousagenciesfunctioningindependently
resultinginproblems,e.g.duplicationofworkandinconsistenciesintheestimatesofvital
statisticsissuedbyeachagency.
Isthevitalstatisticssystemabletogeneratebothnationalandsubnationalstatisticsonbirthsand
deathsannually?
a Yesannualstatisticsaregeneratedonbirths,deathsandcausesofdeathbysexandageatboth
nationalandsubnationallevels;
b Annualstatisticsofbirthsanddeathbysexandagearegeneratedatthenationalandsub
nationallevelsbutcauseofdeathstatisticsbysexandageareonlyavailablenationally;
c Thevitalstatisticssystemscanonlygeneratebirthsanddeathsbysexandageforreporting
regionsandnotforthewholecountry;causeofdeathdataareobtainedfromhospitalsonly;
d Notheinformationcollectedbythecivilregistrationsystemisnotcompiledforstatistical
purposes.
Coverageofbirthanddeathregistration
9
Accordingtothemostrecentevaluation,howcompleteisbirthregistrationinyourcountry?(if
nonationalevaluationexists,usethesimplemethodofcalculatingcompletenessshowninBox
1)
a Arecentevaluationshowedthatcoverageofbirthregistrationwas90%orhigher(specifythe
dateandmethodusedtocalculatecompleteness,seeBox1);
b Arecentevaluationshowedthatcoverageofbirthregistrationwasbetween70%and89%
(specifythedateandmethodusedtocalculatecompleteness,seeBox1);
c Arecentevaluationsuggeststhatcompletenessofbirthregistrationwasbetween50%and69%
d Arecentevaluationshowedthatlessthanhalfofallbirthswereregistered,ortherehasbeenno
recentevaluationofthecompletenessofbirthregistration
10
Accordingtothemostrecentevaluation,howcompleteisdeathregistrationinyourcountry?
(ifnonationalevaluationexists,usethesimplemethodofcalculatingcompletenessshownin
Box1)
a Arecentevaluationshowedthatcoverageofdeathregistrationwas90%orhigher(specifythe
dateandmethodusedtocalculatecompleteness,seeBox1);
b Arecentevaluationshowedthatcoverageofdeathregistrationwasbetween70%and89%
c Arecentevaluationsuggeststhatcompletenessofdeathregistrationwasbetween50%and69%
Annexes
No.
Question
Score
d Arecentevaluationshowedthatlessthanhalfofalldeathswereregistered,ortherehasbeenno
recentevaluationofthecompletenessofdeathregistration
Datastorageandtransmission
11
Howarebirthanddeathrecordstransmittedfromtheperipherytoacentralstorageinthecapitalcity?
a Allinformationisexchangedelectronicallyfromlocaltoregionaltocentraloffice;
b Papercopiesaresenttotheregionalofficeandprocessedthereforelectronictransmissionto
thecentraloffice;
c Thesystemisstillmainlypaperbasedwithcopiesbeingsenttotheregionaloffice,fromwhere
theyarescannedandsenttothecentralofficeforprocessing;or
d Papercopiesareusedthroughoutthesystemtotransferbirthanddeathrecordstoacentral
storagefacility.
12
Whatproceduresareinplacetoensurethatalllocal/regionalofficesreporttothecentraloffice
accordingtoagreedtimelines?
a Anagreedscheduleforreportingtothecentralofficeexistswithreportingdeadlinestakenvery
seriouslyandcloselymonitoreditisrarelynecessarytosendoutreminders;
b Anagreedscheduleforreportingtothecentralofficeexistsandthisislargelyadheredtodelays
fromthefieldareusuallycommunicatedtothecentraloffice;
c Althoughascheduleofreportingfromtheperipheryexists,thisisnotstrictlyadheredtoand
thereislittlethatthecentralofficecandotoensurethetimelysubmissionofdata;or
d Thelocalofficesreportinanadhocmannertothecentralofficeandlittlemonitoringisdoneby
thecentralofficetoencouragemoretimelyandregularreporting.
ICDcompliantpracticesandcertificationinandoutsidehospitals
13
DoesthecountryusethestandardInternationalFormofMedicalCertificateofCauseofDeathfor
reporting?
