ROUND TABLE
ROUND TABLE DISCUSSION

A data warehouse approach can manage multiple data sets

Jørn Braa

Department of Informatics, University of Oslo, PO Box 1080, Blindern, Norway (email: jbraa@ifi.uio.no)

Development of essential national indicators and data sets — or national standards — is regarded as the key issue in country health information system reform. Most countries, however, fail to achieve this goal. The reasons are: fragmentation (difficulty in reaching agreement on standards across health programmes); focus on reporting rather than on use of data and information; constantly changing needs (e.g. with regard to HIV/AIDS); and standards that are "cast in stone" (software and paper tools are difficult to change).

Despite these problems, South Africa has managed to develop national standards that are flexible enough to "absorb" local innovations and changes over time. The following points may help to explain why this is so.

• The "hierarchy of standards" ("information needs" in Shaw's figure) has been a powerful tool to negotiate a balance between the national needs for control with the local (e.g. province or health programme) needs for flexibility or more data. While all health units are required to collect and report the core national data, they are at the same time allowed to collect their own additional data.
• Use of information is highlighted by linking data sets to targets and indicators.
• The flexible approach to standards following the hierarchy makes it easy to absorb and implement changes over time; there is no "final" data set. Local innovations are allowed for and may eventually be included in the national data set.
• The flexibility of the South African District Health Information System (DHIS) database application is crucial to managing the ever changing national and local data sets. Data elements, indicators and data sets are added, edited and managed by the health services themselves, thus making it possible to manage multiple data sets at district level. This "data repository" or "warehouse" approach may be a key to how the lessons from South Africa could be applied in other countries.

Over the years, I have been involved in efforts to apply the South African lessons in many countries. It has not been easy. National health information system databases and reporting formats tend to be rigid and unable to respond to changes, thus leading to fragmentation of the system. The HIV/AIDS programmes are currently aggravating this situation.

So what can be done? Current efforts to establish integrated data sets in contexts as different as Addis Ababa (Ethiopia), Botswana, Zanzibar (United Republic of Tanzania), Andhra Pradesh (India) and Ho Chi Minh City (Viet Nam) may provide some answers. Here data sets from all or most programmes are combined and streamlined by sorting out overlaps, gaps and inconsistencies. Following the South African district data warehouse approach, the combined essential data set is then further improved and reduced by focusing on the need-to-know indicators. Programme-specific software applications are linked electronically to the DHIS, thus providing a shared data repository. The objective of integrating all indicators relevant to the Millennium Development Goals has proven important in building consensus.

Purists may argue that the data warehouse approach based on flexible standards advocated here is violating the spirit of the South African minimum essential data set approach, by taking a combined — maximum — data set as the point of departure. It may, however, be the most appropriate way to apply the South African indicator-driven approach in a situation increasingly dominated by strong programmes and multiple uncoordinated data sets and software applications.

Competing interests: none declared.