District Health Management Information Research Articles

Community overview on the differential prevalence of Hepatitis E in two sub-counties in Kitgum District, Uganda: a mixed study design

BackgroundAn epidemic of Hepatitis E infection occurred in Kitgum district, northern Uganda in 2009. In that epidemic, more than 10,422 people were infected, and over 166 deaths were registered. Kitgum District Health Management Information Systems (HMIS) showed that Hepatitis E cases continued to occur in Mucwini more than in Kitgum Matidi sub-county despite instituting similar epidemic control measures in the two communities. The tenacity of the virus in Mucwini sub-county had remained unclear. This study aimed to assess communities’ views and perspectives on the differential prevalence of Hepatitis E in the two sub-counties of Kitgum Matidi and Mucwini in northern Uganda.MethodsA mixed study using qualitative and quantitative methods was used. Four Focus group discussions and six key informant interviews were conducted with the village health teams, local council chairpersons, health workers, and community members. These participants were chosen purposively because of their expertise and experience in community health services. Face-to-face interview guides were administered to obtain detailed information on factors associated with the differential occurrence of Hepatitis E in the two sub-counties. This study was approved by a local IRB and the Uganda National Council of Science and Technology (UNCS&T).ResultsThe most substantial findings were the differences in prevention and control practices in the two communities. Residents of Mucwini were less compliant with infection, prevention, and control guidelines, and disagreements between local councilors and village health teams in Mucwini over allowances led to poor implementation and non-adherence to guidelines on community control of the epidemic.ConclusionA differentially higher prevalence of Hepatitis E in Mucwini than in Kitgum Matidi resulted from poor personal and community hygiene and non-adherence to behavior change communication among residents of Mucwini than their counterparts in Kitgum Matidi. The authors recommend a more proactive approach to managing an epidemic by securing the willingness of the affected community to adopt appropriate infection prevention and control guidelines. In addition, disagreements among stakeholders should be resolved quickly so that all community members adhere to control measures.

Evaluation of the malaria surveillance system – Adaklu District, Volta Region, Ghana, 2019

ObjectivesWe evaluated the malaria surveillance system in Adaklu District of the Volta Region of Ghana to determine if the system was meeting its objectives and assessed its usefulness and attributes. Study designDescriptive cross-sectional design was used in evaluating the surveillance system. MethodsWe interviewed stakeholders using a semi-structured questionnaire on case detection and reporting. We assessed the system attributes using the Centers for Disease Control and Prevention updated guidelines for evaluating public health surveillance systems. We extracted and reviewed malaria surveillance data from the District Health Management Information System 2. Summary statistics and direct content analysis were performed on quantitative and qualitative data respectively. ResultsOf the 80,441 suspected malaria cases recorded in Adaklu District from 2014 to 2018, 47,917 (59.6%) cases were confirmed. The system was meeting its objective of detecting malaria cases and monitoring trends in the population however, the system missed an epidemic in August 2016. Data generated from the surveillance system is used by the NMCP to aid in the distribution of logistics such as LLINs, RDT test kits, and track malaria control progress in the district. Staff at all levels were able to detect, confirm, treat and report malaria. All sub-districts/health facilities reported to the district and reports were all accurate and timely. The predictive value positive was 62.9%. ConclusionsThe malaria surveillance system in Adaklu District was useful and meeting its set objective of monitoring trends of malaria in the population. It was simple, flexible, acceptable and representative; however, the system was not detecting epidemics. The District Health Management Team should set alert and epidemic thresholds to help detect promptly epidemics of malaria in the district.

Determinants of male involvement in antenatal care at Palabek Refugee Settlement, Lamwo district, Northern Uganda