a Yestheformisalwaysusedbydoctorstoverifycauseofdeath;
b Theformisalwaysusedwhendeathsoccurinhealthfacilitiesthroughoutthecountryandwhere
doctorscertifydeathbutisnotgenerallyusedinothersituations;
c Theformisusedtocertifydeathonlyinmajorhospitals;
d Notheformisnotusedforcertifyingcausesofdeath.
14
Whererelevant,intheabsenceofmedicalcertification,isverbalautopsyroutinelyusedtodetermine
thecauseofdeath?
a Yes,verbalautopsyisroutinelyappliedtocertifydeathusingtheinternationalstandardtool[1]or
similarquestionnaire;
b Verbalautopsyusingtheinternationalstandardtoolisprogressivelybeingintroducedbutisnot
currentlyingeneraluse;
c Verbalautopsyisusedbutisnotbasedontheinternationalstandardtool;
d Verbalautopsyisnotroutinelyusedtodeterminecauseofdeathincaseswherethedeathisnot
certifiedbyaphysician.
Practicesaffectingthequalityofcauseofdeathdata
15
Whattrainingdodoctorsreceiveforcertifyingthecauseofdeath?
a AllmedicalstudentsareintroducedtotheICDduringtheirstudiesandtaughthowtocertify
causeofdeathandcorrectlycompletethedeathcertificate;
b NospecialtraininginICDordeathcertificationisincludedinthemedicalcurriculum,butall
medicalstudentslearnaboutICDanddeathcertificationduringtheirinternships;
c NospecialtraininginICDordeathcertificationisincludedinthemedicalcurriculumandonly
limitedonthejobtrainingisavailableduringinternships;or
d NotrainingoronthejobinstructionsinICDanddeathcertificationisgiventodoctors.
Annexes
No.
16
Question
Score
Whatproportionofcausesofdeathinyourcountryisclassifiedasilldefined?
a <10%;
b 1019%;
c 2039%;or
d 40%ormore
ICDcodingpractices
17
Inyourcountry,iscauseofdeathcodedaccordingtoanationallanguageversionoftheICD?
a YesICDcodingisdoneusinganationallanguageversionoranationallyagreedinternational
language;
b ICDcodingisdone,butthereisnonationallanguageversionavailablewhichmakesthecoders'
taskmoredifficult;
c ICDcodingisdoneaccordingtoashortlistinthenationallanguage;or
d NotheICDisnotused.
Coderqualificationandtraining,andqualityofcoding
18
WhatqualificationsdomortalitycodershaveforcodingmortalityinaccordancewithICDprinciplesand
rules?
a MortalitycodersmustpassaformaltestfollowingacompulsoryandintensiveICDtraining
course;additionalcoursesareofferedlaterasneeded;
b AllmortalitycodersaregivenashorttrainingcourseinICDandarethenexpectedtolearnon
thejobfrommoreexperiencedcoders;
c NewcodersareinstructedbymoreexperiencedonesandgiventheICDvolumesandexpectedto
learnbydoing;
d Newcodersareprovidedwithminimalinstructionsfromothercodersandreceiveonly
incompleteICDmaterials.
19
Whatqualityassuranceproceduresareinplaceforcheckingthecoding?
a Anationalregularprocedureisinplacetoreviewarandomsampleofcodedcertificatesand
feedbackisgiven;
b Nationalevaluationorarandomsampleofcodedcertificatestakesplaceoccasionally;
c Qualityevaluationislefttothelocalsupervisorswhosometimeschecktheworkofindividual
coders;
d Noproceduresexistandnoevaluationsofthequalityofcodinghavebeencarriedout.
Dataqualityandplausibilitychecks
20
Whatconsistencyandplausibilitychecksonfertilityandmortalitylevelsarecarriedoutbeforethedata
arereleased?
a Checksonoveralllevelsoffertilityandmortalityratesbasedonthevitalstatisticsdataaremade
bycalculatingratesorratiosandcomparingtheseovertime,atsubnationallevel,aswellasto
dataderivedfromothersources(e.g.census,householdsurveys);
b Checksontheoveralllevelsoffertilityandmortalityratesbasedonthevitalstatisticsare
undertakenbycalculatingratesorratiosandcomparingthesetoearliertimeseries;
c Checksarelimitedtocomputerprogrammesthatsimplycheckforcompilationerrorsbeforethe
