Review of health
information systems (HIS)
in selected countries
TABLE OF CONTENTS
1. OVERVIEW ................................................................................................................. 3
2. MAPPING OF ESSENTIAL HEALTH-RELATED INFORMATION ......................................... 4
; 2.1: General census of population and households .............................................. 4 ; 2.2: Birth and mortality statistics ........................................................................ 4 ; 2.3: Health surveys ............................................................................................. 4
3. 3. CURRENT STATUS OF THE NATIONAL HEALTH INFORMATION SYSTEM (NHIS) ......... 6
; 3.1: Legal and institutional framework of the NHIS, principal players and
mechanisms for coordination .............................................................................. 6 ; 3.2: Evaluation of the health system and specific programmes ............................ 8 ; 3.3: Mechanisms of coordination, harmonization, and data-quality control ......... 9
; 3.4: Dissemination of health information .......................................................... 11
4. STRENGTHS AND WEAKNESSES OF THE NHIS ............................................................ 12
Current organization of the health system
The health system in Mexico is fragmented and health services are provided by the following:
A. The Social Security System consisting of a number of different institutions
depending on type of employer. The Mexican Institute for Social Security (IMSS)
provides care to workers in the formal economy, the Institute of Health and Social
Security for State Workers (ISSSTE) provides care to government workers, and
PEMEX to oil company workers. Workers in the armed forces are also covered by
a specific social security system. The Social Security System covers around 51%
of the population.
B. Public services provided by the federal and state ministries of health (MOH)
provide care to the uninsured population. Included here is the health component of
the poverty-alleviation programmes run by the government. Mexico has a
decentralized health system and therefore each of the 32 States is responsible for
the public provision of care.
C. The private sector which is financed mainly by out-of-pocket expenditure and
private insurance schemes. This sector provides care to both the uninsured and the
insured population. Private providers are located mainly in the cities, and facilities
are very dispersed – there are less than 100 hospitals with more than 50 hospital
beds; however the private sector comprises 25% of hospital beds.
This fragmentation of the health system means that the national health information system is also fragmented. The Ministry of Health, the private sector and the social security institutions all have information systems which are compiled in the National Health Information System (NHIS). An example of the consequences for the information system stemming from the fragmented health system can be seen in the analysis of hospital discharges. Yearly, there is an average of six million discharges, 45% from social security institutions, 35% from the MOH, and 20% from the private sector.
2. MAPPING OF ESSENTIAL HEALTH-RELATED INFORMATION
2.1: General census of population and households
; Periodicity: Conducted every ten years in years ending in zero.
; Coverage: All the population.
; Topics: Household and population characteristics.
; Individual census: in each household, information from all residents is obtained. ; Temporal coverage: Information is available from 1985 up to 2000. ; Geographical coverage: Basic information is presented at national level, state,
municipality and basic geo-statistical area; further information is presented at state
; Entity responsible: The National Institute of Statistics, Geography and Informatics
2.2: Birth and mortality statistics
; Periodicity: yearly.
; Topics: Basic concept is live births according to the UN definition. ; Main variables reported: date of birth and date of registration, place of birth,
personnel attending the birth (trained, untrained), type of birth, sex, age at time of
registration, place of residence of the mother, age at time of giving birth, number
of live births and surviving children, education, employment status, marital status,
age of the father, education, employment status.
; Temporal coverage: Information is available from 1893 up to 2001. ; Geographical coverage: national, state, municipality, town, village (registries of
births within the country and of Mexicans living abroad).
Mortality (general and fetal deaths)
; Mortality is registered in the death certificate and certificate of fetal deaths. ; Periodicity: annual.
; Topics: Basic concepts are general and fetal deaths, as defined by UN and WHO. ; Geographical coverage: National, state, municipality and town, village. ; Responsibility for registration: civil registry and ministerio publico in case of
accidents and violent deaths.
2.3: Health surveys
Mexico has a National System of Health Surveys, with the most recent providing information on health status, nutrition, addictions, risk factors, etc. as shown in TABLE 1. In addition, the analysis of information, as well as the calculation of health indicators, relies upon the use of the non-health variables provided by the surveys shown in TABLE 2, and conducted by the National Institute of Statistics, Geography and Informatics.