BackgroundIn 2014, Uganda launched the National Male Involvement Strategy in Maternal and Child Health. In 2020, the District Health Management Information System report for Lamwo district, where Palabek Refugee Settlement is located, indicated a 10% male involvement in antenatal care (ANC) at the settlement. We investigated determinants of male involvement in ANC in Palabek Refugee Settlement to inform programs on improvement of male involvement in ANC in a refugee setting.MethodologyWe conducted a community-based cross-sectional analytical study among a proportionate sample of mothers in Palabek Refugee Settlement from October-December 2021. Using a standardized questionnaire, we collected information on demographics and the constructs of the socio-ecological model where consent was given. We summarized data in tables and figures. We used Pearson chi-square test to determine significance of independent variables at bivariate level. A multivariable logistic regression model was run for all variables found significant at bivariate analysis to determine association between the different independent variables and male involvement in ANC.ResultsWe interviewed 423 mothers. The mean age of their male partners was 31 years, SD 7. 81% (343/423) of male partners had formal education, with 13% (55/423) having a source of income and 61% (257/423) having access to ANC information during their pregnancy. The level of male involvement in ANC in Palabek Refugee Settlement was 39% (164/423). Male involvement in ANC was positively associated with access to information on ANC (AOR 3.0; 95%Cl: 1.7–5.4) and frequent couple discussion on ANC (AOR 10.1; 95%Cl: 5.6–18.0). However, it was negatively associated with distance ≥ 3 km to the health facility (AOR 0.6 ;95%Cl: 0.4-1.0).ConclusionsApproximately one in three male partners in Palabek Refugee Settlement were involved in ANC. Male partners who had access to information during ANC and those who had frequent discussions were more likely to get involved in ANC. Men who lived ≥ 3 km from the health facility were less likely to be involved in ANC. We recommend intensified awareness creation on importance of male involvement in ANC and implementation of integrated community outreaches to reduce distance to the health facility.

Analysis of dog bite surveillance data, Volta Region, Ghana, 2020

IntroductionDog bite is the second most common injury sustained by humans after snake bites, and it is amongst the top 12 causes of non-fatal injuries worldwide. Globally, 59,000 human deaths occur annually due to rabies, and 95% of these deaths occur in Asia and Africa. Dog bites remained a public health concern in Ghana, with three out of every 1000 incidence resulting in human rabies. Analysis of the surveillance data is key in understanding the burden of dog bites in the Volta region. This study describes the epidemiology of dog bites in the Volta Region, Ghana, to inform policy on prevention and control.MethodsWe conducted a descriptive analysis of secondary data on dog bites. We obtained aggregate data from 2015 to 2019 from the District Health Management Information System (DHMIS). Variables extracted were gender, age, and location. Data were entered into a Microsoft Excel cleaned, reviewed, and analyzed. We used descriptive statistics to summarize results into frequency and proportion and displayed results in tables, graphs, and maps.ResultsDuring the study period, 4737 dog bite cases were identified from a population of 1,907,529 (incidence of 248 per 100,000). Twelve (0.25%) humans were confirmed for rabies with a 100% case fatality rate. Males accounted for 2455 (51.8%) of dog bite cases. The age group between 10 and 19 years (21.9%) was most affected. About 35.0% (1640/4737) were administered with the anti-rabies vaccine, and 25.3% (1200/4737) were administered anti-tetanus toxoid. Keta district (550 per 100000) reported the highest incidence of dog bites. Dog bite cases were highest in the third and fourth quarters of 2016 and the first quarter of 2017.ConclusionThe incidence of dog bites and rabies was high in the Volta region. Children and adolescents were mostly affected. There was a low coverage rate of anti-rabies vaccine and anti-tetanus toxoids usage. We recommended that the Regional Health Directorates and the Regional Veterinary Department develop robust strategies to control stray or free-roaming dogs in the Volta region.

A review of geospatial methods for population estimation and their use in constructing reproductive, maternal, newborn, child and adolescent health service indicators

BackgroundHousehold survey data are frequently used to measure reproductive, maternal, newborn, child and adolescent health (RMNCAH) service utilisation in low and middle income countries. However, these surveys are typically only undertaken every 5 years and tend to be representative of larger geographical administrative units. Investments in district health management information systems (DHMIS) have increased the capability of countries to collect continuous information on the provision of RMNCAH services at health facilities. However, reliable and recent data on population distributions and demographics at subnational levels necessary to construct RMNCAH coverage indicators are often missing. One solution is to use spatially disaggregated gridded datasets containing modelled estimates of population counts. Here, we provide an overview of various approaches to the production of gridded demographic datasets and outline their potential and their limitations. Further, we show how gridded population estimates can be used as alternative denominators to produce RMNCAH coverage metrics in combination with data from DHMIS, using childhood vaccination as examples.MethodsWe constructed indicators on the percentage of children one year old for diphtheria, pertussis and tetanus vaccine dose 3 (DTP3) and measles vaccine dose (MCV1) in Zambia and Nigeria at district levels. For the numerators, information on vaccines doses was obtained from each country’s respective DHMIS. For the denominators, the number of children was obtained from 3 different sources including national population projections and aggregated gridded estimates derived using top-down and bottom-up geospatial methods.ResultsIn Zambia, vaccination estimates utilising the bottom-up approach to population estimation substantially reduced the number of districts with > 100% coverage of DTP3 and MCV1 compared to estimates using population projection and the top-down method. In Nigeria, results were mixed with bottom-up estimates having a higher number of districts > 100% and estimates using population projections performing better particularly in the South.ConclusionsGridded demographic data utilising traditional and novel data sources obtained from remote sensing offer new potential in the absence of up to date census information in the estimation of RMNCAH indicators. However, the usefulness of gridded demographic data is dependent on several factors including the availability and detail of input data.