dataarepublished;
d Therearenospecificdataqualityandplausibilitychecksroutinelycarriedoutonthebirthand
deathstatistics.
21
Whatconsistencyandplausibilitychecksareappliedtocauseofdeathdata?
a Inadditiontocheckingthestabilityofcauseofdeathpatternsovertime,theproportionofill
defineddeathsisroutinelymonitored,andageandsexpatternsofmajorcausesofdeathare
checkedforplausibility;
b Routineschecksoftheconsistencyofcauseofdeathpatternsaremadetoensurethatmortality
fromanydiseasegroupdoesnotvarysignificantlyfromyeartoyearandthatanyfluctuationscan
Annexes
No.
Question
Score
beexplained;
c Checksarelimitedtoautomatedchecksforcompilationanddataentryerrors;
d Therearenoconsistencyandplausibilitychecksroutinelycarriedoutoncauseofdeathdata.
Annexes
No.
Question
Score
Dataaccess,disseminationanduse
22
Doesthecountrypublishannualnumbersofbirthsdisaggregatedbysex,ageandgeographicalor
administrativeregion?
a Yesannualdataonbirthsarepublishedbyallthreedisaggregation(age,sexandgeographicor
administrativeregion);
b Annualdataonbirthsarepublishedbyanytwoofthedisaggregation;
c Annualdataonbirthsareavailablebutdisaggregatedbysexonly;
d Noannualstatisticsonbirthsarepublished.
23
Doesthecountrypublishannualnumbersofdeathsdisaggregatedbysex,ageandgeographicalor
administrativeregion?
a Yesannualdataondeathsarepublishedbyallthreedisaggregation;
b Annualdataondeathsarepublishedbytwoofthedisaggregation;
c Annualdataondeathsareavailabledisaggregatedbysexonly;
d Noannualstatisticsondeatharepublished.
24
Whatisthedelaybetweenthereferenceyearsandthepublicationofdetailednationalstatisticson
causeofdeathclassifiedbysexandage?
a lessthan2years;
b From2yearsbutlessthan3years;
c Fromthreeyearsbutlessthan5years;
d 5yearsormore
25
Howaredataonvitaleventsbeingusedforpolicyandprogrammepurposes?
a Dataonbirths,deathsandcausesofdeatharewidelyusedforsocioeconomicplanningandfor
monitoringthehealthstatusofthepopulation,includingtheuseofcauseofdeathdatafor
publichealthpurposes;
b DataonbirthsanddeathsareusedforreportingonhealthrelatedindicatorssuchastheMDGs
andothernationalhealthrelatedgoalsbutcausespecificdataarerarelyusedforpublichealth
purposes;
c Onlydataonbirthsfareusedforreportingonsomeindicatorssuchasfertility;
d Datafromthecivilregistrationandvitalstatisticssystemsarenotusedforpolicyandprogramme
purposes.
Totalscore
Percentagescore
54
72%
Scoresbetween65%and84%indicatethatCR&VSSfunctionbutwith
someelementsthatfunctionpoorly
Scores(%)
<34Dysfunctional
3564Weak
6584Functionalbutinadequate
85100Satisfactory
Annexes
WHO 2011
www.moh.org.iq
www.emro.who.int/iraq

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IraqHealthInformationSystem

Dissemination & use

NationalHealthAccount(NHA)whoseresultswill bereleasedinNationalConference inSeptember

Policy and planning

Institutions, HR and financing

Health & diseases records

Health service records

D. Measles vacc. coverage

E. Deliveries by skilled h. prof.

F. TB treatment success rate under DOTS

G. GGHE per capita

H. Private expenditure per capita

I. Health workforce 1,000 population

J. Smoking prevalence (15 years and older)

Analysis and use of information

Information use for policy and advocacy

Information use for planning and priority setting

Information use for resource allocation

Information use for implementation and action

Dissemination & use

TheMinistry of Health hasmade tremendous efforts to develop HVSD.Other healthcare providers

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