TABLE 1: Health surveys in Mexico
Year Type of Survey Main variables Coverage
1986 National Health Survey National and by State 1987 National Seroepidemiological Survey National and by State
National Nutrition Survey National and regions 1988 National Survey on Addictions National and regions 1993 National Survey of Chronic Diseases National and regions
National Nutrition Survey National and regions 1994 National Survey of Vaccination National and regions
National Health Survey National and regions 1998 National Survey on Addictions
National Nutrition Survey Malnutrition, micronutrient National and 4 main
evaluation, risk factors, regions of the country,
obesity and overweight urban and rural
2000 National Health Survey National and by states 2002 National Health Systems Performance Health status (self-National and state level
Assessment Survey assessed), risk factors, (40 000 households)
mortality, coverage of
responsiveness of the
TABLE 2: Non-health surveys in Mexico
1983 National Survey of Urban Employment, socio-Started with 16 Conducted monthly
Employment demographic urban areas and by with preliminary
variables, economic 2003 includes 32 results and by
variables cities trimester
1984 National Income and Income and National Conducted every two
Expenditure Household expenditure of years approximately
1992 National Survey of Fertility, mortality, National (urban-Every five years
Demographic Dynamics migration patterns, rural), state
1988 National Employment Employment National, state, By trimester for (and Survey characteristics, socio-urban areas information by state, ten demographic urban population and more variables, economic the national times) variables aggregates are
published annually 1999 Survey of Family Violence Metropolitan area
of Mexico City
1996 National Survey of Social security National
and Employment and Social coverage
2000 Security (Annex of social
security survey within the
3. CURRENT STATUS OF THE NATIONAL HEALTH INFORMATION SYSTEM (NHIS)
3.1: Legal and institutional framework of the NHIS, principal players and
mechanisms for coordination
The General Health Law establishes that the MOH, as head of the health sector, is responsible for the stewardship of the National Health Information System (NHIS). Furthermore, the internal rules and norms of the MOH dictate that the General Direction for Health Information is responsible for carrying out this task.
The conceptual framework of the NHIS (FIGURE 1) highlights the stewardship
function of the MOH as it regulates and coordinates the activities related to the collecting, processing, and administration of data and information, as well as the knowledge generated by the different institutions that comprise the National Health System.
FIGURE 1: Conceptual framework of the National Health Information System
The NHIS gathers information on the resources, services provided (hospital and ambulatory), health needs, population and coverage. In this sense, it concentrates information from the MOH, the private sector and the social security institutions as shown in FIGURE 2.
FIGURE 2: Health Information System – interaction between functions, players
RegulationDemographicFinancialDiseasesPersonalDynamicsGenerateMortalityHumanHealthIntegrateIntegrarColectiveLive birthsstatusDisseminationInsured andPhysicalDisabilityAnalysisnon insuredInfrastructure
The legal framework for the activities of the NHIS is the Law of Statistical and Geographic Information. Article 14 of this Law establishes that:
The organization and regulation of the necessary activities for the
integration of the national information systems will be established in the
national, sectorial and regional statistical development programs.
The MOH therefore published in 2001 the Action Plan for the Health Information System, highlighting the actions necessary to improve the quality, accuracy, consistency and comparability of the data collected.
The System for Epidemiologic Surveillance, as part of the NHIS, registers information on health-related conditions including diseases subject to compulsory reporting (diseases preventable by vaccination, communicable diseases, sexually transmitted diseases, and vector-transmitted diseases, among others). Weekly reporting of these diseases is performed in standardized formats. The Official Norm for Epidemiologic Surveillance establishes the criteria and variables that must be followed by public and private providers.
The subsystem for information on services provided presents information regarding the supply and demand of services provided by health units, or at community level. This information is useful in evaluating the performance of such units, in assessing health-services coverage, and determining their productivity.
Another component of the NHIS is the subsystem for information on health needs (and damages). This includes information on morbidity and its causes, and this is used to follow up the performance of specific programmes and for planning purposes.
3.2: Evaluation of the health system and specific programmes
The NHIS is linked to the evaluation and planning process. The evaluation of the National Health System is done at different levels. Firstly, there is a need to conduct a follow-up of the programmes and specific goals established by the National Health Programme. Secondly, there is also an assessment of overall health systems performance. The evaluation system recognizes three fundamental dimensions –
health determinants; health conditions; and performance of the health system. These three dimensions allow for an evaluation of the attributes of health systems. In 1995, 1the National Health Council adopted 58 health indicators that evaluate these
attributes (TABLE 3).