Evaluation of malaria surveillance system, Adaklu District, Volta Region, Ghana, 2019

Background: Globally, 219 million cases of malaria were recorded in 2017 with Ghana contributing 10.2 million cases, deaths was 599 and 327 were among children under 5 years. Despite the multiple interventions implemented to control malaria in the Volta Region, prevalence still remains high. We evaluated the system in Adaklu District, Volta Region to determine if the system is meeting its objectives of monitoring trends, and detecting epidemics, and assessed its usefulness and attributes. Methods & Materials: We extracted and reviewed malaria data from District Health Management Information System II covering the period of January 2014 and December 2018. We interviewed stakeholders using semi-structured questionnaire on their awareness and involvement in the system, case detection and reporting. System attributes were assessed using the CDC updated guidelines for evaluating public health surveillance. We performed summary descriptive statistics on quantitative data and directed content analysis on qualitative data. Results: Of a total 76,384 suspected malaria cases recorded in Adaklu District over the five-year period, 27,498 (57.4%) cases were recorded between March and October. Health care workers demonstrated good knowledge about the disease but had no idea about the IDSR case definition. All fifteen facilities reported malaria data each month. Stakeholders demonstrated no difficulty diagnosing and reporting cases. The average estimated predictive value positive was 62.9%, data quality was 95% and 100% timely for report submission. The system was used to monitor morbidity trends and evaluate control and preventive measures. There were no alert or epidemic thresholds to detect epidemics. The system missed an epidemic in August 2016. Conclusion: The system in Adaklu District was useful, simple, acceptable, representative with good data quality. Seasonal pattern was observed between March and October each year. The district needs to implement Seasonal Malaria Chemoprevention especially among children to help reduce the incidence among children under five years. We assisted them to set alert and epidemic thresholds based on past data.

Contracting of private medical practitioners in a National Health Insurance pilot district: What has been the effect on primary healthcare utilisation indicators?

BackgroundIn 2012, the National Department of Health in South Africa started contracting of private medical practitioners (MPs) as part of the first phase of National Health Insurance (NHI) in 11 pilot districts to improve access to healthcare.AimThe aim of this study was to describe the effect of contracting private MPs on the utilisation of primary healthcare (PHC) services in public healthcare facilities.SettingA National Health Insurance pilot district compared to a non-pilot district.MethodsA quasi-experimental ecological study design was used to compare selected PHC utilisation indicators in the District Health Management Information System from June 2010 to May 2014 between a pilot and a non-pilot district. Both single and controlled interrupted time series analyses were used for comparing before and after implementation of the intervention.FindingsSingle interrupted time series analysis showed an increase in adults remaining on anti-retroviral therapy, clients seen by a nurse practitioner and clients 5 years of age and older in both districts. However, controlled interrupted time series analysis found no difference in all parametres. Despite a decrease in total headcounts in both districts using single interrupted time series analysis, controlled interrupted time series analysis found no differences in all parameters before and after the intervention.ConclusionsThe increase in utilisation of PHC services in the pilot district may not be attributable to the implementation of contracting private MPs, but likely the result of other healthcare reforms and transitions taking place in both districts around the same time.

Malaria incidence among children less than 5\xa0years during and after cessation of indoor residual spraying in Northern Uganda

