1. Introduction

This thesis describes the analysis and construction of a health information system in a district health system in a developing country. The needs of and the expectations in information systems in this setting must be seen in the context of the involved health systems. These are different from health systems in industrialized countries not only because of the available resources. The historical background of a health system, the involvement of external agencies and the cultural set up also has an impact on the structure of health systems as they are today.

1.1. District Health Systems Based on Primary Health Care

Todays' health care systems in developing countries have undergone many structural changes over the years. Resulting from this, the health seeking individual is confronted with a variety of health services. There is on the one hand the private and mainly informal sector. Here the traditional healers can be found, which taken by themselves already offer a wide spectrum of services (compare [OPPONG (1989)] for Nigeria) and a complex understanding of health (compare [HELLER (1989)] for Nepal and [GREIFELD and ROSSBACH (1989)] for Colombia). Other services in this sector range from quacks over well sorted drugstores to private clinics operated by qualified medical doctors. Another great impact have the facilities, which were set up in the context of missionary ambitions from Christian and Islamic organizations and structures funded by non-profit initiatives. These usually have strong links to the other big sector, the formal governmental health care system, although they are often in a competitive relationship ([DIESFELD (1989)], p.102).

Governmental health care systems are normally integrated into the national administration, thus being characterized by the organizational structures left by the colonial powers. The providing structures are usually described by three levels. The primary care level comprises basic promotive, preventive and curative services. The secondary care level stands for referential hospitals with broad based curative services. Specialized services with high standards can be found in national hospitals on the tertiary care level. Historically, the tertiary level is comparatively overfunded, for which the Ghanaian situation in 1979 often serves as an extreme example. Here the tertiary level received 40% of the health budget to serve 1% of the population while the primary level targeted 90% of the population with a mere 15% share of the health budget ([MATOMORA (1995)] et al.).

In 1973 a WHO study revealed that because of this, three quarters of the rural population in developing countries had no access to modern health services. On these grounds, the "Primary Health Care" approach was introduced by the WHO in 1975. It was specified as an action program in the Alma Ata declaration in 1978 and serves as a global guideline for health service planning from then on ([DIESFELD and BICHMANN (1989)]). As an holistic approach, primary health care targets eight elements in the fields of intersectoral primary prevention, preventive medicine and basic curative medicine at the community level with a referral system. These elements should be realized respecting seven principles. According to these principles, primary health care must

1. respect the needs and lifestyles of the target population,
2. be an integral part of the national health system,
3. include other health related sectors,
4. involve the communities in planning, decision making and realization,
5. rely on local resources and be cost-effective,
6. integrate and coordinate preventive, curative, rehabilitative and promotive measures,
7. take place near the targeted level.

The paradigm of primary health care forwarded different strategies. The establishment of community based health care initiatives, as promoted by churches and other non-governmental organizations, aimed at the deployment of village health posts with scantily trained village health workers. These efforts turned out to be rather short lived due to the lack of a clearly defined framework ([MATOMORA (1995)]). On the other hand a variety of vertical health programs were launched, of which a sample is listed in table 1.1-1:

Since the vertical nature of these programs undermined the holistic idea of the primary health care concept, they were heavily criticized. They were considered as movements, of which "each has characteristics of a crusade, bordering on ideology beyond the simplicity of a program or activity" ([CHEN (1988)]).

Currently the emphasis of health systems development aims at the district level as an intermediate level between the central national structures and the community based structures of the pure primary health care approach. In this context, a district health system based on primary health care is supposed to be a "more or less self-contained segment of the national health system. It comprises first and foremost a well-defined population within a clearly delineated administrative and geographical area. It includes all the relevant health care activities in the area, whether governmental or otherwise. [...] It will be most effective if coordinated by an appropriately trained health officer working to ensure as comprehensive a range as possible of promotive, preventive, curative and rehabilitative health activities" ([WHO (1987a)] as quoted in [TARIMO (1991)], p. 4). The district level is therefore a coordinating instance of the diversified spectrum of health services in the district. District health systems ideally contain a network of primary health units and a district hospital for referral of cases, which exceed the capabilities of a health unit. The coordinating health officer, often referred to as the district medical officer, is the head of a competent management team, the district health team ([MATOMORA (1995)]).

The integrative paradigm of the district approach creates a compact but complex health system, in which the many historically evolved and the still upcoming entities have to be combined. Meeting the expectations of the communities, the national level, the various vertical programs and the very diversified private sector therefore imposes a great challenge on the management capabilities of the district health team, which is normally constrained by a chronically bad and still worsening economic background ([WHO (1989)]).