TABLE 3: Framework for the design of indicators
HealthconditionsHealthconditionsMorbilityDissabilityMortalityMorbilityDissabilityMortalityEffectiveness*HypertensionDissabilitiesFertilityEffectiveness*HypertensionDissabilitiesFertilityDiabetes MellitusHealthexpectancyatbirthDiabetes MellitusHealthexpectancyatbirthHealth StatusHealth StatusAcuterespiratoryinfectionsInfantmortalityAcuterespiratoryinfectionsInfantmortality
PerformanceofthehealthsystemPerformanceofthehealthsystemResourcesPersonal servicesNon personal servicesResourcesPersonal servicesNon personal servicesPharmaceuticalsFirstlevelofcareVector controlPharmaceuticalsFirstlevelofcareVector controlAccesibility**ProstheticequipmentBirthEnvironmental/sanitaryregulationsAccesibility**ProstheticequipmentBirthEnvironmental/sanitaryregulationsHospital bedsHospital servicesHospital bedsHospital servicesPhysiciansandnursesPhysiciansandnurses
TechnicalqualityInterpersonal qualityAcceptabilityTechnicalqualityInterpersonal qualityAcceptabilitySurgery InfectionsWaiting timeUsersatisfactionSurgery InfectionsWaiting timeUsersatisfactionQualityHospital mortalityQualityHospital mortalityresponsivnessresponsivnessCertificationof medical unitsCertificationof medical unitsand health professionalsand health professionals
% of the expenditure% of the expenditureEfficiencyEfficiencyvisits/doctorvisits/doctorHealthHealthto administrationto administrationCoverageCoveragesurgeries/hospitalsurgeries/hospitalEffective coverageEffective coveragepaymentspayments
Suficiency of moneyExpenditureequilibriumSuficiency of moneyExpenditureequilibriumHealthexpenditureas % GDPPublic/privateexpenditureHealthexpenditureas % GDPPublic/privateexpenditure
Publichealthexpas % oftotal publicPublichealthexpas % oftotal publicexpenditureexpenditureFinancialhealthFinancialhealthFederal/statehealthexpenditureFederal/statehealthexpenditurePercapita healthexpenditureExpenditureoncurativecare/expenditureonpreventivecarePercapita healthexpenditureExpenditureoncurativecare/expenditureonpreventivecare
Source: Health Systems Performance Assessment Action Plan, Ministry of Health
Additionally, the system must ensure equity and a gender perspective. Equity is analysed by measuring gaps in the indicators amongst different populations. The gender perspective is evaluated by disaggregating the indicators by gender where this is possible.
1 The National Health Council is formed by the 32 state ministers of health and the federal minister of health.
3.3: Mechanisms of coordination, harmonization, and data-quality control
A Technical Committee of Health Statistics has recently been established with the Minister of Health as its president. The vice-president is the head of the National Institute of Statistics, Geography and Informatics, and the Technical Secretariat is the General Direction for Health Information. The directors of the social security institutions are members, and the private sector is represented by its different organizations. The Committee oversees the activities of the Inter-institutional Health Information Group, and promotes the establishment of agreements and the adoption of consensus among the different institutions.
The executive branch of the Committee is represented by the Inter-institutional Health Information Group which includes representatives from the public and private sector, the National Institute of Statistics, Geography and Informatics, the National Population Council, and the Ministry of Finance. The National Institute of Statistics, Geography and Informatics is responsible for providing data from the census, socio-demographic surveys, household surveys and vital registries. The National Population Council provides information regarding population projections as well as the components of population dynamics – fertility, mortality, and migration patterns.
greatly upon cooperation among the different statistical offices.
FIGURE 3: Activities of the Health Information System by administrative level
The NHIS is the sum of the regional information systems. The MOH establishes the norm in conjunction with the state ministries of health. The federal MOH also conducts visits to ensure that states are correctly using the standardized forms, and that data quality is maintained.
Controlling data quality
The list of the 58 result indicators shown in TABLE 3 is based on a common
methodology and terminology necessary to ensure comparability. The components of this framework are:
; the WHO family of international classifications;
; the operative systems for the collection of information regarding the health of the
; overall health indicators such as life expectancy, years of life lived with disability,
The Mexican Center for the Classification of Diseases (CEMECE) is responsible for promoting the adequate use of WHO classifications, and is therefore very important for controlling the quality of data.
Mortality statistics are reported according to ICD. This classification, although useful for determining causes of death, is not used for reporting the health status of the population. For this purpose, the ICF is also used.
Reporting on health expenditure at national and state level is based upon the national health accounts methodology jointly proposed by WHO and OECD. This
methodology uses the International Classification of Health Accounts. Both private and public health expenditures are reported.
Currently, the heads of the different health programmes actively participate in the selection of variables and indicators to be reported, and this promotes the use of information for planning and evaluation processes. The Official Norm for Health Information is the guiding instrument that unifies criteria, standardizes concepts and establishes guidelines for the adequate collection, processing, and analysis of public and private health information. This is particularly relevant for private-sector information since there is already greater parity among public-sector information sources.
To ensure quality of the data from the jurisdictional level, the reports are reviewed from two perspectives:
; Use of quantitative criteria – consists of the use of algorithms to check for errors
in columns and rows, and special adjustments for specific variables. These criteria
stem from the rules for registering and processing information contained in the
Law of Statistical and Geographic Information.
; Use of qualitative criteria – refers to the basic characteristics the information must