BackgroundIn June 2015, a malaria epidemic was confirmed in ten districts of Northern Uganda; after cessation of indoor residual spraying (IRS). Epidemic was defined as an increase in incidence per month beyond one standard deviation above mean incidence of previous 5 years. Trends in malaria incidence among children-under-5-years were analysed so as to describe the extent of change in incidence prior to and after cessation of IRS.MethodsSecondary data on out-patient malaria case numbers for children-under-5-years July 2012 to June 2015 was electronically extracted from the district health management information software2 (DHIS2) for ten districts that had IRS and ten control districts that didn’t have IRS. Data was adjusted by reporting rates, cleaned by smoothing and interpolation and incidence of malaria per 1000 population derived. Population data obtained from 2002 and 2014 census reports. Data on interventions obtained from malaria programme reports, rainfall data obtained from Uganda National Meteorological Authority. Three groups of districts were created; two based on when IRS ended, the third not having IRS. Line graphs were plotted showing malaria incidence vis-à-vis implementation of IRS, mass net distribution and rainfall. Changes in incidence after withdrawal of IRS were obtained using incidence rate ratios (IRR). IRR was calculated as incidence for each month after the last IRS divided by incidence of the IRS month. Poisson regression was used to test statistical significance.ResultsIncidence of malaria declined between spray activities in districts that had IRS. Decline in IRR for 4 months after last IRS month was greater in the sprayed than control districts. On the seventh month following cessation of IRS, incidence in sprayed districts rose above that of the last spray month [1.74: 95% CI (1.40–2.15); and 1.26: 95% CI (1.05–1.51)]. Rise in IRR continued from 1.26 to 2.62 (95% CI 2.21–3.12) in June 2015 for districts that ended IRS in April 2014. Peak in rainfall occurred in May 2015.ConclusionThere was sustained control of malaria incidence during IRS implementation. Following withdrawal and peak in rainfall, incidence rose to epidemic proportions. This suggests a plausible link between the malaria epidemic, peak in rainfall and cessation of IRS.

Assessing the quality of routine data for the prevention of mother-to-child transmission of HIV: An analytical observational study in two health districts with high HIV prevalence in South Africa

BackgroundThe prevention of mother-to-child transmission of HIV (PMTCT) is a key maternal and child-health intervention in the context of the HIV/AIDS pandemic in South Africa. Accordingly, the PMTCT programmes have been incorporated in the routine District Health Management Information System (DHMIS) which collects monthly facility-based data to support the management of public-health services. To date, there has been no comprehensive evaluation of the PMTCT information system. ObjectivesThis study seeks to evaluate the quality of output indicators for monitoring PMTCT interventions in two health districts with high HIV prevalence. MethodsAn analytical observational study was undertaken based on the Performance of Routine Information System Management (PRISM) framework and tools, including an assessment of the routine PMTCT data for quality in terms of accuracy and completeness. Data were collected from 57 public health facilities for six pre-defined PMTCT data elements by comparing the source registers with the routine monthly report (RMR), and the RMR with the DMHIS for January and April 2012. This was supplemented by the analysis of the monthly data reported routinely in the DMHIS for the period 2009–2012. Descriptive statistics, analysis of variance (ANOVA) and Bland Altman analysis were conducted using STATA® Version 13. ResultsAlthough completeness was relatively high at 91% (95% CI: 78–100%) at facility level and 96% (95% CI: 92–100%) at district level, the study revealed considerable data quality concerns for the PMTCT information with an average accuracy between the register and RMR of 51% (95% CI: 44–58%) and between the RMR and DHMIS database of 84% (95% CI: 78–91%). We observed differences in the data accuracy by organisational authority. The poor quality of the data was attributed partly to insufficient competencies of health information personnel. ConclusionsThe study suggests that the primary point of departure for accurate data transfer is during the collation process. Institutional capacity to improve data quality at the facility level and ensure core competencies for routine health information system (RHIS)-related tasks are needed. Further exploration of the possible factors that may influence data accuracy, such as supervision, RHIS processes, training and leadership are needed. In particular understanding is needed about how individual actions can bring about changes in institutional routines.

Maintaining Maternal and Child Health Services During the Ebola Outbreak: Experience from Pujehun, Sierra Leone.

Background:During the Ebola outbreak the overall confidence of the population in the national health system declined in Sierra Leone, with a reduction in the use of health services. The objective of this study is to provide information on understanding of how Ebola impacted maternal and child health services in Sierra Leone. Data come from an operational setting which is representative of the communities affected by the outbreak.Methods:By integrating hospital registers and contact tracing form data with healthcare workers and local population interviews, the transmission chain was reconstructed. Data on the utilization of maternal and neonatal health services were collected from the local district’s Health Management Information System. The main measures put in place to control the Ebola epidemic were: the organization of a rapid response to the crisis by the local health authorities; triage, contact tracing and quarantine; isolation, clinical management and safe burials; training and community sensitization.Results:A total of 49 case patients were registered between July and November 2014 in the Pujehun district. Hospitalization rate was 89%. Overall, 74.3% of transmission events occurred between members of the same family, 17.9% in the community and 7.7% in hospital. The mean number of contacts investigated per case raised from 11.5 in July to 25 in September 2014. The 2014 admission trend in the pediatric ward shows a decrease after beginning of June: the reduction was almost significant in the period July-December (p 0.05). The admission in the maternity ward showed no statistical differences in comparison with the previous year (p 0.07). Also the number of deliveries appeared to be similar to the previous year, without significant variations (p 0.41).Conclusion:The Ebola outbreak reduced the number of patients at hospital level in Pujehun district. However, the activities undertaken to manage Ebola, reduced the spread of infection and the impact of the disease in mothers and children. A number of reasons which may explain these results are presented and discussed.

Strengthening district-based health reporting through the district health management information software system: the Ugandan experience.

BackgroundUntimely, incomplete and inaccurate data are common challenges in planning, monitoring and evaluation of health sector performance, and health service delivery in many sub-Saharan African settings. We document Uganda’s experience in strengthening routine health data reporting through the roll-out of the District Health Management Information Software System version 2 (DHIS2).MethodsDHIS2 was adopted at the national level in January 2011. The system was initially piloted in 4 districts, before it was rolled out to all the 112 districts by July 2012. As part of the roll-out process, 35 training workshops targeting 972 users were conducted throughout the country. Those trained included Records Assistants (168, 17.3%), District Health Officers (112, 11.5%), Health Management Information System Focal Persons (HMIS-FPs) (112, 11.5%), District Biostatisticians (107, 11%) and other health workers (473, 48.7%). To assess improvements in health reporting, we compared data on completeness and timeliness of outpatient and inpatient reporting for the period before (2011/12) and after (2012/13) the introduction of DHIS2. We reviewed data on the reporting of selected health service coverage indicators as a proxy for improved health reporting, and documented implementation challenges and lessons learned during the DHIS2 roll-out process.ResultsCompleteness of outpatient reporting increased from 36.3% in 2011/12 to 85.3% in 2012/13 while timeliness of outpatient reporting increased from 22.4% to 77.6%. Similarly, completeness of inpatient reporting increased from 20.6% to 57.9% while timeliness of inpatient reporting increased from 22.5% to 75.6%. There was increased reporting on selected health coverage indicators (e.g. the reporting of one-year old children who were immunized with three doses of pentavelent vaccine increased from 57% in 2011/12 to 87% in 2012/13). Implementation challenges included limited access to computers and internet (34%), inadequate technical support (23%) and limited worker force (18%).ConclusionImplementation of DHIS2 resulted in improved timeliness and completeness in reporting of routine outpatient, inpatient and health service usage data from the district to the national level. Continued onsite support supervision and mentorship and additional system/infrastructure enhancements, including internet connectivity, are needed to further enhance the performance of DHIS2.

Does supervision improve health worker productivity? Evidence from the Upper East Region of Ghana

To assess whether supervision of primary health care workers improves their productivity in four districts of Northern Ghana. We conducted a time-use study during which the activities of health workers were repeatedly observed and classified. Classification included four categories: direct patient care; documentation and reporting; staff development and facility operations; and personal time. These data were supplemented by a survey of health workers during which patterns of supervision were assessed. We used logistic regression models with health facility fixed effects to test the hypothesis that supervision increases the amount of time spent providing direct patient care (productivity). We further investigated whether these effects depend on whether or not supervision is supportive. Direct patient care accounted for <25% of observations. In bivariate analyses, productivity was higher among midwives and in facilities with a high volume of care. Supervisory visits were frequent in those four districts, but only a minority of health workers felt supported by their supervisors. Having been supervised within the last month was associated with a significantly higher proportion of time spent on direct patient care (OR = 1.57). The effects of supervision on productivity further depended on whether the health workers felt supported by their supervisors. Supportive supervision was associated with increased productivity. Investments in supervision could help maximize the output of scarce human resources in primary health care facilities. Time-use studies represent an objective approach in monitoring the productivity of health workers and evaluating the impact of health-system interventions on human resources.

HMIS and decision-making in Zambia: re-thinking information solutions for district health management in decentralized health systems

At the onset of health system decentralization as a primary health care strategy, which constituted a key feature of health sector reforms across the developing world, efficient and effective health management information systems (HMIS) were widely acknowledged and adopted as a critical element of district health management strengthening programmes. The focal concern was about the performance and long-term sustainability of decentralized district health systems. The underlying logic was that effective and efficient HMIS would provide district health managers with the information required to make effective strategic decisions that are the vehicle for district performance and sustainability in these decentralized health systems. However, this argument is rooted in normative management and decision theory without significant unequivocal empirical corroboration. Indeed, extensive empirical evidence continues to indicate that managers' decision-making behaviour and the existence of other forms of information outside the HMIS, within the organizational environment, suggest a far more tenuous relationship between the presence of organizational management information systems (such as HMIS) and effective strategic decision-making. This qualitative comparative case-study conducted in two districts of Zambia focused on investigating the presence and behaviour of five formally identified, different information forms, including that from HMIS, in the strategic decision-making process. The aim was to determine the validity of current arguments for HMIS, and establish implications for current HMIS policies. Evidence from the eight strategic decision-making processes traced in the study confirmed the existence of different forms of information in the organizational environment, including that provided by the conventional HMIS. These information forms attach themselves to various organizational management processes and key aspects of organizational routine. The study results point to the need for a radical re-think of district health management information solutions in ways that account for the existence of other information forms outside the formal HMIS in the district health system.

Evaluation of existing District Health Management Information Systems: A case study of the District Health Systems in Kenya

This paper discusses some of the issues and challenges of implementing appropriate and coordinated District Health Management Information System (DHMIS) in environments dependent on external support especially when insufficient attention has been given to the sustainability of systems. It also discusses fundamental issues which affect the usability of DHMIS to support District Health System (DHS), including meeting user needs and user education in the use of information for management; and the need for integration of data from all health-providing and related organizations in the district. This descriptive cross-sectional study was carried out in three DHSs in Kenya. Data was collected through use of questionnaires, focus group discussions and review of relevant literature, reports and operational manuals of the studied DHMISs. Key personnel at the DHS level were not involved in the development and implementation of the established systems. The DHMISs were fragmented to the extent that their information products were bypassing the very levels they were created to serve. None of the DHMISs was computerized. Key resources for DHMIS operation were inadequate. The adequacy of personnel was 47%, working space 40%, storage space 34%, stationery 20%, 73% of DHMIS staff were not trained, management support was 13%. Information produced was 30% accurate, 19% complete, 26% timely, 72% relevant; the level of confidentiality and use of information at the point of collection stood at 32% and 22% respectively and information security at 48%. Basic DHMIS equipment for information processing was not available. This inhibited effective and efficient provision of information services. An effective DHMIS is essential for DHS planning, implementation, monitoring and evaluation activities. Without accurate, timely, relevant and complete information the existing information systems are not capable of facilitating the DHS managers in their day-today operational management. The existing DHMISs were found not supportive of the DHS managers' strategic and operational management functions. Consequently DHMISs were found to be plagued by numerous designs, operational, resources and managerial problems. There is an urgent need to explore the possibilities of computerizing the existing manual systems to take advantage of the potential uses of microcomputers for DHMIS operations within the DHS. Information system designers must also address issues of cooperative partnership in information activities, systems compatibility and sustainability.

Evaluation criteria for district health management information systems: lessons from the Ministry of Health, Kenya

There has been no comprehensive evaluation of the district health management information systems (DHMISs) since the establishment of these systems by the Ministry of Health (MoH), in Kenya. This is partly due to lack of defined criteria for evaluating the systems. The objective of this study is to design evaluation criteria for assessing the viability, sustainability and ultimate contribution of DHMIS in the management of the district health system (DHS) in Kenya. This descriptive cross-sectional study was undertaken in three DHSs in Kenya. Empirical evidence was collected through interviews, complemented by a comprehensive review of relevant literature, reports and operational manuals of various health information systems in Kenya. A set of evaluation criteria for DHMISs in Kenya was designed for each of the three phases of implementation: phase one-pre-implementation evaluation criteria (categorized as policy and objectives, technical feasibility, financial viability, political viability and administrative operability) to be applied at the design stage; phase two-concurrent (operational) implementation evaluation criteria to be applied during implementation of the new system; phase three-post-implementation evaluation criteria (classified as internal-quality of information; external-resources and managerial support; ultimate-systems impact) to be applied after operating the implemented system for at least 3 years. In designing a DHMIS model there is need to have built-in these three sets of evaluation criteria which should be used in a phased manner. Pre-implementation evaluation criteria should be used to evaluate the system's viability before more resources are committed to its implementation; concurrent (operational) implementation evaluation criteria should be used to ascertain the status of the on-going implementation with the view to either fine-tune or abandon it altogether before more resources are used on it; and post-implementation evaluation criteria should be used to assess its overall effectiveness (if it has achieved its hypothesized benefits) towards the management of DHS.